Necrotizing Fasciitis (Flesh Eating Disease): Difference between revisions

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'''Original Editors '''- Sara&nbsp;Halliday &amp; Ashley Walker&nbsp;[[Pathophysiology of Complex Patient Problems|from Bellarmine University's&nbsp;Pathophysiology of Complex Patient Problems project.]]  
'''Original Editor '''- [[User:Sara Halliday|Sara Halliday]] & [[User:Ashley Walker|Ashley Walker]] [[Pathophysiology of Complex Patient Problems|from Bellarmine University's&nbsp;Pathophysiology of Complex Patient Problems project.]]  


'''Lead Editors'''  &nbsp;   
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} &nbsp;   
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== <br>Definition/Description  ==
== Introduction ==


Necrotizing Fasciitis (NF) is a bacterial infection that consists of rapidly progressing necrosis of fascia and subcutaneous fat that eventually results in necrosis of the overlying skin and muscle.<ref name="Shupak">Shupak A, Shoshani O, Goldenberg I, Barzilai A, Moskuna R, Bursztein S. Necrotizing fasciitis: An indication for hyperbaric oxygenation therapy? Surg. 1995 November; 118 (5): 873-78.</ref>&nbsp; The most rapidly progressing type of necrotizing fasciitis is Group A, streptococcal infection, also known as flesh-eating bacteria. Necrotizing fasciits can also involve microbial infections with a singular bacteria (monomicrobial) or a combination of bacteria (polymicrobial). &nbsp;Necrotizing Fasciitis can occur due to several reasons (traumatic and nontraumatic) and in a variety of patient populations. Some conditions have been found to predispose patients to the risk of infection. &nbsp;Most of these conditions cause immunosuppression and include DM, malignancy, drug abuser, and chronic renal disease.<ref name="Hsiao">Hsiao C-T, Weng H-H, Yuan Y-D, Chen C-T, Chen I-C. Predictors of mortality in patients with necrotizing fasciitis. American Journal of Emergency Medicine. 2008 April 19; 26: 170–75</ref>
Necrotizing fasciitis is a potentially life-threatening bacterial infection that consists of rapidly progressing necrosis of [[fascia]] and subcutaneous tissues.<ref name="Shupak">Shupak A, Oren S, Goldenberg I, Barzilai A, Moskuna R, Bursztein S. [https://s3.amazonaws.com/academia.edu.documents/42000785/Necrotizing_fasciitis_An_indication_for_20160203-5553-y7ezh7.pdf?AWSAccessKeyId=AKIAIWOWYYGZ2Y53UL3A&Expires=1551897434&Signature=7EsXPS1tVhqlIlfq9l5MPU7srdA%3D&response-content-disposition=inline%3 Necrotizing fasciitis: an indication for hyperbaric oxygenation therapy?] Surgery 1995;118(5):873-8.</ref><ref name=":0">Bechar J, Sepehripour S, Hardwicke J, Filobbos G. [https://publishing.rcseng.ac.uk/doi/pdfplus/10.1308/rcsann.2017.0053 Laboratory risk indicator for necrotising fasciitis (LRINEC) score for the assessment of early necrotising fasciitis: a systematic review of the literature.] The Annals of The Royal College of Surgeons of England 2017 May 27;99(5):341-6.</ref><ref name=":1">Schroder̈ A, Gerin A, Firth GB, Hoffmann KS, Grieve A, von Sochaczewski CO. A systematic review of necrotising fasciitis in children from its first description in 1930 to 2018. BMC infectious diseases. 2019 Dec;19(1):317.</ref>  At first the tissues overlying are not affected, a possible cause of late diagnosis and surgical intervention.<ref name=":2">Wallace HA, Perera TB. [https://www.ncbi.nlm.nih.gov/books/NBK430756/ Necrotizing fasciitis.] InStatPearls [Internet] 2021 Jul 27. StatPearls Publishing.Available:https://www.ncbi.nlm.nih.gov/books/NBK430756/ (accessed 2.2.2023)</ref> The most rapidly progressing type of necrotizing fasciitis is Group A streptococcal infection, also known as flesh-eating bacteria. Necrotizing fasciits can also involve microbial infections with a singular bacteria (monomicrobial) or a combination of bacteria (polymicrobial). &nbsp;


