Wheeless' Textbook of Orthopaedics - necrotizing fascitits is any necrotizing soft tissue infection spreading along fascial planes, with or without overlying cellulitis; - also called Meleney ulcer, NF is severe manifestation of lymphangitis that progresses in a frightening manner within a few hours; - tissue necrosis develops rapidly behind advancing wall of inflammation that limits penetration by antibiotics; - desquamation followed by gangrene may be relentless; - clinical signs of pain, hyperyrexia, and chills are severe; - skin lesions are incised and drained or aspirated to obtain fluid for culture; - initial findings are localized pain and minimal swelling, often w/ no visible trauma or discoloration of the skin; - dermal induration and erythema eventually become evident; - eventually the patient has limited range of motion, chills, fever; - dx is confirmed when a probed can be passed laterally along fascial cleft in a open wound; - blistering of the epidermis is a late finding;

Medical Microbiology Section 5. Introduction to Infectious Diseases 100. Bone, Joint, and Necrotizing Soft Tissue Infections Jon T. Mader Jason Calhoun General Concepts Sections include:- Introduction Necrotizing Soft Tissue Infections Crepitant Anaerobic Cellulitis Necrotizing Fasciitis Nonclostridial Myonecrosis Clostridial Myonecrosis Fungal Necrotizing Cellulitis Joint Infections Gonococcal Arthritis Nongonococcal Arthritis Diagnosis of Bacterial Arthritis Granulomatous Arthritis Bone Infections Hematogenous Osteomyelitis Contiguous-Focus Osteomyelitis Chronic Osteomyelitis Diagnosis of Bacterial Osteomyelitis Skeletal Tuberculosis Fungal Osteomyelitis References

Full text article Journal of Clinical Microbiology Sept 1995 p2382-2387

Poster. Weber et al, Aurora Health Care and Hyperbaric and Wound Care Associates, Milwaukee

Editorial Paediatrics and Child Health May/June 2001, Volume 6, Number 5 Flesh-eating disease: A note on necrotizing fasciitis H Dele Davies MD MSc, Child Health Research Unit, Alberta Children’s Hospital and Departments of Pediatrics, Microbiology and Infectious Diseases and Community Health Sciences, University of Calgary, Calgary, Alberta There has been much media attention in the past few years to the condition dubbed ‘flesh-eating disease’, which refers, primarily, to a form of invasive group A beta hemolytic streptococcal (GABHS) infection that leads to fascia and muscle necrosis. In 1999, the Canadian Paediatric Society issued a statement on the state of knowledge and management of children, and close contacts of persons with all-invasive GABHS disease (1). The present note is intended to deal specifically with necrotizing fasciitis (NF) by providing an update on the limited current state of knowledge, diagnosis and management. Surveillance to establish actual national rates and epidemiology of NF through the Canadian Paediatric Society is proposed.

Flesh-eating disease: A note on necrotizing fasciitis H Dele Davies MD MSc, Child Health Research Unit, Alberta Children’s Hospital and Departments of Pediatrics, Microbiology and Infectious Diseases and Community Health Sciences, University of Calgary, Calgary, Alberta Paediatrics and Child Health May/June 2001, Volume 6, Number 5 There has been much media attention in the past few years to the condition dubbed ‘flesh-eating disease’, which refers, primarily, to a form of invasive group A beta hemolytic streptococcal (GABHS) infection that leads to fascia and muscle necrosis. In 1999, the Canadian Paediatric Society issued a statement on the state of knowledge and management of children, and close contacts of persons with all-invasive GABHS disease (1). The present note is intended to deal specifically with necrotizing fasciitis (NF) by providing an update on the limited current state of knowledge, diagnosis and management. Surveillance to establish actual national rates and epidemiology of NF through the Canadian Paediatric Society is proposed

