Necrotizing fasciitis: Difference between revisions

Jump to navigation Jump to search
No edit summary
No edit summary
Line 23: Line 23:
==Treatment==
==Treatment==
The diagnosis is confirmed by either [[blood culture]]s or aspiration of [[pus]] from [[Biological tissue|tissue]], but early medical treatment is crucial and often presumptive; thus, antibiotics should be started as soon as this condition is suspected. Initial treatment often includes a combination of intravenous antibiotics including [[penicillin]], [[vancomycin]] and [[clindamycin]]. If necrotizing fasciitis is suspected, surgical exploration is always necessary, often resulting in aggressive [[debridement]] (removal of infected tissue). As in other maladies characterized by massive wounds or tissue destruction, hyperbaric oxygen treatment can be a valuable adjunctive therapy, but is not widely available. [[Amputation]] of the affected organ(s) may be necessary. Repeat explorations usually need to be done to remove additional necrotic tissue. Typically, this leaves a large open wound which often requires skin grafting. The associated systemic inflammatory response is usually profound, and most patients will require monitoring in an [[intensive care unit]].
The diagnosis is confirmed by either [[blood culture]]s or aspiration of [[pus]] from [[Biological tissue|tissue]], but early medical treatment is crucial and often presumptive; thus, antibiotics should be started as soon as this condition is suspected. Initial treatment often includes a combination of intravenous antibiotics including [[penicillin]], [[vancomycin]] and [[clindamycin]]. If necrotizing fasciitis is suspected, surgical exploration is always necessary, often resulting in aggressive [[debridement]] (removal of infected tissue). As in other maladies characterized by massive wounds or tissue destruction, hyperbaric oxygen treatment can be a valuable adjunctive therapy, but is not widely available. [[Amputation]] of the affected organ(s) may be necessary. Repeat explorations usually need to be done to remove additional necrotic tissue. Typically, this leaves a large open wound which often requires skin grafting. The associated systemic inflammatory response is usually profound, and most patients will require monitoring in an [[intensive care unit]].
===Antimicrobial regimen===
* Necrotizing fasciitis<ref name="pmid24947530">{{cite journal| author=Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL et al.| title=Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. | journal=Clin Infect Dis | year= 2014 | volume= 59 | issue= 2 | pages= 147-59 | pmid=24947530 | doi=10.1093/cid/ciu296 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24947530  }} </ref>
:* 1. '''Mixed infections'''
::* 1.1 '''Adults'''
:::* Preferred regimen (1): [[Piperacillin-tazobactam]] 3.37 g IV q6–8h {{and}} [[Vancomycin]] 30 mg/kg/day IV q12h
:::* Note: In case of severe pencillin allergy, use clindamycin or metronidazole with an aminoglycoside or fluoroquinolone
:::* Preferred regimen (2): [[Imipenem]]-[[cilastatin]] 1 g IV  q6–8h
:::* Preferred regimen (3): [[Meropenem]] 1 g IV q8h
:::* Preferred regimen (4): [[Ertapenem]] 1 g IV q24h
:::* Preferred regimen (5): [[Cefotaxime]] 2 g IV q6h {{and}} [[Metronidazole]] 500 mg IV q6h