The progression of the infection begins with the introduction of bacteria to the site and typically a result of trauma to the skin, however, trauma is not a necessary component. Once the infection is seeded locally, the bacteria spreads through deep fascial planes causing widespread tissue damage and infection. The spread of bacteria can cause ischemia to the area due to thrombosis occurring in blood vessels which can eventually result in gangrene.&nbsp;<ref name="Puvanendran">Puvanendran R, Huey J, Pasupathy S. Necrotizing fasciitis. Can Fam Physician 2009 October; 55 (10): 981-7</ref><br>  
Necrotizing fasciitis can occur due to several reasons (traumatic and non-traumatic) and in a variety of patient populations. Some conditions have been found to predispose patients to the risk of infection. Most of these conditions cause immunosuppression and include [[diabetes]], malignancy, drug abuse, and chronic renal disease.<ref name="Hsiao">Hsiao C-T, Weng H-H, Yuan Y-D, Chen C-T, Chen I-C. [https://www.sciencedirect.com/science/article/pii/S073567570700304X Predictors of mortality in patients with necrotizing fasciitis.] American Journal of Emergency Medicine 2008; 26: 170–75.</ref>  


== Prevalence  ==
The progression of the infection begins with the introduction of bacteria to the site and typically a result of trauma to the skin, however, trauma is not a necessary component. Once the infection is seeded locally, the bacteria spreads through deep fascial planes causing widespread tissue damage and infection. The spread of bacteria can cause ischemia to the area due to thrombosis occurring in blood vessels which can eventually result in gangrene.<ref name="Puvanendran">Puvanendran R, Huey JC, Pasupathy S. [http://www.cfp.ca/content/cfp/55/10/981.full.pdf Necrotizing fasciitis.] Canadian family physician 2009;55(10):981-7.</ref>
 
{{#ev:youtube|DYktrffWlHY}}
The number of cases reported for necrotizing fasciitis in adults is 0.40 cases per 100,000 people/year while the incidence in children is reportably higher at 0.08 cases per 100,000 people/year.<ref name="File">File Jr TM, Tan JS, DiPersio JR. Group A streptococcal necrotizing fasciitis. Diagnosing and treating the “flesh-eating bacteria syndrome”. Cleve Clin J Med 1998; 65(5):241-9.</ref>&nbsp; Necrotizing Fasciitis is considered a rare condition, however, the mortality rate remains high. Evidence has estimated the mortality rate to be at 20-40%.<ref name="Jallali">Jallali N. et al. Hyperbaric oxygen as adjuvant therapy in the management of necrotizing fasciitis. The American Journal of Surgery 2005; 198:462–466</ref>&nbsp; According to the Center for Disease Control there is an estimated&nbsp;9,000-11,500 cases of necrotizing fasciitis occur each year in the United States, with a resultant 1,000-1,800 deaths annually. <br>
== Epidemiology ==
Necrotizing fasciitis in some regions of the world is as common as one in every 100,000 people, compared to about 0.4 in every 100,000 people per year in the United States.<ref name=":2" />&nbsp; Necrotizing fasciitis is considered a rare condition, however, the mortality rate remains high. Evidence has estimated the mortality rate to be at 20-40%, increasing with the delay in initial diagnosis.<ref name=":0" /><ref name="Jallali">Jallali N, Withey S, Butler PE. [https://www.sciencedirect.com/science/article/pii/S0002961005000942 Hyperbaric oxygen as adjuvant therapy in the management of necrotizing fasciitis.] The American Journal of Surgery 2005;189(4):462-6.</ref>  