Necrotizing soft-tissue infections encompass a wide variety of clinical syndromes resulting from introduction of various pathogens into injured or devitalized tissue. The extent of microbial involvement in such tissue may range from simple contamination, which results in self-limited bacterial proliferation with few, if any, clinical symptoms to overt and progressive local tissue necrosis, which, if untreated, may lead to septicemia and death. Early differentiation among these infections is not always possible, as there are overlapping classification criteria.
This chapter will provide an overview of necrotizing soft-tissue infections in the upper extremity focusing on gas gangrene, or clostridial myonecrosis, and necrotizing fasciitis to facilitate early diagnosis and optimal management of these lethal diseases.
Authors - Waldo E. Floyd III, M.D. Betsy N. Perry, MD Mercer University School of Medicine Emory University School of Medicine Macon, GA 31201

Currents: Fall 2002, Volume 3, Number 4 Hyperbaric oxygen therapy enhances tissue healing Zlatko Anguelov (in collaboration with Eric Greensmith, M.D.) History: Compressed air has been used as a therapeutic tool since medieval times with variable success and without any knowledge of what may cause its beneficial effect on disease. In the mid-1950s hyperbaric oxygen (HBO) came into use in the U.S. and the Netherlands, especially for conducting surgical operations under pressure. Clinicians noted that patients were less cyanotic after anesthesia in a hyperbaric chamber and since, nitrous oxide became a powerful anesthetic when administered under increased pressure. HBO use declined in the early 1970s because of lack of serious research on the mechanisms of action and appropriate indications. In this country a revival of the field occurred in the late 1970s when the Undersea Medical Society became involved in clinical hyperbarics, and a textbook on HBO therapy was published. University of Iowa

Hyperbaric Oxygen Therapy In Necrotizing Fasciitis: Panacea, Useful Adjunct, or Nostrum? J. Jeffrey Brown, MD "...hyperbaric oxygen has drawn a dramatic line between those who do not have a hyperbaric chamber and are skeptic, and those who do have one and believe." TK Hunt(1) The overall mortality rate of patients with necrotizing fasciitis approaches 40%.(2) Hollabough et al.(3) have reported their experiences with the use of adjunctive hyperbaric oxygen therapy (HBO) and reduced the mortality rates in patients with Fournier's gangrene from 42% (5/12) in those who did not receive HBO to 7% (1/14) in those treated with HBO. While it might seem that the surgical community would embrace a treatment modality that promised such a dramatic benefit, the fact is that skepticism seems to be the prevailing sentiment in most major surgical texts and review articles. Namely, that until the results of prospective randomized trials are reported the use of HBO in necrotizing soft tissue infections must be considered only potentially useful. Unfortunately, Hollabaugh's study does not meet these rigid criteria.

American College of Hyperbaric Medicine Preferred Protocols The term “Meleney’s ulcer” describes a distinct pathological entity also called progressive bacterial synergistic gangrene. When Meleney described the condition, he had no access to sophisticated culture techniques necessary to isolate fastidious anaerobic bacteria that cause the condition. However, he observed that these wounds, described exclusively in post-operative abdominal incisions, included a mixture of organisms. From his culture results, he deduced that the margin of the ulcer was advanced by the synergistic effect of two organisms growing in a hypoxic environment. Those organisms were a micro-aerophilic, non-hemolytic Streptococcus, and a hemolytic Staphylococcus aureus. Also, the wound could be colonized by other organisms, such as Amoeba and Proteus. Subsequent literature has suggested that cutaneous Amebiasis may be the correct diagnosis of Meleney’s synergistic gangrene (Davison, 1988), or Entamoeba histolytica. The abdominal wall ulcerations originally described by Meleney expanded slowly, spreading by 1 to 2 cm per day. Histology revealed microvascular thrombosis in the dermis followed by liquefaction. The overlying epidermis became devascularized and necrotic. The macroscopic picture is of a full skin thickness ulcer with a rolled necrotic margin, bounded by a zone of painful erythema, denoting the subepidermal spread of the infection.

