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.

From Emerging Infectious Diseases Multidrug-Resistant Acinetobacter Extremity Infections in Soldiers Posted 08/11/2005 Kepler A. Davis; Kimberly A. Moran; C. Kenneth McAllister; Paula J. Gray Abstract War wound infection and osteomyelitis caused by multidrug-resistant (MDR) Acinetobacter species have been prevalent during the 2003–2005 military operations in Iraq. Twenty-three soldiers wounded in Iraq and subsequently admitted to our facility from March 2003 to May 2004 had wound cultures positive for Acinetobacter calcoaceticus-baumannii complex. Eighteen had osteomyelitis, 2 burn infection, and 3 deep wound infection. Primary therapy for these infections was directed antimicrobial agents for an average of 6 weeks. All soldiers initially improved, regardless of the specific type of therapy. Patients were followed up to 23 months after completing therapy, and none had recurrent infection with Acinetobacter species. Despite the drug resistance that infecting organisms demonstrated in this series, a regimen of carefully selected extended antimicrobial-drug therapy appears effective for osteomyelitis caused by MDR Acinetobacter spp.

Research Focus Musculoskeletal Manifestations of HIV Infection from The AIDS Reader ® Posted 03/25/2003 Ann-Marie Plate, MD, Brian A. Boyle, MD Introduction Musculoskeletal disorders are relatively common during the course of HIV infection, although they are more prevalent in the late stages of disease. These disorders cause a significant amount of morbidity, and occasionally mortality, in HIV-infected patients, and some chronic musculoskeletal disorders may cause a significant decrease in the patient's quality of life. This column will focus on the most common musculoskeletal disorders HIV clinicians are likely to encounter and will provide a review of the most recent literature on each disorder. The spectrum of musculoskeletal disorders in HIV-infected patients ranges from myopathies and arthralgias to rheumatic disorders such as Reiter syndrome and psoriatic arthritis. Infection and septic arthritis are also common entities. The prevalence of inflammatory musculoskeletal manifestations remains uncertain; however, studies indicate that the prevalence of these disorders may be influenced by the risk factors responsible for HIV infection: patients who use injection drugs or have hemophilia are more susceptible to septic arthritis and osteomyelitis, whereas Reiter syndrome is more common among homosexual HIV-infected patients. Contents - Introduction Myopathies Inflammatory Arthropathies Infections Neoplastic Condition References

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.

E-Medicine 2005 Necrotizing Fasciitis Michael Maynor, MD, Clinical Assistant Professor, Department of Hyperbaric/Emergency Medicine, Louisiana State University School of Medicine For more than a century, many authors have described soft tissue infections. Their occurrence has been on the rise because of an increase in immunocompromised patients with diabetes mellitus, cancer, alcoholism, vascular insufficiencies, organ transplants, HIV, or neutropenia. Necrotizing fasciitis can occur after trauma or around foreign bodies in surgical wounds, or it can be idiopathic, as in scrotal or penile necrotizing fasciitis. Necrotizing fasciitis has also been referred to as hemolytic streptococcal gangrene, Meleney ulcer, acute dermal gangrene, hospital gangrene, suppurative fascitis, and synergistic necrotizing cellulitis. Fournier gangrene is a form of necrotizing fasciitis that is localized to the scrotum and perineal area. Necrotizing fasciitis is a progressive, rapidly spreading, inflammatory infection located in the deep fascia, with secondary necrosis of the subcutaneous tissues. Because of the presence of gas-forming organisms, subcutaneous air is classically described in necrotizing fasciitis. This may be seen only on radiographs or not at all. The speed of spread is directly proportional to the thickness of the subcutaneous layer. Necrotizing fasciitis moves along the deep fascial plane. These infections can be difficult to recognize in their early stages, but they rapidly progress. They require aggressive treatment to combat the associated high morbidity and mortality. The causative bacteria may be aerobic, anaerobic, or mixed flora, and the expected clinical course varies from patient to patient.

Necrotizing Fasciitis From Apophysomyces elegans Infection Following Trauma from Infections in Medicine Posted 08/08/2002 Lorraine M. Dowdy, DO, Jose G. Castro, MD, Carlos Duchesne, MD, Timothy Cleary, MD Abstract Following a motorcycle accident, a 29-year-old man had fixation of a femoral fracture with an intramedullary rod. After he was discharged, the wound deteriorated rapidly and did not improve despite multiple debridements and antibiotic therapy. Apophysomyces elegans grew on cultures, and treatment with amphotericin B was followed by healing and plastic reconstruction.

