Necrotizing Fasciitis

Today we saw a case of necrotizing skin and soft tissue infection (not quite necrotizing fascitis) presenting in the groin area of a diabetic patient.

Patients who inject drugs or who have diabetes, obesity, or immunosuppression are at higher risk of these infections. Pain is an early presenting feature with later development of haemodynamic instability. Early changes resemble cellulitis; however, late changes include tense edema outside the area of compromised skin, pain disproportionate to appearance, skin discoloration, blisters/bullae and necrosis, and crepitus and/or subcutaneous gas.





Necrotizing fascitis (review) can be characterized based on the pathogens involved:

• Type I: Mixed aerobic and anaerobic infection. Often in diabetics. Includes Fornier's gangrene where the infection involves the fascial planes in the perineal area and in males can involve the scrotum and penis.
  
• Type II: Group A Streptococcus and MRSA
• Other organisms (below)
  

Treatment:

• Highly skilled surgical debridement and source control
• Appropriate antibiotics (in GAS penicillin G and clindamycin for Type I broad spectrum anaerobic and gram negative coverage -- i.e. piperacillin-tazobactam)
• IVIG -the case-control study on the use of IVIG in Invasive Group A Streptococcal disease is available here.
• Treatment of close contacts discussed here.