== Etiology ==
Necrotizing fasciitis is caused as a direct sequela of bacterial infection that enters the body through a break in the skin (in roughly 80% of all cases).The most common bacteria associated with necrotiing fasciitis after minor trauma is '''Group A''' '''Streptococcus'''. When necrotizing fasciitis develops after surgery, it is likely a mix of bacteria. Upon entering the body, it rapidly reproduces and emits toxins/enzymes that damage fascia and soft tissue.&nbsp;The bacteria will shield itself from the body's immune system which speeds up the proliferation along tissue planes.<ref name="NF">The National Necrotizing Fasciitis Foundation. What is NF? Available from: http://www.nnff.com/what-is-nf.html (accessed 1 April 2012).</ref><br>[[File:NecFasc earlySx.jpeg|thumb|Early presentation|alt=|333x333px]]
== Characteristics/Clinical Presentation  ==
== Characteristics/Clinical Presentation  ==
[[File:Necrotizing fasciitis left leg.JPEG|thumb|Erythmia and necrosis of the left leg]]
The patient may initially present with:
* increasing pain,
* tenderness to palpation to the local area and periwound,
* purpura, erythema, swelling.<ref>Kiat HJ, Natalie YH, Fatimah L. Necrotizing fasciitis: How reliable are the cutaneous signs?. Journal of emergencies, trauma, and shock. 2017 Oct;10(4):205.</ref>
* , crepitus, purulent drainage and usually a history of some type of trauma.<ref name=":0" />
* Complaints of flu-like symptoms (nausea, vomiting, fever, malaise etc.) are also common.
* Patients can present with symptoms of sepsis that include fever, tachycardia, altered mental state and diabetic ketoacidosis that typically accompanies trauma to the skin.<ref name="Puvanendran" />
* Progressive symptoms include subcutaneous bleeding, gangrene and necrosis, which can lead to systemic inflammatory response syndrome (SIRS), septic shock and even death.<ref name=":0" />
Clinical presentation of necrotizing fasciitis varies and can typically be mistaken for other pathologies, such as [[cellulitis]] and superficial skin infections. Awareness of the presentation of necrotizing fasciitis clinically is critical due to the rapid progression of the disease. Evidence has shown that accurate diagnosis is difficult with only 15% to 34% of patients with necrotizing fasciitis having the appropriate admittion diagnosis.<ref name="Puvanendran" /> Misdiagnosis often occurs due to the vague symptoms that may be present (i.e. erythema, fever, pain), or the lack thereof.&nbsp;


The patient may initially present with increasing pain, tenderness to palpation to the local area and periwound, erythema, swelling, crepitus, purulent drainage and usually a history of some type of trauma. Complaints of flu-like symptoms (nausea, vomiting, fever, malaise etc.) are also common. Patients can present with symptoms of sepsis that include fever, tachycardia, altered mental state and diabetic ketoacidosis that typically accompanies trauma to the skin.<ref name="Puvanendran">Puvanendran R, Huey J, Pasupathy S. Necrotizing fasciitis. Can Fam Physician 2009 October; 55 (10): 981-7.</ref>
== Types ==
 
Necrotizing fasciitis can be classified into 2 types:  
Clinical presentation of necrotizing fasciitis varies and can typically be mistaken for other pathologies, such as cellulitis and superficial skin infections. Awareness of the presentation of necrotizing fasciitis clinically is critical due to the rapid progression of the disease. Evidence has shown that accurate diagnosis is difficult with only 15% to 34% of patients with necrotizing fasciitis having the appropriate admitting diagnosis.<ref name="Puvanendran">Puvanendran R, Huey J, Pasupathy S. Necrotizing fasciitis. Can Fam Physician 2009 October; 55 (10): 981-7.</ref> Misdiagnosis often occurs due to the vague symptoms that may be present (i.e erythema, fever, pain) or the lack thereof.&nbsp;<br>
# Type 1: is defined as necrotizing fasciitis caused by both aerobic and anaerobic bacteria,
 
# Tpe 2 :is caused by group A betahaemolytic Streptococcus and Staphylococcus aureus.<ref name=":0" />
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; Initial Appearance<br>
 
[[Image:NecFasc.jpg|thumb|center|393x372px|Courtesy of University of Louisville Hospital]]
 
== Associated Co-morbidities  ==
 
Studies have shown that there are certain factors that can predispose patients to contract an infection. A recent study found that 70.3% of patients diagnosed with NF had diabetes mellitus.&nbsp;<ref name="Wong">Wong CH, Chang HC, Pasupathy S, Khin LW, Tan JL, Low CO. Necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality. J Bone Joint Surgery Am 2003;85-A(8):1454-60.</ref>
 
<br>Risk factors for necrotizing fasciitis:<ref name="Puvanendran">Puvanendran R, Huey J, Pasupathy S. Necrotizing fasciitis. Can Fam Physician 2009 October; 55 (10): 981-7.</ref><br>• Diabetes<br>• Chronic disease<br>• Immunosuppresion<br>• Intravenous drug use<br>• Peripheral vascular disease<br>• Renal failure<br>• Underlying malignancy<br><br>
 
Typically necrotizing fasciitis occurs following some type of trauma to the skin, however, non-traumatic causes have also been reported. The causative factor may be as trivial as a scratch or insect bite.<ref name="Puvanendran">Puvanendran R, Huey J, Pasupathy S. Necrotizing fasciitis. Can Fam Physician 2009 October; 55 (10): 981-7.</ref>&nbsp; There have also been reported cases of necrotizing fasciitis occurring following acupuncture treatment and joint aspirations.&nbsp;<br>
 
