The evolving characteristics and care of necrotizing soft-tissue infections
Introduction
The Confederate Army surgeon Joseph Jones first described necrotizing fasciitis in 1871 [2]. Other terms historically used include necrotizing erysipelas, hemolytic streptococcal gangrene, nonclostridial crepitant cellulitis, nonclostridial gas gangrene, synergistic necrotizing cellulites, bacterial synergistic gangrene, necrotizing cellulitis, and gangrenous erysipelas. When it involves the perineum and scrotum, it is referred to as Fournier's gangrene, first described by Alfred Jean Fournier in 1843 [3]. The Centers for Disease control and Prevention (CDC) estimates 10,000–15,000 cases of invasive group A streptococcus annually, with 5–10% of those being necrotizing fasciitis [4]. Necrotizing fasciitis is much more prevalent in adults but has been reported in children [5]. Early manifestations include erythema with spreading edema, crepitus, and vesicles. Late manifestations may include cutaneous anesthesia, dermal gangrene, coagulopathy, and cellulitis refractory to antibiotics. Other criteria have been proposed to aid in the clinical diagnosis, including admission WBC greater than 15.4 × 109/L and serum sodium less than 135 mmol/L [6]. Streptococcal toxic shock syndrome with group A streptococcus may occur in patients with necrotizing fasciitis and may carry an associated mortality of 30–60% in the first 72–96 h [7]. A streptococcal toxic shock-like syndrome with necrotizing fasciitis has also been described with group B streptococcus [8]. Some investigators have theorized an immunogenetic basis for different outcomes of invasive streptococcal infections [9].
Necrotizing soft-tissue infections such as necrotizing fasciitis and Fournier's gangrene are associated with a significant incidence of patient morbidity and mortality. Traditionally, these patients have been treated by surgeons in the community, but these difficult cases are increasingly being referred to burn centers for specialized wound and critical care issues [1]. In this study, we report our institution's recent experience with a large series of necrotizing soft-tissue infections cared for in our burn center using approaches that have been developed for the care of burn patients.
Section snippets
Study design
The study protocol was approved by the Institutional Review Board. A retrospective chart review was performed of our soft-tissue database for all patients admitted to the burn center from 1998 to 2003. We identified 65 consecutive patients admitted to our center from 1998 to 2003 during this 5-year period with rapidly spreading necrotizing soft-tissue infections that required radical surgical debridement. We did not include those patients with abscesses requiring wide area incision and
Patient demographics
We identified a total of 65 patients during the period examined, of which 36 (55%) were male and 29 (45%) female. Mean age was 51 ± 1.83 years. Fifty-six patients identified themselves with a particular racial group: 41 (73%) were Caucasian, 9 (16%) African–American, and 6 (11%) Hispanic. Of these, 42 (64%) carried the diagnosis of necrotizing fasciitis, 9 (14%) had a diagnosis of Fournier's gangrene, and 14 (22%) were diagnosed as necrotizing soft-tissue infections. The number seen at our
Discussion
Since it was first described by the Confederate Army surgeon Joseph Jones in 1871 [2], necrotizing fasciitis has variously been termed necrotizing erysipelas, hemolytic streptococcal gangrene, nonclostridial crepitant cellulitis, nonclostridial gas gangrene, synergistic necrotizing cellulites, bacterial synergistic gangrene, necrotizing cellulitis, and gangrenous erysipelas. The umbrella term of necrotizing soft-tissue infections also includes Fournier's gangrene, which involves the perineum
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