Necrotizing fasciitis (NF) is a life-threatening form of infection involving rapidly spreading inflammation and extensive necrosis of the skin, subcutaneous tissue, and superficial fascia with or without overlying cellulitis. NF is a rare soft tissue infection and the case of NF in the world range from 0.30 to 15 cases per 100,000 people. The case should get early diagnosed and appropriately treated as delayed diagnosis and treatment for NF may contribute to extremely high mortality.
Diabetes mellitus (DM) has been reported to be a common underlying disease in NF patients for 44.5–72.3% in various cases. Patients with DM were confronted with a higher risk of amputation and were more susceptible to polymicrobial and monomicrobial infection. Diabetic patients exhibit impaired cutaneous wound healing and increased susceptibility to infection, which may affect the course of soft-tissue infections. The mnemonic STAFF reminds us what to evaluate for Subcutaneous Thickening Air and Facial Fluid. This means we have to evaluate the fascial and subcutaneous tissue thickening, abnormal fluid accumulation in the deep fascia layer, and in advanced cases, subcutaneous air.
Early diagnosis of NF is mandatory. However, it is not always possible as the signs are indistinguishable from those found in non-necrotizing cellulitis and abscesses. Any delay could cause fatal, given its association with more extensive surgery, higher rates of amputation, and higher mortality rates. One of the laboratory-based scoring systems is the LRINEC score used to distinguish NF from other soft tissue infections such as cellulitis or abscess. LRINEC score ≥6 predicts prognoses in terms of higher mortality, rate of amputation, complications, and mechanical ventilation requirement. The gold standard in diagnosing NF is exploratory surgery where it is common to find “dishwater” or foul-smelling discharge, necrosis or lack of bleeding, and loss of the normal resistance of the fascia to finger dissection. Intra-operative biopsy with Gram stain can be used in some cases but is not necessary as findings from the exploratory surgery are often definitive.
Early antibiotic therapy must be established against a wide range of microorganisms. Current recommendations from the IDSA for empiric antibiotic treatment include broad-spectrum antibiotics while waiting for the tissue and blood samples to be cultured. If cultures demonstrate sensitive Streptococcus pyogenes, there is a general agreement that a combination of penicillin G and clindamycin (high doses) is the preferred option. Current recommendations from the IDSA for empiric antibiotic treatment include broad-spectrum antibiotics such as vancomycin or linezolid (given its effect on exotoxin production) plus piperacillin-tazobactam or a carbapenem as well as clindamycin, given it suppresses streptococcal toxin and cytokine production.
Emergency surgical debridement of the affected tissues is the primary management modality for NF. Surgical debridement, necrosectomy, and fasciotomy are the main aspects of surgical treatment. Surgical intervention is life-saving and must be performed as early as possible since a delay in treatment beyond 12 h in fulminant forms of NF can prove fatal. Surgical debridement should be repeated during the next 24 h or later, depending on the clinical course of the necrotizing infection and vital functions.
This study reported two cases of NF in a 56-year-old female and a 38-year-old male who demonstrated typical signs and symptoms of NF. Both presented to the hospital with skin necrosis in the lower extremity, sepsis shock, and multiorgan failure. Based on the clinical presentation, physical examination, and additional examination, a diagnosis of NF was made. The LRINEC score was used to distinguish NF from other soft tissue infections. Both patients were treated with empirical antibiotics, surgical debridement, and planned to be amputated, but the patients were hemodynamically unstable and passed away before the amputation proceeded.
It is imperative to perform an aggressive exploration and excision of all the necrotic and devitalized areas, with margins of 5–10 mm. Although some studies did not find a significant correlation between early surgical debridement and clinical outcomes, it is globally accepted that any delay in diagnosis and surgery is associated with a clear increase in mortality. Thus, the good control of diabetic patients for the prevention of NF is very important.
It can be concluded that NF is a rare disease that is often found in people with diabetes mellitus. Early diagnosis of NF can reduce the risk of death where the diagnosis of NF is supported by the LRIEC score which can be distinguished from other infections. The key management of NF includes the use of empirical antibiotics, debridement, amputation, and maintaining glycemic control to determine the patient’s prognosis.
Author: Hermina Novida, dr., Sp.PD.