:::* Preferred regimen (6): [[Cefotaxime]] 2 g IV q6h {{and}} [[Clindamycin]] 600–900 mg IV q8h
::* 1.2 '''Pediatrics'''
:::* Preferred regimen (1): [[Piperacillin-tazobactam]] 60–75 mg/kg/dose of the [[Piperacillin]] component IV q6h {{and}} [[Vancomycin]] 10–13 mg/kg/dose IV q8h
:::* Note: Severe pencillin allergy, use clindamycin or metronidazole with an aminoglycoside or fluoroquinolone)
:::* Preferred regimen (2): [[Meropenem]] 20 mg/kg/dose IV q8h
:::* Preferred regimen (3): [[Ertapenem]] 15 mg/kg/dose IV q12h for children 3 months-12 years
:::* Preferred regimen (4): [[Cefotaxime]] 50 mg/kg/dose IV q6h {{and}} [[Metronidazole]] 7.5 mg/kg/dose IV q6h
:::* Preferred regimen (5): [[Cefotaxime]] 50 mg/kg/dose IV q6h {{and}} [[Clindamycin]] 10–13 mg/kg/dose IV q8h
:* 2. '''Streptococcus infection'''
::* 2.1 '''Adults'''
:::* Preferred regimen: [[Penicillin]] 2–4 MU IV q4–6h {{and}} [[Clindamycin]] 600–900 mg IV q8h
:::* Note: In case of severe pencillin allergy, use vancomycin, linezolid, quinupristin/dalfopristin, daptomycin
::* 2.2 '''Pediatric'''
:::* Preferred regimen: [[Penicillin]] 0.06–0.1 MU/kg/dose IV q6h {{and}} [[Clindamycin]] 10–13 mg/kg/dose IV q8h
:::* Note: In case of severe pencillin allergy, use vancomycin, linezolid, quinupristin/dalfopristin, daptomycin
:* 3. '''Staphylococcus aureus'''
::* 3.1 '''Adults'''
:::* Preferred regimen (1): [[Nafcillin]] 1–2 g IV q4h
:::* Note: In case of severe pencillin allergy, use vancomycin, linezolid, quinupristin/dalfopristin, daptomycin
:::* Preferred regimen (2): [[Oxacillin]] 1–2 g IV q4h
:::* Preferred regimen (3): [[Cefazolin]] 1 g IV q8h
:::* Preferred regimen (4): [[Vancomycin]] 30 mg/kg/day IV q12h
:::* Preferred regimen (5): [[Clindamycin]] 600–900 mg IV q8h
::* '''Pediatrics'''
:::* Preferred regimen (1): [[Nafcillin]] 50 mg/kg/dose IV q6h
:::* Note: In case of severe pencillin allergy, use vancomycin, linezolid, quinupristin/dalfopristin, daptomycin
:::* Preferred regimen (2): [[Oxacillin]] 50 mg/kg/dose IV q6h
:::* Preferred regimen (3): [[Cefazolin]] 33 mg/kg/dose IV q8h
:::* Preferred regimen (4): [[Vancomycin]] 15 mg/kg/dose IV q6h
:::* Preferred regimen (5): [[Clindamycin]] 10–13 mg/kg/dose IV q8h (bacteriostatic; potential cross-resistance and emergence of resistance in erythromycin-resistant strains; inducible resistance in MRSA)
:* 4. '''Clostridium species'''
::* 4.1 '''Adults'''
:::* Preferred regimen: [[Clindamycin]] 600–900 mg IV q8h {{and}} [[Penicillin]] 2–4 MU IV q4–6h 
::* 4.2 '''Pediatrics'''
:::*Preferred regimen: [[Clindamycin]] 10–13 mg/kg/dose IV q8h {{and}} [[Penicillin]] 0.06-0.1 MU/kg/dose IV q6h
:* 5. '''Aeromonas hydrophila'''
::* 5.1 '''Adults'''
:::* Preferred regimen (1): [[Doxycycline]] 100 mg IV q12h {{and}} [[ciprofloxacin]] 500 mg IV q12h
:::* Preferred regimen (2): [[Doxycycline]] 100 mg IV q12h {{and}} [[ceftriaxone]] 1 to 2 g IV q24h
::* 5.2 '''Pediatrics'''
:::* Not recommended for children but may need to use in life-threatening situations
:* 6. '''Vibrio vulnificus
::* 6.1 '''Adults'''
:::* Preferred regimen (1): [[Doxycycline]] 100 mg IV q12h {{and}} [[ceftriaxone]] 1 g IV qid 
:::* Preferred regimen (2): [[Doxycycline]] 100 mg IV q12h {{and}} [[cefotaxime]] 2 g IV tid
::* 6.2 '''Pediatrics'''
:::* Not recommended for children but may need to use in life-threatening situation