== Medications  ==
 
Necrotizing fasciitis is treated with antibiotics usually administered intravenously, however, until surgical debridement has occurred tissue hypoxia limits the efficacy of intravenous antibiotics.<ref name="Puvanendran">Puvanendran R, Huey J, Pasupathy S. Necrotizing fasciitis. Can Fam Physician 2009 October; 55 (10): 981-7.</ref>&nbsp;&nbsp;A high dose antibiotic regimen is critical in the treament of the infection in order to limit the amount of tissue damage that may occur. &nbsp;Also, the inflammation that is associated with the infection causes intense pain and discomfort that is unrelieved by analgesic medications.<ref name="Bisno">Bisno AL, Cockerill FR, Bermudez CT. The Initial Outpatient-Physician Encounter in Group A Streptococcal Necrotizing Fasciitis. Clinical Infectious Diseases. 2000 Aug; 31:607–8.</ref>&nbsp;&nbsp;These two clinical findings present in necrotizing fasciitis assist to differentiate it from cellulitis.<br>
 
== Diagnostic Tests/Lab Tests/Lab Values  ==
 
Diagnostic tests vary from each facility but the most common imaging includes computed tomography (CT), ultrasound (US), and magnetic resonance imaging (MRI).&nbsp; On the CT, deep fascial thickening, enhancement, fluid and gas in the soft tissue planes in and around superficial fascia are indicators of NF.&nbsp; For a positive finding using US, thickening and distortion of deep fascia, and fluid collections along deep fascia are denoted.&nbsp; MRI indicators include deep fascial thickening, deep fascial fluid collections, and hyperintense T2W signal within muscles.&nbsp; MRI becomes controversial because some authors state that fascial enhancement is an indicator, while other authors state that lack of fascial enhancement is a positive finding.&nbsp; <br>
 
Laboratory tests utilized for necrotizing fasciitis are the same as ones used for severe soft tissue infections which include:<br>• Complete blood count<br>• Electrolytes<br>• Erythrocyte sedimentation rate<br>• C-reactive protein<br>
 
A numerical score sheet, called the laboratory risk indicator for necrotizing fasciitis (LRINEC), was devised from lab parameters as a possible indicating tool for detection of necrotizing fasciitis. Score of ≥6 has a positive predictive value of 92% and a negative predictive value of 96%. <ref name="Wong">Wong C, Wang Y. The diagnosis of necrotizing fasciitis. Current Opinion In Infectious Diseases 2005; 18: 101-106.</ref>
 
[[Image:LRINEC.png]]<br>
 
In addition, blood and pus cultures could be examined and surgical exploration may be indicated to confirm the diagnosis of NF.<ref name="Fazeli">Fazeli M, Keramati M. Necrotizing fascitis: an epidemiologic study of 102 cases. Indian Journal Of Surgery 2007;69:136-139.</ref>
 
== Etiology/Causes  ==
 
Necrotizing Fasciitis is caused from bacteria.&nbsp; The most common bacteria associated with NF after minor trauma is Group A Strep.&nbsp; When NF&nbsp;is developed after surgery, it is likely a mix of bacteria.&nbsp; Once entering the body, it rapidly reproduces and emits toxins/enzymes that damage fascia and soft tissue.&nbsp; The bacteria will shield itself from the body's immune system which speeds up the proliferation along tissue planes.<ref name="NF">The National Necrotizing Fasciitis Foundation. What is NF? www.nnff.org/nnff_what.htm (accessed 1 Apr 2012).</ref><br>
 
Any condition that disrupts the skin's characteristics can result in infection.&nbsp; Some of these conditions include skin trauma, infected needle (i.e. IV drug abusers), psoriasis, bed sores, chicken pox, and bug bites.<ref name="Fazeli">Fazeli M, Keramati M. Necrotizing fascitis: an epidemiologic study of 102 cases. Indian Journal Of Surgery 2007;69:136-139.</ref>
 
== Systemic Involvement  ==
 
There are multiple systems that are compromised because of necrotizing fasciitis.&nbsp; If untreated, NF can lead to multi-system organ failure.&nbsp; Specific systems involved include:&nbsp; integumentary, cardiovascular, pulmonary, gastrointestinal, genitourinary, and immunologic.&nbsp; The integumentary system is involved because of the tissue decay spawned from the infection.&nbsp; The cardiovascular system is implicated from the hypotension that occurs as a sign of NF.&nbsp; In addition, heart failure can result from advancement of the condition.&nbsp; The pulmonary system can be compromised from eventual respiratory failure that can occur in later stages.&nbsp; Common signs of NF is nausea and vomiting, which affects the gastrointestinal system.&nbsp; Renal failure can also develop which connects the genitourinary system involvement.&nbsp; With fever being a common sign, the immunological system becomes affected as well.<ref name="Goodman">Goodman C, Snyder T. Differential Diagnosis for Physical Therapists Screening for Referral. 4th ed. St. Louis: Saunders Elsevier, 2007.</ref><br>
 
