Necrotizing fasciitis is a bacterial infection of the skin, subcutaneous tissue, and muscles. The most common pathogens are group A streptococci, staphylococci or clostridia. The affected tissue must be completely removed in order not to endanger the life of the patient.
What is necrotizing fasciitis?
Fasciitis is a necrotizing fascia disease. It is an inflammation in the fascial tissue in which cells perish. The inflammatory disease is also known as necrotizing fasciitis. The incidence is given as up to one case per 100,000 inhabitants. The inflammation is caused by bacteria and progresses like lightning. See phonejust for Laryngocele Meaning.
The skin and subcutaneous tissue are affected, with involvement of the fascia. For this reason, the disease is assigned to bacterial soft tissue infections. The most important risk factors include circulatory disorders, such as can occur in the context of superordinate metabolic diseases. Depending on the species of the bacterial pathogen, two subgroups of nacrotizing fasciitis are distinguished.
These subgroups are referred to as type I and type II of the disease and can show different courses. In immunodeficient patients, the course of infections is generally more severe. If the bacteria involved reach the bloodstream of these patients, the risk of sepsis or septic shock is high. As a result, necrotizing fasciitis can mature into a life-threatening condition for immunodeficient patients.
People with circulatory disorders in peripheral vessels are most commonly affected by necrotizing fasciitis. Disorders of the lymphatic drainage and immune deficiency also promote the development of the disease. Metabolic diseases, especially diabetics, are particularly at risk. The infection is usually triggered by skin injuries or abscesses in the skin, which allow bacteria to enter the subcutaneous tissue.
Intramuscular injections such as therapeutic injections for diabetes or therapeutic surgical interventions can also open the gates to the subcutaneous tissue for bacteria. Group A streptococci are considered to be the most important causative agents of necrotizing fasciitis. Theoretically, staphylococci or clostridia can also cause the infection, but are rarely involved in clinical practice.
Sometimes the infection is also a mixed infection:
- Necrotizing fasciitis type 1, for example, corresponds to an aerobic-anaerobic mixed infection and occurs mainly after surgical interventions. *Necrotizing fasciitis type 2 is caused by group A streptococci, making it the most common form of infection.
- A special form of necrotizing fasciitis is Fournier’s gangrene in the groin and genital region, which particularly affects men. Newborns with omphalitis have an increased susceptibility to necrotizing fasciitis of the umbilical region.
Symptoms, Ailments & Signs
Patients with necrotizing fasciitis suffer from rather unspecific symptoms at the beginning of the infection. The initial symptoms include above all local pain and a more or less high fever. Initially, these symptoms are often associated with chills, exhaustion and similar signs of infection.
Within the first week, the areas slowly swell due to inflammatory processes. The skin over the infectious focus is usually bluish-red in color and gradually becomes bluish-grey. Due to the inflammatory processes in the subcutaneous tissue, the upper one becomes overheated and often produces confluent blisters. The blisters contain a light to dark red liquid with a viscous consistency.
In an advanced stage, the affected tissue becomes necrotic. The necrosis can be more or less extensive and usually affects not only the soft tissue but also the nerves and muscles. From this point on, pain is usually no longer present, as the sensitive nerves in the area gradually die off.
In most cases, the patient’s fever increases during these processes. If the pathogens involved reach the bloodstream, a temporary bacteremia occurs in immunologically healthy patients, which is compensated for by the immune system. In immunocompromised patients, the bacteremia can persist and lead to sepsis.
Diagnosis & course of disease
Air pockets in the muscle fascia can be documented by CT when diagnosing necrotizing fasciitis. If there is a suspicion, a microbiological diagnosis takes place, in which the blisters are punctured or biopsies take place. A Gram preparation provides crucial diagnostic information. The microbial culture is part of the standard diagnostics.
Early diagnosis has a positive effect on the prognosis. Due to the rapid progression, mortality in the case of a delayed diagnosis is high at 20 to 50 percent, especially for type II. The prognosis is particularly unfavorable if the trunk region is involved.
In this disease, those affected suffer from a bacterial infection. In most cases, however, the entire infected tissue is surgically removed, so that complications are usually avoided. Patients with this disease suffer from a high fever and also from tiredness and exhaustion.
Body aches and headaches can also occur and significantly reduce the patient’s quality of life. There is also swelling of the skin and the skin itself usually turns brown. Blisters continue to form on the skin. If the disease is not treated, the nerves die and paralysis or other sensory disturbances occur. This nerve damage is usually not reversible and cannot be restored.
In serious cases, the disease can also lead to blood poisoning and thus to the death of the person concerned. As a rule, the disease is treated without complications. With the help of antibiotics, most symptoms can be limited relatively well. With early diagnosis, there is a completely positive course of the disease, and there is no reduction in the patient’s life expectancy.
When should you go to the doctor?