Necrotizing Fasciitis of the Upper Extremity Resulting From a Water Moccasin Bite from Southern Medical Journal Posted 12/30/2002 Michael F. Angel, MD, Feng Zhang, MD, PhD, Matthew Jones, BS, James Henderson, MD, Stanley W. Chapman, MD Abstract and Introduction Abstract Aeromonas hydrophila infection has been described as the cause of necrotizing fasciitis in patients with suppressed immune systems, burns, or trauma in an aquatic setting. We report a case in which severe necrotizing fasciitis involving hand, arm, chest, and lateral side of trunk, along with toxic shock, developed after the patient was bitten by a venomous snake. Mixed aerobic and anaerobic bacteria, including A hydrophila, were isolated from the wound culture. The patient was treated with antivenom, a diuretic regimen, broad spectrum antibiotics, and 18 separate surgical procedures. After the application of skin grafts, the wound completely healed. This case illustrates that a venomous snakebite may result in infection with A hydrophila and can cause severe necrotizing fasciitis. Early and aggressive surgical intervention should be implemented as soon as the necrotizing fasciitis is diagnosed.

Lisa Banks Presentation to New York College of Podiatric Medicine Surgical Club

Family Practice Notebook Necrotizing Soft Tissue Infection Necrotizing Fasciitis Fournier's Gangrene Definitions Necrotizing Fasciitis Deep subcutaneous infection Fournier's Gangrene Massive infection and swelling of scrotum and penis Extends into perineum or abdominal wall, and legs Pathophysiology Infection spreads between fascia and SQ tissue Fibrous bands prevent infectious spread Present in head and distal extremities Lacking in trunk and proximal extremities Risk factors Age over 50 years Malnutrition Hypoalbuminemia Alcoholism Immunocompromised state Cancer Corticosteroid use Poor vascular supply Peripheral Vascular Disease Diabetes Mellitus Skin trauma Burn Injury Trauma Intravenous Drug Abuse Recent surgery Miscellaneous risk factors Obesity Break in Gastrointestinal or Genitourinary mucosa Colon Cancer Diverticula Hemorrhoids or Anal Fissure Urethral tear Symptoms and Signs progression (in order of occurrence) Pain and Unexplained fever Swelling Brawny edema and tenderness Dark red induration Bullae filled with blue or purple fluid Skin friable, bluish, maroon, or black Extensive thrombosis of dermal blood vessels Extension to deep fascia leads to brown-gray appearance Rapid spread along fascial planes, veins and lymph Toxicity, shock, and multi-organ failure Signs: Distribution Extremities (53%) Perineum or buttocks (20%) Trunk (18%) Head and neck (9%) References Bosshardt (1996) Arch Surg 131:846-52 Etiologies Group A Streptococcus (Streptococcus Pyogenes) Begins deep at non-penetrating minor trauma Contusion seeded by transient bacteremia Gas production only if mixed infection Severe toxicity, renal Impairment may precede shock Myositis in 20-40% cases Creatine Phosphokinase (CPK) is markedly elevated Mortality: 20-50% despite Penicillin Mixed aerobic and Anaerobic Bacteria Break in Gastrointestinal or Genitourinary mucosa Fournier's Gangrene Comorbid conditions associated with mixed infection Diabetes Mellitus Peripheral Vascular Disease Staphylococcus aureus Clostridium perfringens Hyperbaric Oxygen treatment may help in Gas Gangrene Diagnosis: Findings Suggestive of Necrotizing Fasciitis Fever (Temperature over 100.4 F) Soft tissue erythema, edema and severe pain Vessicles, Bullae or Necrosis Crepitation is only variably present Labs Complete Blood Count White Blood Cell count over 16,300 per mm3 Hemoglobin less than 10 mg/dl Platelet Count <150,000 per mm3 Serum Electrolytes Serum Sodium under 135 meq/L Serum Calcium under 8.4 mg/dl Coagulation Studies Prothrombin Time (PT) prolonged Partial Thromboplastin Time (aPTT) prolonged Arterial Blood Gas Arterial pH <7.35 Differential Diagnosis See Skin Infection (Pyoderma) Cellulitis Erysipelas Necrotizing Insect Bite (e.g. Brown Recluse Spider) Management: Surgical exploration to fascia and muscle Early exploration within 12 hours is critical Observe for Necrotizing fasciitis Myositis Gangrene Technique Visualize deep structures Remove necrotic materials Reduce compartment pressure Send material for Gram Stain and Culture Management: Empiric Combination Regimen (3 drug therapy) Anaerobe coverage Clindamycin 600-800mg IV q8h or Flagyl 750mg q6h Gram Positive coverage Ampicillin or Penicillin Gram Negative coverage Gentamicin 1.0-1.5 mg/kg q8h (after 2mg/kg load) Single agent regimen Ceftriaxone 2 g IV every 12 hours Ampicillin-Sulbactam (Unasyn) 2-3g IV q6h Ticarcillin-Clavulanate (Timentin) Piperacillin-Tazobactam (Zosyn) Combination for Penicillin allergic patient Vancomycin and Gentamicin or Aztreonam Alernative combination protocol Ceftazidime (Fortaz) and Clindamycin or Metronidazole Other measures Maximize nutritional status References Elliott (2000) Am J Surg 179:361-6 Headley (2003) Am Fam Physician 68(2):323-8 Wall (2000) J Am Coll Surg 191:227-31