== Medical Management (current best evidence)  ==
 
An aggressive form of treatment for Necrotizing Fasciitis is necessary due to the rapid progression of the infection once contracted. The typical management includes intravenous broad-spectrum antibiotics and early surgical debridement in order to remove the necrotic tissue.<ref name="Puvanendran">Puvanendran R, Huey J, Pasupathy S. Necrotizing fasciitis. Can Fam Physician 2009 October; 55 (10): 981-7.</ref> &nbsp;Early recognition is vital for successful treatment. If detected during the early stages, surgical debridement can be minor and more localized to the infected epidermis, subcutaneous and adipose tissue.&nbsp;
 
In the later stages of necrotizing fasciitis, systemic shock can occur resulting in failure of many organ systems. Respiratory failure, heart failure, low blood pressure and renal failure may occur in this stage. Limb amputation is necessary once the infection begins to spread to other organ systems.
 
Hyperbaric oxygen therapy has been proposed as an adjunct therapy for the treatment of necrotizing fasciitis. However, evidence has found conflicting results on the efficacy of this treatment. &nbsp;In a recent systemic review, the main advantages of hyperbaric oxygen therapy in addition to standard regimes are tissue preservation and decreased mortality.<ref name="Jallali">Jallali N et al. Hyperbaric oxygen as adjuvant therapy in the management of necrotizing fasciitis. The American Journal of Surgery 2005; 198:462–466.</ref> &nbsp;However, in another study, Golger et al found that the addition of hyperbairc oxygen therapy showed no improvement in mortality rate.<ref name="Golger">Golger A, Ching S, Goldsmith CH, Pennie RA, Bain JR. Mortality in patients with necrotizing fasciitis. Plast Reconstr Surg 2007; 119(6): 1803-7.</ref> &nbsp;A need exists for higher levels of research to be conducted for more conclusive results. <br>
 
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; Following initial Surgical Debridement
 
[[Image:Before picture.JPG|thumb|center|294x221px|Courtesy of University of Louisville Hospital]]
 
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; After Surgical Debridement&nbsp;<br>
 
[[Image:After.JPG|thumb|center|276x207px|Courtesy of University of Louisville Hospital]]
 
== Physical Therapy Management (current best evidence)  ==
 
Physical therapy management will primarily occur after surgical debridement.&nbsp; The PT may utilize negative pressure wound therapy (NPWT) to enhance blood perfusion and promote granulation tissue, especially in the depth of the wound.&nbsp; In addition, NPWT can remove exudate, which decreases the inhibitory mediators and matrix metalloproteinases that interfere with the healing process.<ref>Baharestani M. Negative pressure wound therapy in the adjunctive management of necrotizing fascitis: examining clinical outcomes. Ostomy Wound Management 2008;54:44-50.</ref>&nbsp; At times, pulse lavage with suction could be utilized for debridement.&nbsp; In addition, non-contact, low frequency ultrasound can be used for debridement facilitation.&nbsp; After the wound has healed, scar management is important in preventing adhesions.&nbsp; Range of motion, mobility, and exercise is crucial in the prevention of contractures.<ref name="Broers">Broers, M. Necrotizing Fasciitis at University Hospital [online]. E-mail to Sara Halliday ([email protected]) 2012 Apr 1 [cited 2012 Apr 4].</ref>
 
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp; Negative Pressure Wound Therapy
 
[[Image:Negative Pressure.JPG|thumb|center|295x221px|Courtesy of University of Louisville Hospital]]<br>  


== Alternative/Holistic Management (current best evidence)  ==
== Systemic Involvement ==


