Necrotising Faciitis

What is Necrotizing Fasciitis? Necrotizing Fasciitis is a horrible disease that affects the skin and soft tissue beneath it. It is a disease of the skin and surrounding tissue. It is contagious, and it is potentially deadly. Necrotizing Fasciitis is a severe complication of group A streptococcal infection. The bacteria have been known to be flesh-eating bacteria. However, researchers show that the bacteria do not actually “eat” the tissue. They cause the destruction of skin and muscle by releasing toxins, which include streptococcal pyrogenic exotoxins. It is a rare bacterial infection that invades the skin and tissues under the skin. Asttrino 1).

The tissues die rapidly, so it is important for doctors to catch it early. This disease increases sensitivity, releases toxins, increases the permeability of the vessels, inhibits blood supply. There are several stages of necrotizing fasciitis. Normally people who get necrotizing fasciitis have a weak immune system, have chronic health problems, have cuts or surgical wounds, had chicken pox recently, or use steroid medicines. There are three types of necrotizing fasciitis. Type A is polymicrobial, type B is, Group A Streptococcal, and type C is gas gangrene. The most common type is type B (Asttrino 1).

Classification of necrotizing fasciitis has evolved over time. Types of necrotizing fasciitis are: Type A, polymicrobial, involves non-group A beta-hemolytic streptococcal infection plus anaerobes and/or facultative anaerobes. It is frequently a postoperative, often abdominal infection with gas-forming organisms: anaerobic Bacteroides, Peptococcus and Clostridium; and facultative anaerobic bacteria such as alpha-hemolytic Streptococcus, Escherichia coli, Enterobacter, Klebsiella or Proteus species. Type B, monomicrobial group A beta-hemolytic streptococcal infection, is seen occasionally in conjunction with Staphylococcus aureus.

It is also known as beta-hemolytic streptococcal gangrene. Infections involving an extremity more commonly are monomicrobial. Type C infections are caused by marine Vibrio species (Gram-negative rods), such as V. vulnificus (the most virulent). The portal of entry for infection is through an abrasion or puncture wound caused by fish, by a cut or by an insect bite. Pathologic Vibrio species synthesize extracellular toxins that mediate soft-tissue damage in necrotizing fasciitis (Todar 4).

Necrotizing fasciitis caused by Aeromonas hydrophila has also been reported. It is an xidase-positive, facultative anaerobic, unipolar, flagellated, Gram-negative bacillus found in fresh or brackish water in many parts of the United States. In one report, 98% of 83 necrotizing fasciitis patients had bacterial growth with an average of 4. 6 isolates per specimen. Mixed aerobic-anaerobic flora was recovered in 68% of specimen (Todar 4). Necrotizing soft-tissue infections are actually a disease with a severe outcome characterized by a fulgurous progression of the inflammation in soft-tissue with a disastrous immediate prognosis and risk of major functional sequelle (secondary consequences).

Only prompt diagnosis and rapid care, including an immediate use of appropriate antibiotherapy and extensive surgical treatment, can improve the outcome. Diagnosis and treatment and adequate management of this disease are very important. The progression of the infection begins with the introduction of bacteria to the site and typically a result of trauma to the skin; however, trauma is not a necessary component. Once the infection is seeded locally, the bacteria spreads through deep facial planes causing widespread tissue damage and infection.

The spread of bacteria can cause ischemia to the area due to thrombosis occurring in blood vessels which can eventually result in gangrene. Necrotizing fasciitis is part of a spectrum of soft-tissue infections first described by Hippocrates in the fifth century B. C. as a complication of “erysipelas. During the civil war which 46% of the 2,642 soldiers afflicted died from its complications? There were reports of a series of 20 patients in 1924 as having “hemolytic streptococcal gangrene,” later called Meleney’s gangrene. It was later named necrotizing fasciitis in 1952.

Recent outbreaks of necrotizing fasciitis have resulted in sensational headlines, such as Killer Bug,” “Flesh-Eating Bacteria” and “Galloping Gangrene Causative Agent The most common and deadly causative agent is streptococcus pathogens, or group A streptococcus. Necrotizing fasciitis is most commonly caused by a strain of A streptococcus, the same bacterium that causes streptococcus pharyngitis or strep throat. Many other bacteria especially those that thrive in oxygen-deprived environments, like inside the human body can also cause necrotizing fasciitis.