==Prognosis==
==Prognosis==

Revision as of 14:07, 12 August 2015

WikiDoc Resources for Necrotizing fasciitis

Articles

Most recent articles on Necrotizing fasciitis

Most cited articles on Necrotizing fasciitis

Review articles on Necrotizing fasciitis

Articles on Necrotizing fasciitis in N Eng J Med, Lancet, BMJ

Media

Powerpoint slides on Necrotizing fasciitis

Images of Necrotizing fasciitis

Photos of Necrotizing fasciitis

Podcasts & MP3s on Necrotizing fasciitis

Videos on Necrotizing fasciitis

Evidence Based Medicine

Cochrane Collaboration on Necrotizing fasciitis

Bandolier on Necrotizing fasciitis

TRIP on Necrotizing fasciitis

Clinical Trials

Ongoing Trials on Necrotizing fasciitis at Clinical Trials.gov

Trial results on Necrotizing fasciitis

Clinical Trials on Necrotizing fasciitis at Google

Guidelines / Policies / Govt

US National Guidelines Clearinghouse on Necrotizing fasciitis

NICE Guidance on Necrotizing fasciitis

NHS PRODIGY Guidance

FDA on Necrotizing fasciitis

CDC on Necrotizing fasciitis

Books

Books on Necrotizing fasciitis

News

Necrotizing fasciitis in the news

Be alerted to news on Necrotizing fasciitis

News trends on Necrotizing fasciitis

Commentary

Blogs on Necrotizing fasciitis

Definitions

Definitions of Necrotizing fasciitis

Patient Resources / Community

Patient resources on Necrotizing fasciitis

Discussion groups on Necrotizing fasciitis

Patient Handouts on Necrotizing fasciitis

Directions to Hospitals Treating Necrotizing fasciitis

Risk calculators and risk factors for Necrotizing fasciitis

Healthcare Provider Resources

Symptoms of Necrotizing fasciitis

Causes & Risk Factors for Necrotizing fasciitis

Diagnostic studies for Necrotizing fasciitis

Treatment of Necrotizing fasciitis

Continuing Medical Education (CME)

CME Programs on Necrotizing fasciitis

International

Necrotizing fasciitis en Espanol

Necrotizing fasciitis en Francais

Business

Necrotizing fasciitis in the Marketplace

Patents on Necrotizing fasciitis

Experimental / Informatics

List of terms related to Necrotizing fasciitis


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

Necrotizing fasciitis or fasciitis necroticans, commonly known as “flesh-eating bacteria,” is a rare infection of the deeper layers of skin and subcutaneous tissues, easily spreading across the fascial plane within the subcutaneous tissue. Many types of bacteria can cause necrotizing fasciitis (eg. Group A streptococcus, Vibrio vulnificus, Clostridium perfringens, Bacteroides fragilis), of which Group A streptococcus (also known as Streptococcus pyogenes) is the most common cause.

Causes

Symptoms

The infection begins locally, at a site of trauma, which may be severe (such as the result of surgery), minor, or even non-apparent. The affected skin is classically, at first, very painful without any grossly visible change. With progression of the disease, tissue becomes swollen, often within hours. Diarrhea and vomiting are common symptoms as well. Inflammation does not show signs right away if the bacteria is deep within the tissue. If it is not deep, signs of inflammation such as redness and swollen or hot skin show very quickly. Skin color may progress to violet and blisters may form, with subsequent necrosis (death) of the subcutaneous tissues. Patients with necrotizing fasciitis typically have a fever and appear very ill. More severe cases progress within hours, and the mortality rate is high, about 30%. Even with medical assistance, antibiotics take a great deal of time to react to the bacteria, allowing the infection to progress to a more serious state.[1] [2]

Pathophysiology

“Flesh-eating bacteria” is a misnomer, as the bacteria do not actually eat the tissue. They cause the destruction of skin and muscle by releasing toxins (virulence factors). These include streptococcal pyogenic exotoxins and other virulence factors. S. pyogenes produces an exotoxin known as a superantigen. This toxin is capable of activating T-cells non-specifically. This causes the over-production of cytokines that over-stimulate macrophages. The macrophages cause the actual tissue damage by releasing oxygen free radicals that are normally intended to destroy bacteria but are capable of damaging nearly any macromolecule they contact in the body.

Treatment

The diagnosis is confirmed by either blood cultures or aspiration of pus from tissue, but early medical treatment is crucial and often presumptive; thus, antibiotics should be started as soon as this condition is suspected. Initial treatment often includes a combination of intravenous antibiotics including penicillin, vancomycin and clindamycin. If necrotizing fasciitis is suspected, surgical exploration is always necessary, often resulting in aggressive debridement (removal of infected tissue). As in other maladies characterized by massive wounds or tissue destruction, hyperbaric oxygen treatment can be a valuable adjunctive therapy, but is not widely available. Amputation of the affected organ(s) may be necessary. Repeat explorations usually need to be done to remove additional necrotic tissue. Typically, this leaves a large open wound which often requires skin grafting. The associated systemic inflammatory response is usually profound, and most patients will require monitoring in an intensive care unit.