The treatment of necrotizing fasciitis strongly emphasizes immediate medical management.&nbsp; Alternative management does not appear to be an option as it lacks evidence.<br><br>  
There are multiple systems that are compromised as the result of necrotizing fasciitis.&nbsp;If untreated, necrotizing fasciitis can lead to multi-system organ failure. Specific systems involved include:<ref name="Goodman">Goodman C, Snyder T. Differential Diagnosis for Physical Therapists Screening for Referral. 4th ed. St. Louis: Saunders Elsevier, 2007.</ref>
* Integumentary system:  Tissue decay spawned from the infection
* Cardiovascular system:  Implicated from the hypotension that occurs as a sign of necrotizing fasciitis. In addition, [[Heart Failure|heart failure]] can result from advancement of the condition.&nbsp;
* Pulmonary system:  Can be compromised from eventual [[Respiratory Failure|respiratory failure]] that can occur in later stages
* Gastrointestinal system:  Common sign of nausea and vomitting
* Genitourinary system:  Can lead to renal failure
* Immunologic system:  Comon sign of fever


== Differential Diagnosis ==
=== Risk Factors:  ===
* [[Diabetes]] (accosiated with 70.3% of patients in a 2003 study)<ref name="Wong">Wong CH, Chang HC, Pasupathy S, Khin LW, Tan JL, Low CO. [https://journals.lww.com/jbjsjournal/subjects/Infection/Abstract/2003/08000/Necrotizing_Fasciitis__Clinical_Presentation,.5.aspx Necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality.] J Bone Joint Surgery Am 2003;85-A(8):1454-60.</ref>
* Chronic disease
* Immunosuppresion
* Intravenous drug use
* [[Peripheral Arterial Disease|Peripheral vascular disease]]
* Renal failure
* Underlying malignancy<ref name="Puvanendran" />
== Diagnostic Procedures: ==
* [[CT Scans|CT scans]]: Deep fascial thickening, enhancement, fluid and gas in the soft tissue planes in and around superficial fascia are indicators of necrotizing faciitis.
{| border="0" cellspacing="1" cellpadding="1"
|-
|[[File:NecFasc CT1.jpg|none|thumb]]
|[[File:NecFasc CT.jpg|none|thumb]]
|[[File:NecFasc CT3.jpg|none|thumb]]
|}
* [[Ultrasound Scans|Ultrasound]]:  Thickening and distortion of deep fascia, and fluid collections along deep fascia are denoted
* [[MRI Scans|MRI]]:  Deep fascial thickening, deep fascial fluid collections, and hyperintense T2W signal within muscles
** Controversial topic as some authors state that fascial enhancement is an indicator, while other authors state that lack of fascial enhancement is a positive finding.


Certain conditions need to be considered during the diagnosis process for necrotizing fasciitis.&nbsp; Those conditions include:<ref name="Medscape">Medscape Reference. Necrotizing Fasciitis Differential Diagnosis. http://emedicine.medscape.com/article/2051157-differential (accessed 1 Apr 2012).</ref>
* Laboratory tests: (same as ones used for severe soft tissue infections)
** Full blood count
** Electrolytes
** Erythrocyte sedimentation rate
** C-reactive protein


• Cellulitis<br>• Acute Epididymitis<br>• Gas Gangrene<br>• Hernias<br>• Orchitis<br>• Testicular Torsion<br>• Toxic Shock Syndrome<br>  
* Frozen section biopsy:  Limited due to high costs involved<ref name=":0" /><br>
A numerical score sheet, called the laboratory risk indicator for necrotizing fasciitis (LRINEC), was devised from lab parameters as a possible indicating tool for detection of necrotizing fasciitis. Score of ≥6 has a positive predictive value of 92% and a negative predictive value of 96%.<ref name="Wong" />


== Case Reports/ Case Studies  ==
Scoring of the '''LRINEC''' of less than 5 is indicative of a low risk of <50%; a score of 6-7 of an intermediate risk and a score of 8 and more indicates an high risk of more than 75%. The scoring is based on the following criteria:
{| class="wikitable"
!Parameter
!Range
!Score
|-
|Hb (g/dl)
|>13.5
11.0 - 13.5


Groth D, Henderson SO. [http://www.sciencedirect.com/science/article/pii/S073567579990205X Necrotizing Fasciitis Due to Appendicitis]. Am J Emerg Med 1999; 17: 594- 596.
<11
|0
1


Hefny AF, Abu-­Zidan FM. [http://www.ncbi.nlm.nih.gov/pubmed/20517775 Necrotizing fasciitis as an early manifestation of tuberculosis: report of two cases.] Turkish Journal of Trauma &amp; Emergency Surgery 2010;16 (2):174-176.
2
|-
|White cells (10^9/L)
|<15
15 - 25