The bacteria that can cause the condition exist normally in the environment and are even found in the body, but a person’s immune system is usually able to fight off infection. Group A Strep, for instance, is often in the throat but exists in a small enough number not to cause problems. Even if swallowed, the worst a person may experience is vomiting or diarrhea. Occasionally, however, the bacteria find their way into the bloodstream. That can happen through a cut or abrasion.

But sometimes blunt trauma can lead to infection. If the trauma causes a bit of internal bleeding, even just a black-and-blue mark, the bacteria inside the body sees the blood and decides to attack it. They lodge in the damaged tissue and quickly spread. The bacteria can enter the body through cuts such as surgical wounds. In rare cases the bacteria produces poisons that damage the soft tissue below the skin and cause more dangerous infection that can spread quickly along the tissue of the muscle.

Necrotizing Fasciitis can also get in wounds that come in contact with ocean water, raw saltwater fish, or raw oysters, including injuries from handling sea animals such as crabs. An intestinal surgery site or in tumors or gunshot injuries in the intestines, a muscle strain, or bruise, even if there is no break in the skin. As we know bacteria can be the cause of most cases of necrotizing fasciitis, only rarely does other organism such as fungi cause this disease. Clostridium bacteria could be considered as a cause especially if gas is found in the infected tissue.

In general, the bacteria that cause necrotizing fasciitis utilize similar methods to cause and advance the disease. Most produce toxins that inhibit the immune response, damage or kill tissue, produce tissue hypoxia, specifically and dissolve connective tissue. This disease is not contagious, but the organisms that may lead to its development are contagious, usually by direct contact between people or items that transfer the bacteria. People usually need a break in their skin like a cut or abrasion for the flesh-eating bacteria to cause disease.

Improper wound closure can also cause infection. Reservoir From what I read humans are the primary reservoir among Group A Strep is the causative agent for several diseases and is “among the most common human pathogens (Todar 4). This bacterium also causes scarlet fever, empetigo, cellulitis, and sepsis (Todar 4). ” “The only known natural reservoir of the streptococcus pyogenes is the skin and mucous membranes of humans (Luckman and Horistov 3). ” Transmission is spread by person-to-person contact with mucous of infected persons or through contact with infected wounds or sores n the skin (Luckman and Horistov 3).

Modes of Transmission Most often the bacteria enter the body through an opening in the skin, quite often a very minor opening, even as small as a paper cut, a staple puncture, or a pin prick. It can also enter through weakened skin, like a bruise, blister, or abrasion. It can also happen following a major trauma or surgery, and in some cases there appears to be no identifiable point of entry. Transmission via respiratory droplets, hand contact with nasal discharge and skin contact with impetigo lesions are the most important modes of transmission.

The pathogen can be found in its carrier state in the anus, vagina, skin and pharynx and contact with these surfaces can spread the infection. The bacterium can be spread to cattle and then back to humans through raw milk as well as through contaminated food sources. Necrotizing fasciitis can usually occur because of contamination of skin lesions or wounds with the infectious agent. Symptoms Necrotizing fasciitis is difficult to diagnose in the early stage because symptoms, such as tenderness, swelling, redness, and pain at the affected site, are similar to other, less threatening skin diseases such as cellulitis and erysipelas .

Symptoms of necrotizing fasciitis may develop quickly, as soon as 24 hours after a minor skin injury. The rapid onset of symptoms is one of the most important clues that you may need immediate medical care. Another common symptom of this disease is pain that greater than sudden would expect. (Center for Disease Control and Prevention 5). The most common early symptom of necrotizing fasciitis includes; sudden severe pain in the affected area, fever, nausea, vomiting, fatigue, and other flu-like symptoms. There could be redness, heat, swelling, and fluid-filled blisters in the skin on the affected areas.

If the infection is deep in the tissue, these signs of the inflammation may not develop right away. Later symptoms may include signs of shock (including confusion, fainting, or dizziness). These symptoms are often are worse when you get up from sitting or lying down. These symptoms are usually caused by a drop in blood pressure. Scaling peeling or discolored skin over the affected are, which are signs of tissue death, or gangrene. Without treatment, death is likely and can occur rapidly (Center for Disease Control and Prevention 5).

The course of the disease was the same to whatever part of the body it spread. In 1871, Joseph Jones, who studied more than 2,600 cases of the disease during the Civil War described the disease, which was common among soldiers due to the conditions at the front. In 1883 Jean-Alfred Fournier described a condition he coined Fournier’s Gangrene; necrotizing fasciitis when it attacks the genital area. He noted that diabetic patients might be at a higher risk of developing this disease. Dr. B. Wilson was the first to use the term “necrotizing fasciitis” in 1952. This term is still generally considered to be the most accurate and concise description of the disease (NNFF Fact Sheet 8).