Necrotizing Soft Tissue Infections: A Guide to Early Diagnosis and Initial Therapy Posted 10/15/2003 South Med J 96(9):900-905, 2003. James A. Majeski, MD, PHD, Joseph F. John Jr., MD
Abstract and Introduction Abstract Necrotizing skin and soft tissue infections are caused by many different bacteria, are frequently polymicrobial, and may have a deceptively innocent early clinical presentation. Clostridial and nonclostridial necrotizing infections are frequently similar in their early presentation. The initial presentation of these infections can be insidious, which results in delay in diagnosis and the start of therapy. The clinician must use sound medical principles of clinical history and meticulous examination in each patient, combined with constant suspicion, to establish a timely diagnosis. This group of infectious diseases is associated with frequent morbidity and significant mortality rates, which increase with any delay in the diagnosis and the initiation of medical and surgical therapy. Also associated with these necrotizing infections is an excessive index of litigation. This review is intended as a guide for the clinician in making an early diagnosis of any necrotizing skin and soft tissue infection and initiating effective medical and surgical therapy.

Author: Ahmad Bo-Eisa, MD, Chairman, Program Director, Department of Orthopedic Surgery, King Fahad Hospital, Saudi Arabia Coauthor(s): Sadek Al-Omran, MD, Consultant Of Pediatrics and Pediatric Nephrologist, Departments of Pediatrics and Pediatric Nephrology, Maternity and Children's Hospital-Al-Ahsa, Saudi Arabia; Abbas Al-Abbad, MD, Pediatric Nephrology Fellowship Program Director, Section of Pediatric Nephrology, Department of Pediatrics, Pediatrics, King Faisal Specialist Hospital and Research Center Riyadh, Saudi Arabia Osteomyelitis is a difficult-to-treat infection of bone and bone marrow. It is progressive and results in inflammatory destruction of the bone, bone necrosis, and new bone formation. Bacterial osteomyelitis causes substantial morbidity worldwide, despite continued progress toward understanding its pathophysiology and optimal management. The approach to osteomyelitis depends upon the route by which bacteria gained access to bone, bacterial virulence, local and systemic host immune factors, and patient age. While imaging studies and nonspecific blood tests may suggest the diagnosis, an invasive technique is generally required to identify the causative pathogens. Antibacterial regimen selection has been largely guided by knowledge of the relative activities and pharmacokinetics of individual drugs, supported by data from animal models. Definitive therapy often requires a combined medical and surgical approach. Newer microvascular and distraction osteogenesis techniques and the use of laser Doppler allow more complete surgical resection of infected material while maintaining function. Despite recent advances, aggressive medical and surgical therapy fails in many patients with osteomyelitis. More accurate diagnostic methods, better ways to assess and monitor the effectiveness of therapy, and novel approaches to eradicate sequestered bacteria are needed.