== Resources <br> ==
>25
|0
1


The National Necrotizing Fasciitis Foundation. Available online at [http://www.nnff.org/ http://www.nnff.org/]  
2
|-
|Sodium (mmlo/L)
|<135
|2
|-
|Creatinine (μmol/L)
|>141
|2
|-
|Glucose
|>10
|1
|-
|C-reactive protein
|>150
|4
|}
In addition, blood and pus cultures could be examined and surgical exploration may be indicated to confirm the diagnosis of necrotizing faciitis.<ref name="Fazeli">Fazeli M, Keramati M. Necrotizing fascitis: an epidemiologic study of 102 cases. Indian Journal Of Surgery 2007;69:136-139.</ref> . However,the LRINEC scoring system lacked diagnostic sensitivity. Elevated serum lactate was supported as both a diagnostic and prognostic indicator<ref>Hodgins N, Damkat-Thomas L, Shamsian N, Yew P, Lewis H, Khan K. Analysis of the increasing prevalence of necrotising fasciitis referrals to a regional plastic surgery unit: a retrospective case series. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2015 Mar 1;68(3):304-11.</ref>
== Differential Diagnosis : ==
* [[Cellulitis]]<ref name="Bisno">Bisno AL, Cockerill FR, Bermudez CT. [https://academic.oup.com/cid/article/31/2/607/300208 The Initial Outpatient-Physician Encounter in Group A Streptococcal Necrotizing Fasciitis.] Clinical Infectious Diseases 2000 Aug; 31:607–8.</ref>
* Superficial skin infections
* Acute epididymitis
* Gas gangrene
* [[Hernia|Hernias]]
* Orchitis
* Testicular torsion
* Toxic shock syndrome


PubMed Health. Available online at&nbsp;[http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002415/ www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002415/]
== Medical Management:  ==
{{#ev:youtube|6eR1IiGGB2I}}
[[File:Necrotizing fasciitis left leg debridement.JPEG|thumb|Surgical debridement]]
An aggressive form of treatment for necrotizing fasciitis is necessary due to the rapid progression of the infection once contracted. The typical management includes intravenous broad-spectrum antibiotics and early surgical debridement in order to remove the necrotic tissue.<ref name="Puvanendran" />&nbsp;Until surgical debridement has occurred, tissue hypoxia limits the efficacy of intravenous antibiotics.<ref name="Puvanendran" />&nbsp;A high dose antibiotic regimen is critical in the treatment of the infection in order to limit the amount of tissue damage that may occur.&nbsp;The inflammation that is associated with the infection causes intense pain and discomfort that is unrelieved by analgesic medications.<ref name="Bisno" />&nbsp;These two clinical findings present in necrotizing fasciitis assist to differentiate it from [[cellulitis]]. Early recognition is vital for successful treatment. If detected during the early stages, surgical debridement can be minor and more localized to the infected epidermis, subcutaneous and adipose tissue.<ref>El-khani U, Nehme J, Darwish A, Jamnadas-Khoda B, Scerri G, Heppell S, Bennett N. Multifocal necrotising fasciitis: an overlooked entity?. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2012 Apr 1;65(4):501-12.</ref>&nbsp;


== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
Wound care is of utmost importance following surgical debridement<ref>Corona PS, Erimeiku F, Reverté-Vinaixa MM, Soldado F, Amat C, Carrera L. Necrotising fasciitis of the extremities: implementation of new management technologies. Injury. 2016 Sep 1;47:S66-71.</ref>. Depending on the extent of the pathology, extensive debridement might be needed, resulting in big operative wounds. This holds a subsequent risk for further wound infections, and optimal wound care is of utmost importance. Vacuum dressings or negative pressure wound therapy might be used to facilitate the process of wound healing, by enhancing blood perfusion and promote granulation tissue, especially in the depth of the wound. This removes exudate, which decreases the inhibitory mediators and matrix metalloproteinases that interfere with the healing process.<ref>Baharestani M. [https://europepmc.org/abstract/med/18480505 Negative pressure wound therapy in the adjunctive management of necrotizing fascitis: examining clinical outcomes.] Ostomy Wound Management 2008;54:44-50.</ref>


Search Terms:&nbsp; Necrotizing Fasciitis
In the later stages of necrotizing fasciitis, systemic shock can occur resulting in failure of many organ systems. [[Respiratory Failure|Respiratory failure]], [[Heart Failure|heart failure]], low blood pressure and renal failure may occur in this stage. Limb amputation is necessary once the infection begins to spread to other organ systems.  
<div><rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1ZAz9AIS267PrEV5Oe0GyXWNZfn6RFS65v4LWDu9_afTzEygPQ|charset=UTF-8|short|max=10</rss></div>
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==


