Necrotizing Fasciitis - Term Paper Example

Running Head: NECROTIZING FASCIITIS NECROTIZING FASCIITIS of the Under the guidance of APA format Word Count Necrotizing Fasciitis Necrotizing fasciitis is inflammatory infection of the deep fascia which is not only rapidly spreading and progressive, but also is associated with subcutaneous tissue necrosis (Edlich, 2010). The organisms causing this condition are typically gas-forming organisms, leading to accumulation of air in the subcutaneous tissue. The rate of spread of the disease is directly proportional to subcutaneous layer thickness.

This condition is also known as acute dermal gangrene, hemolytic streptococcal gangrene, Meleney ulcer, hospital gangrene, necrotizing cellulitis and suppurative fascitis. When the condition affects the perineal and the scrotal region, it is known as Fournier gangrene. The infection is difficult to recognise in the early stages of illness. It progresses very rapidly and is associated with high mortality and morbidity (Majeski and John, 2003). Hence it is very important to recognise and aggressively manage the condition.

Pathophysiology The condition is characterised by necrosis of the fascia and the subcutaneous tissue. The most common cause of necrotizing fasciitis is group-A beta hemolytic streptococcus. Some researchers are of the opinion that the condition is polymicrobial. The bacteria can be anerobic, aerobic or even mixed. Some of the other commonly reported organisms are staphylococci, peptostreptococcus, bacteroides, pseudomonas klebsiella, e.coli and clostridium. Multibacterial symbiotic relationship and synergy are the factors which influence rapid growth of the bacteria (Rogers and Perkins, 2006).

Underlying morbidities contribute to the development of the disease, some of which are venous insufficiency, diabetes mellitus and atherosclerotic vascular disease. The condition usually affects the extremities, especially the legs. Trauma can precede the condition (Edlich, 2010). Clinical presentation The clinical course varies from one patient to another. The patient presents with pain that is out of proportion of clinical findings. In majority of the cases, the condition develops from an already existing infection.

In the early stages, there is usually erythema. later, the patient may develop fever, severe pain and chills. Skin changes include ulceration of the skin, formation of bullae, necrotic eschars, formation of gas in the tissues and draining of fluid from the site. Many patients develop sepsis and shock, much before there is clinical worsening of the skin lesions (Edlich, 2010). Diagnosis Diagnosis is mainly established based on clinical symptomatology and history of exposure (Taviloglu, and Yanar, 2007).

Blood culture is essential to identify the organism and decide on antibiotic therapy. X-ray may reveal gas in the tissue. CT scan, MR imaging and doppler studies may show gas in the tissues and help in evaluating the extent of the disease. Other tests which may be useful are total leucocyte counts, white blood cell counts, blood urea nitrogen and sodium. The latter two are expected to be decreased in necrotizing fasciitis (Edlich, 2010). Management The patient must be initiated with broad spectrum intravenous antibiotics and fluid resuscitation with Ringer's lactate solution and normal saline must be done.

The patient must be taken up for surgical debridement of the necrotized tissue as soon as possible. The debridement must be aggressive. It is important to establish a hemostasis in a meticulous manner. Though initially, broad spectrum antibiotics are to be initiated, antibiotic therapy must be based on culture reports. The drug of choice in streptococcal infection is penicillin G. An alternative to this drug is clindamycin. Third generation cephalosporins or metronidazole are useful for anearobic coverage.

One standard coverage is gentamycin along with chloramphenicol or clindamycin. If enterococci are suspected through gram stain, ampicillin may be added (Maynor, 2011). Patients with necrotizing fasciitis frequently develop sepsis and septic shock and may need supplemental oxygen, endotracheal intubation and continuous cardiac monitoring. Hyperbaric oxygen therapy may be initiated for enhanced wound healing. The therapy also leads to increased functioning of the polymorphonuclear lymphocytes, has bacteriocidal effect, improves defence mechanism of the tissue against infection and prevents spread of the necrosis.

Aggressive administration of hyperbaric oxygen after surgical debridement improves prognosis (Edlich, 2010). Prevention Prevention of this condition is possible by providing effective treatment of any skin condition. Any measure to prevent infection prevents necrotizing fasciitis. In diabetes patients, hand washing is important. It is also important to check extremities for wounds and cuts. Patients who are immunouppressed and have chronic diseases like chronic liver conditions must be very careful not to get any infections.

Vibrio vulnificus is a deadly organism that causes necrotizing fasciitis in those with liver disease and hence must avoid exposure to warm sea water and sea food. The condition is not contagious, but physicians and other health care providers must make very attempt to prevent spread of the pathogens that underlie the cause of necrotizing fasciitis (Edlich, 2010). Prognosis Untreated necrotizing fasciitis has poor prognosis. Even when appropriate treatment is administered in a timely manner, the mortality rate can be as high as 25 percent.

The condition can be associated with morbidity like scar formation, limb amputation, etc (Edlich, 2010). References Edlich, R.F. (2010). Necrotizing Fasciitis and Purpura Fulminans. Medscape Reference. Retrieved on 26th August, 2011 from http://emedicine.medscape.com/article/1348047-overview Maynor, M.E. (2011). Emergent Management of Necrotizing Fasciitis. Medscape Reference. Retrieved on 26th August, 2011 from http://emedicine.medscape.com/article/784690-overview Majeski, J.A., John, J.F. Jr. (2003). Necrotizing soft tissue infections: a guide to early diagnosis and initial therapy.

South Med J., 96(9), 900-5. Rogers, R.L., Perkins, J. (2006). Skin and soft tissue infections. Prim Care., 33(3), 697-710. Taviloglu, K., and Yanar, H. (2007). Necrotizing fasciitis: strategies for diagnosis and management. World J Emerg Surg., 2, 19.