Incubation Period As I stated earlier necrotizing fasciitis can quickly develop, as soon as 24 hours after a minor skin injury. The rapid onset of symptoms is one of the most important clues that you may need medical care immediately. Common entry point for the bacteria is through a wound such as a burn, cut, scrape, or insect bite. Within 24 hours after the bacteria have entered the wound, swelling, heat, redness, and tenderness can spread quickly from the original wound site. Within 24 to 48 hours after spreading, the redness may darken to purple and then to blue.

Blisters containing yellow fluid may also form. Within 4 to 5 days after initial infection, gangrene develops. Within 7 to 10 days, dead skin separates from healthy skin as the infection continues to spread into other tissue. Certain strains of bacteria such as streptococci can be more aggressive, shortening the entire process to 2 to 4 days. Treatment Early medical treatment is very important, and antibiotics should be started as soon as this condition is suspected. Initial treatment often includes a combination of intravenous antibiotics including piperacillin/tazobactam, vancomycin, and clindamycin.

Cultures are taken to determine appropriate antibiotic coverage, and antibiotics may be changed when culture results are obtained. Diagnostics test vary from each facility but the most common imaging includes CT scan, ultrasound, and MRI. With the CT scan, deep facial thickening, enhancement, fluid and gas in the soft tissue planes in and around superficial fascia are indicators of necrotizing fasciitis. Laboratory test include: a complete blood count, electrolytes, and erythrocytes sedimentation rate, and a c-reactive protein. These laboratory tests are the same test used to determine soft tissue infections.

Typically a person diagnosed with necrotizing fasciitis must be treated in the hospital with antibiotic IV therapy and surgery to remove the infected tissue. This will be determined by their systems, medical history, and exposure history. If a person has a serious case of necrotizing fasciitis, then as I said before they probably would need surgery to remove the infected tissue. The length of antibiotic therapy generally ranges from four to six weeks are recommended. Intravenous immunoglobulin is an additional treatment option, which helps to neutralize the exotoxins created by the bacteria (Reese R. E. 9).

When necrotizing fasciitis is believed to be the cause of infection, patients, as soon as, possible, should be operated on for a “search and destroy” mission of vigorous and extensive debridement. Infected tissue should be removed until there is no sign of evidence of further infection. Early surgery is the most important factor in increasing survival rate. Skin grafts are often used to repair the damage to the skin after debridement but occasionally amputation is the only sure way to remove the disease. There is no vaccine to prevent a group A streptococcal infections.

Antibiotics are recommended for close contacts of cases of necrotizing fasciitis caused by group A streptococcus. Since this severe form of streptococcal infection can progress so rapidly, the best approach is to get medical attention as soon as symptoms occur. Remember, an important clue to this disease is very severe pain at the site of a wound. To reduce the chance of the tissue under the skin getting infected, always take good care of minor cuts. If you have a small cut or wound, wash it well in warm soapy water, and keep it clean and dry with a bandage.

If the person diagnosed with this disease doesn’t seek medical attention immediately the patient could possibly lead to limb loss or death (Reese R. E. 9). Incidence of disease in Illinois Soft-tissue infections that cause necrosis are by no means new. Cases of necrotizing fasciitis, which was a feared military disease, were documented as far back as the 18th century. During the 19th century, civilian outbreaks of this feared infection were seen and it was referred to as the “malignant ulcer. ” In 1883, Fournier described a necrotizing soft-tissue infection of the male perineum, which was termed “Fournier’s gangrene.

Then in 1952, Wilson used the term “necrotizing fasciitis” to describe the same infection in other parts of the body. The infection received more attention from the press when Muppets creator Jim Henson died of a necrotizing fasciitis infection in 1990. The British tabloids came out with the term “flesh-eating disease” after a cluster of cases in Gloucestershire in 1994. Throughout the 19th and 20th centuries, cases of the disease occurred only sporadically and usually remained restricted to military hospitals during wartime, although some civilian population outbreaks have also occurred.