BMJ 2005;330:830-833 (9 April), doi:10.1136/bmj.330.7495.830 Clinical review Necrotising fasciitis Saiidy Hasham, research registrar in plastic surgery1, Paolo Matteucci, specialist registrar in plastic surgery1, Paul R W Stanley, consultant plastic surgeon1, Nick B Hart, consultant plastic surgeon1 1 Department of Plastic Reconstructive and Hand Surgery, Castle Hill Hospital, Cottingham, East Yorkshire HU16 5JQ Correspondence to: S Hasham saiidyhasham@hotmail.com Necrotising fasciitis is a rare but life threatening condition that requires immediate action, but uncertainties still hamper prompt diagnosis and treatment

Necrotizing Fasciitis from Wounds Posted 11/25/2002 Jennifer T. Trent, MD, Robert S. Kirsner, MD Abstract Necrotizing fasciitis (NF) is a rare, life-threatening infection resulting in necrosis of the skin, subcutaneous tissue, and fascia. Mortality rates have been noted as high as 73 percent. Certain conditions can predispose patients to NF, such as diabetes mellitus, immunosuppressive medications, and AIDS. Patients usually complain of excessive pain as well as constitutional symptoms. Cutaneous findings include diffuse redness and edema progressing to necrosis and hemorrhagic bullae. Because of this rapid progression, it is important to diagnose and treat NF quickly to decrease mortality. Treatment includes broad-spectrum antibiotic coverage, nutritional supplements, hemodynamic support, wound care, and prompt surgical debridement.

E-Medicine 2005 Necrotizing Fasciitis Author: Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School Coauthor(s): Rajendra Kapila, MD, Associate Professor, Department of Medicine, UMDNJ, New Jersey Medical School Necrotizing fasciitis (NF) is an insidiously advancing soft tissue infection characterized by widespread fascial necrosis. A number of bacteria in isolation or as a polymicrobial infection can cause NF. The organisms most closely linked to NF are group A beta-hemolytic streptococci, though these bacteria may cause only a minority of the cases. Most cases are caused by other bacteria or different streptococcal serotypes. NF was first described in 1848. In 1920, Meleney identified 20 patients in China in whom hemolytic streptococcus was the sole organism. Wilson coined the term necrotizing fasciitis in 1952 and found no specific pathologic bacteria related to the disease. A few distinct NF syndromes should be recognized. The 3 most important are type I, or polymicrobial; type II, or group A streptococcal; and type III gas gangrene, or clostridial myonecrosis. A variant of NF type I is saltwater NF, in which an apparently minor skin wound is contaminated with saltwater containing a Vibrio species. NF may occur as a complication of a variety of surgical procedures, including cardiac catheterization (Federman, 2004). Familiarity with NF may facilitate earlier diagnosis and initiation of appropriate therapy.

Surgery in Africa Article Necrotizing Fasciitis While cellulitis and pyomyositis can be treated with reasonable success and low mortality rates, this is not the case for necrotizing soft tissue infections (NSTI). Here mortality rates range from 30-70% and have not decreased significantly despite modern therapy. (40) Reports from Singapore (41), India (42) and Oman (43) give a sense of the non-Western experience. NSTIs can be divided into two major categories: 1. Necrotizing fasciitis (NF) and 2. Gas gangrene. (44) Necrotizing fasciitis is further divided on the basis of clinical picture and microbiology into types I and II. (more)

Necrotizing Fasciitis from Wounds Posted 11/25/2002 Jennifer T. Trent, MD, Robert S. Kirsner, MD Abstract Necrotizing fasciitis (NF) is a rare, life-threatening infection resulting in necrosis of the skin, subcutaneous tissue, and fascia. Mortality rates have been noted as high as 73 percent. Certain conditions can predispose patients to NF, such as diabetes mellitus, immunosuppressive medications, and AIDS. Patients usually complain of excessive pain as well as constitutional symptoms. Cutaneous findings include diffuse redness and edema progressing to necrosis and hemorrhagic bullae. Because of this rapid progression, it is important to diagnose and treat NF quickly to decrease mortality. Treatment includes broad-spectrum antibiotic coverage, nutritional supplements, hemodynamic support, wound care, and prompt surgical debridement.