Symptoms such as chills, fever and exhaustion always require medical evaluation. If skin changes accompany these symptoms, the underlying cause may be necrotizing fasciitis, which must be diagnosed and treated immediately. The risk groups include people who suffer from circulatory disorders, an immune deficiency or disorders of the lymphatic drainage. Diabetics and patients with abscesses, skin injuries or bacterial infections are also at risk and should have the symptoms described quickly clarified.
If the symptoms occur in connection with therapeutic injections, the responsible doctor must be informed. At the latest when visible necrosis and associated joint pain or signs of blood poisoning occur, a doctor must be consulted. Affected people can visit their family doctor or a dermatologist. Depending on the type and severity of the necrotizing fasciitis, other specialists are then involved in the treatment. Advanced disease requires inpatient treatment, with the necroses being surgically removed. Due to the high risk of infection, any surgical wounds must also be monitored and treated by a specialist.
Treatment & Therapy
Necrotizing fasciitis is treated surgically. All affected soft tissues must be radically removed as soon as possible. If too little tissue is removed, fasciitis spreads at a rapid rate, leading to high tissue loss or even death. The pathogens of the infection are extremely aggressive pathogens, so that no germs should be left behind in the tissue during the operation.
Surgical intervention is usually combined with drug therapy. This therapy consists of clindamycin given three times a day, which is often given in combination with penicillin. Many of the pathogens are antibiotic resistant. Therefore, a purely antibiotic treatment is usually not effective. If all surgical and medical measures have been exhausted and no improvement could be brought about, the affected limbs must be amputated to save the life of the patient.
Outlook & Forecast
Immediate surgical therapy significantly improves the patient’s prognosis. Factors such as the advanced age of those affected, female gender and concomitant diseases such as diabetes mellitus also influence the prognosis. It has also been proven that necrotizing fasciitis of the trunk is associated with a significantly poorer outlook for those affected. Likewise, a significantly increased amputation rate and mortality can be mentioned for necrotizing fasciitis, especially after injection therapy. Therefore, the knowledge of all these different prognostic factors at the time of inpatient admission should be the basis for the doctor’s quick decision.
After surgical therapy, the main focus for those affected is intensive medical complex therapy and antibiotics. Because of the surgery, patients may need large amounts of intravenous fluid. Subsequent therapy in a high-pressure oxygen chamber is also recommended. However, it has not been proven to what extent this is helpful.
If toxic shock syndrome develops over the course of the disease, immunoglobulin is administered. The overall death rate averages 30%. The prognosis is worse in elderly patients, as well as those accompanied by other medical disorders, as well as in an advanced stage of the disease. Delay in diagnosis and treatment and insufficient removal of dead tissue worsens prognosis.
Since poor blood circulation and immune deficiency are considered risk factors for necrotizing fasciitis, immune-boosting and blood circulation-promoting measures can be interpreted as preventive measures in the broadest sense.
After the surgical removal of a necrotizing fasciitis, an intensive follow-up check of the tissue is very important. Tissue samples taken regularly are used to examine whether bacteria can still be detected. Affected patients are also prescribed antibiotics.
One problem, however, is that many bacteria that cause necrotizing fasciitis are resistant to conventional antibiotics. There is a risk of new sores forming and enlarging rapidly. For this reason, various preparations are administered in the first few days after the operation and it is examined whether possible bacteria are attacked.
Once a suitable antibiotic has been found, the patients have to take the preparation for several weeks. This is the only way to reduce the risk of re-infestation of necrotizing fasciitis. If organs or limbs have already been attacked by the disease, further operations and therapies may have to be carried out to treat the late effects of the disease.
One risk group are patients with diabetes mellitus. Since the occurrence of wounds is significantly increased by diabetes, patients with diabetes mellitus must be cared for intensively. A regular check-up, for example by a diabetologist, should prevent even small wounds from forming. This is to rule out the possibility of bacteria settling in the tissue and triggering necrotizing fasciitis.
You can do that yourself
Necrotizing fasciitis is life-threatening, and those affected should never try to treat the disorder themselves. However, this does not mean that patients cannot help to reduce the risk and mitigate the consequences of the course of the disease. The sooner the fasciitis is recognized as such, the higher the chances that an amputation can be avoided.
Members of risk groups, including in particular diabetics and people with an immune deficiency, should therefore also closely monitor small everyday injuries and recognize the symptoms of fasciitis. If you suffer from diabetes and suddenly develop a fever shortly after a minor injury while peeling potatoes, you should not dismiss this as the onset of a cold, but consult a doctor as a precaution. Patients at risk should also reduce their risk of injury. Small cuts or abrasions cannot always be avoided. However, the probability of occurrence can be reduced. In particular, protective gloves should always be worn when gardening and doing manual work.
If an injury does occur, the wound must be cleaned and disinfected immediately. Optimal initial care of the wound can reduce the risk of infection and thus also fasciitis. Diabetics can also contribute to strengthening their immune system and improving blood circulation in the limbs through a healthy diet and regular exercise. This also reduces the risk of fasciitis.