Antimicrobial regimen

  • Necrotizing fasciitis[3]
  • 1. Mixed infections
  • 1.1 Adults
  • 1.2 Pediatrics
  • Preferred regimen (1): Piperacillin-tazobactam 60–75 mg/kg/dose of the Piperacillin component IV q6h AND Vancomycin 10–13 mg/kg/dose IV q8h
  • Note: Severe pencillin allergy, use clindamycin or metronidazole with an aminoglycoside or fluoroquinolone)
  • Preferred regimen (2): Meropenem 20 mg/kg/dose IV q8h
  • Preferred regimen (3): Ertapenem 15 mg/kg/dose IV q12h for children 3 months-12 years
  • Preferred regimen (4): Cefotaxime 50 mg/kg/dose IV q6h AND Metronidazole 7.5 mg/kg/dose IV q6h
  • Preferred regimen (5): Cefotaxime 50 mg/kg/dose IV q6h AND Clindamycin 10–13 mg/kg/dose IV q8h
  • 2. Streptococcus infection
  • 2.1 Adults
  • Preferred regimen: Penicillin 2–4 MU IV q4–6h AND Clindamycin 600–900 mg IV q8h
  • Note: In case of severe pencillin allergy, use vancomycin, linezolid, quinupristin/dalfopristin, daptomycin
  • 2.2 Pediatric
  • Preferred regimen: Penicillin 0.06–0.1 MU/kg/dose IV q6h AND Clindamycin 10–13 mg/kg/dose IV q8h
  • Note: In case of severe pencillin allergy, use vancomycin, linezolid, quinupristin/dalfopristin, daptomycin
  • 3. Staphylococcus aureus
  • 3.1 Adults
  • Preferred regimen (1): Nafcillin 1–2 g IV q4h
  • Note: In case of severe pencillin allergy, use vancomycin, linezolid, quinupristin/dalfopristin, daptomycin
  • Preferred regimen (2): Oxacillin 1–2 g IV q4h
  • Preferred regimen (3): Cefazolin 1 g IV q8h
  • Preferred regimen (4): Vancomycin 30 mg/kg/day IV q12h
  • Preferred regimen (5): Clindamycin 600–900 mg IV q8h
  • Pediatrics
  • Preferred regimen (1): Nafcillin 50 mg/kg/dose IV q6h
  • Note: In case of severe pencillin allergy, use vancomycin, linezolid, quinupristin/dalfopristin, daptomycin
  • Preferred regimen (2): Oxacillin 50 mg/kg/dose IV q6h
  • Preferred regimen (3): Cefazolin 33 mg/kg/dose IV q8h
  • Preferred regimen (4): Vancomycin 15 mg/kg/dose IV q6h
  • Preferred regimen (5): Clindamycin 10–13 mg/kg/dose IV q8h (bacteriostatic; potential cross-resistance and emergence of resistance in erythromycin-resistant strains; inducible resistance in MRSA)
  • 4. Clostridium species
  • 4.1 Adults
  • 4.2 Pediatrics
  • 5. Aeromonas hydrophila
  • 5.1 Adults
  • 5.2 Pediatrics
  • Not recommended for children but may need to use in life-threatening situations
  • 6. Vibrio vulnificus
  • 6.1 Adults
  • 6.2 Pediatrics
  • Not recommended for children but may need to use in life-threatening situation

Prognosis

This disease is one of the fastest-spreading infections known, as it spreads easily across the fascial plane within the subcutaneous tissue. For this reason, it is popularly called the “flesh-eating disease,” and, although rare, it became well-known to the public in the 1990s. Even with today's modern medicine, the prognosis can be bleak, with a mortality rate of approximately 25% and severe disfigurement common in survivors.

Other bacterial strains

In February 2004, a rarer but even more serious form of the disease has been observed in increasing frequency, with several cases found specifically in California. In these cases, the bacterium causing it was a strain of Staphylococcus aureus (i.e. Staphylococcus, not Streptococcus as stated above) which is resistant against methicillin, the antibiotic usually used for treatment (see Methicillin-resistant Staphylococcus aureus for details).

“Super Strep” appeared in Ohio and Texas in 1992 and 1993 and was contracted by approximately 140 people. It took under 12 hours to incapacitate most and caused 3 days of very high fevers. The death rate in 1993 was reported to be 10%, with a majority of the victims having mild to severe brain damage.

See also

References

  1. http://www.webmd.com/a-to-z-guides Necrotizing Fasciitis Flesh Eating Bacteria Overview
  2. Tiu,A et al, ANZ J Surg. 2005 Jan-Feb;75(1-2):32-4
  3. Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL; et al. (2014). "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America". Clin Infect Dis. 59 (2): 147–59. doi:10.1093/cid/ciu296. PMID 24947530.


Template:Diseases of the musculoskeletal system and connective tissue

de:Nekrotisierende Fasziitis nl:Necrotiserende fasciitis


Template:WikiDoc Sources