Elsevier

Burns

Volume 31, Issue 3, May 2005, Pages 269-273
Burns

The evolving characteristics and care of necrotizing soft-tissue infections

https://doi.org/10.1016/j.burns.2004.11.008Get rights and content

Abstract

Background:

Necrotizing soft-tissue infections such as necrotizing fasciitis and Fournier's gangrene are a source of high morbidity and mortality. These difficult cases are increasingly being referred to burn centers for specialized wound and critical care issues. In this study, we examine our institution's recent experience with a large series of necrotizing soft-tissue infections.

Study design:

A retrospective chart review was performed of 65 consecutive patients over a 5-year period with necrotizing soft-tissue infections that required radical surgical debridement.

Results:

Overall survival was 83%, with an average length of stay of 32.4 ± 3.32 days for survivors and for the entire group of 29.5 ± 3 days. Time from onset of symptoms to initial presentation to our institution averaged 6.9 ± 1.19 days. Patients averaged 2.9 ± 0.22 surgical procedures, and 46% of patients required skin grafting with an average graft area of 1554 ± 248 cm2. Of the survivors, only 54% were able to return home, with 46% needing further hospitalization or transfer to an inpatient rehabilitation facility.

Conclusions:

There were frequent delays in diagnosis and referrals to and from within our institution, and progress can be made in educating the medical community to identify these patients. Advancements in wound care and critical care have made inroads into the treatment of patients with necrotizing soft-tissue infections. However, these infections continue to be a source of high morbidity and mortality and significant healthcare resource consumption. These challenging patients are best served with prompt diagnosis, immediate radical surgical debridement, and aggressive critical care management. Referral to a major burn center may help provide optimal surgical intervention, wound care, and critical care management.

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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