The Centers for Disease Control and Prevention (CDC) reports that, worldwide, rates of necrotizing fasciitis increased from the mid-1980s to early 1990s (Center for Disease Control and Prevention 5). Increases in the rate and severity of necrotizing fasciitis are associated with increases in the prevalence of toxin-producing strains of S. pyogenes. Group A Streptococcus is a bacterium found in the human throat or on the skin. There are approximately 350 cases of necrotizing fasciitis reported in Illinois each year. Incidence of disease in United States

Approximately 200 to 1500 cases of necrotizing fasciitis are described in the United States yearly. Significant mortality and morbidity is associated with necrotizing fasciitis. The term necrotizing fasciitis refers to 2 distinct types of infection based on the characteristics of the offending pathogen. The general public remains safe from this disease. Although reports in the news have increased our awareness of this condition, the number of persons with the disease has not changed over the last several years.

The Centers for Disease Control and Prevention (CDC) reported that in the U. S. here are on average about 9,000 to 11,500 people with group A streptococcus bacterial infections, one cause of necrotizing fasciitis, each year. Of them, only 6 to 7 percent are invasive, meaning the infection has spread to healthy tissue. For example, in 2010, the CDC reported that 74 people had necrotizing fasciitis, which was less than 6 percent of all strep infections reported that year. The number of cases reported for necrotizing fasciitis in adults is 0. 40 cases per 100,000 people/year while the incidence in children is report ably higher at 0. 08 cases per 100,000 people/year.

Necrotizing Fasciitis is considered a rare condition; however, the mortality rate remains high. Evidence has estimated the mortality rate to be at 20-40%. According to the Center for Disease Control there is an estimated 9,000-11,500 cases of necrotizing fasciitis occur each year in the United States, with resultant 1,000-1,800 deaths annually. Incidence of disease World-Wide I tried finding numbers that showed incidence of necrotizing disease world-wide but I was unable to find it. However, in doing my research I found a couple of notable cases from 1994-2013.

I found that were two cases in Canada and one in France. I’m sure there many more cases that have not been reported. I have found that in 2011 guitarist for the thrash-metal band Slayer contracted the disease, allegedly after being bitten by a spider. In 2011, Peter Watts, a Canadian science fiction author, contracted the disease and he was told that he was only hours away from being dead. Watts claimed that the disease spread rapidly across his leg. Then in 2013 Ryan Scott contracted the disease. Risk Factors There are other risk factors that could lead to necrotizing fasciitis.

These factors include, diabetes, peripheral vascular disease (which is when plaque builds up in the arteries), intravenous drug abuse, obesity, HIV, varicella infection, smoking, cancer, chronic illness and any other disease state that compromise the immune system. (Cain S. 2). In one case of necrotizing fasciitis, diabetes and peripheral vascular disease were found in 75%of the patients studied. Researchers have attempted to identify laboratory markers that may help with early diagnosis. Age older than 50 years, hemoglobin <11g/dL, serum creatine71. mg/dL, white blood cell count >180g/dL, 40,000 cells/mm, temperature > 36 degrees Celsius, heart rate > 110 beats/minute, glucose >180g/dL and serum sodium 135mmo1/L, and elevated c-reactive protein have been found to correlate with development of the disease. The use of nonsteriodal anti-inflammatory drugs (NSAIDS) has been associated with development of necrotizing fasciitis. Personal Thoughts/Conclusion Necrotizing fasciitis remains one of the most devastating soft tissue infections today. In my opinion, scientist, and researchers need a clear approach to this disease.

Early surgical debridement decreases mortality and the aim is to diagnose the condition early, ideally within 24 hours of admission. I have never heard of this disease before I started doing research for this paper. It really made me scared of having any types of cuts, scrapes, or burns. Despite antibiotic therapy and surgical intervention, the mortality and morbidity of necrotizing fasciitis remain high. Only early identification of the necrotizing process can improve the outcome of this life-threatening disease. Necrotizing fasciitis should be suspected in every skin infection with fever, signs of systemic toxicity and severe pain.

An adequate use of radiologic procedures should not delay surgical debridement. Maybe in the future scientist and researchers can come up with a vaccine for group. I know that it is very important to keep all wounds clean and watch close for any signs of infection. If anything changes you should seek medical help immediately. Always maintain good hygiene, frequent hand washing is very important to prevent infection and the spread of infection. I work in a hospital so I know how important is to protect yourself and wear protective clothing.

It was really interesting to me how group A is so important from necrotizing fasciitis to strep throat to being completely benign. It reinforced to me the importance of thoroughly cleaning cuts and scrapes. People can carry the virus without symptoms or any complications until the skin is broken it can then enter the body and cause necrosis and gangrene of the skin. It makes me think of all the times I had a cut or scrape and ignored it and to think it could have possibly, although not likely, turned into this disease had I had bacteria that cause it on my skin.

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