Search Terms:&nbsp;&nbsp;Necrotizing Fasciitis and Treatment
'''Hyperbaric oxygen therapy''' has been proposed as an adjunct therapy for the treatment of necrotizing fasciitis. However, evidence has found conflicting results on the efficacy of this treatment. The main advantages of hyperbaric oxygen therapy in addition to standard regimes are tissue preservation and decreased mortality.<ref name="Jallali" />&nbsp;In another study by Golger et al, it was  found that the addition of hyperbairc oxygen therapy showed no improvement in mortality rate.<ref name="Golger">Golger A, Ching S, Goldsmith CH, Pennie RA, Bain JR. [https://journals.lww.com/plasreconsurg/Abstract/2007/05000/Mortality_in_Patients_with_Necrotizing_Fasciitis.26.aspx Mortality in patients with necrotizing fasciitis.] Plast Reconstr Surg 2007; 119(6): 1803-7.</ref>&nbsp;A need exists for higher levels of research to be conducted for more conclusive results.
<div><rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1TIP92O663qnBbOp7gFhSFMRS1wWKRyA3tIsns5N2yj6Z_pEzi|charset=UTF-8|short|max=10</rss></div>  
== Physiotherapy Management:  ==
== References  ==


see [[Adding References|adding references tutorial]].  
Physiotherapy management will primarily occur after surgical debridement, and mainly focus on maintenance, prevention and management of secondary complications. Physiotherapy does not play a role in the curative management of this pathology. Patients with necrotizing fasciitis have an increased risk for the loss of endurance and strength.
* Prevention: 
** Prophylactic chest physiotherapy to prevent atelectasis, as these patients often spend the most of their time in bed
** Loss of muscle power and range of motion:  By incorporating exercise program
** Loss of function:  Mobility program
** Pressure sores:  Positioning and mobilization
* Maintenance:  Of chest, function and range of motion
* Management of secondary complications:
** [[Pneumonia]]/chest infections/[[Respiratory Failure|respiratory failure]] with the incorporation of chest physiotherapy
** Effects of immobility - Graded strengthening exercise program; transfer training; gait re-education; improve independence; address functional limitations
** Pressure sores:  Positioning and mobilization
** Amputation rehabilitation<ref>Duffin M, Farist K, Novak M. [https://www.augusta.edu/alliedhealth/pt/documents/student-posters/2014/necrotizingfasciitis.pdf The impact of physical therapy on necrotizing fasciitis: A case report.] Georgia Regent University. 2014.</ref><ref>Vaughn A. [https://fgcu.digital.flvc.org/islandora/object/fgcu%3A30631/datastream/OBJ/view/PHYSICAL_THERAPY_INTERVENTION_IN_ACUTE_CARE_FOR_AN_ADOLESCENT_WITH_EXTENSIVE_MUSCLE_DESTRUCTION_FOLLOWING_NECROTIZING_FASCIITIS__A_CASE_REPORT.pdf Physical therapy intervention for in acute care for an adolescent with extensive muscle destruction follwoing necrotizing fasciitis: A case report] [dissertation]. The Faculty of the Marieb College of Health and Human Services Florida Gulf Coast University. 2017.</ref>


<references />
== References ==


[[Category:Infectious_Diseases]][[Category:Bellarmine_Student_Project]][[Category:Medical]]
<references />
[[Category:Bellarmine_Student_Project]]
[[Category:Medical]]
[[Category:Communicable Diseases]]

Latest revision as of 10:51, 5 February 2023

Original Editor - Sara Halliday & Ashley Walker from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Ashley Walker, Sara Halliday, Elaine Lonnemann, Leana Louw, Admin, Shaimaa Eldib, Kim Jackson, 127.0.0.1, Wendy Walker, WikiSysop, Lucinda hampton and Nupur Smit Shah  

Introduction[edit | edit source]

Necrotizing fasciitis is a potentially life-threatening bacterial infection that consists of rapidly progressing necrosis of fascia and subcutaneous tissues.[1][2][3] At first the tissues overlying are not affected, a possible cause of late diagnosis and surgical intervention.[4] The most rapidly progressing type of necrotizing fasciitis is Group A streptococcal infection, also known as flesh-eating bacteria. Necrotizing fasciits can also involve microbial infections with a singular bacteria (monomicrobial) or a combination of bacteria (polymicrobial).  

Necrotizing fasciitis can occur due to several reasons (traumatic and non-traumatic) and in a variety of patient populations. Some conditions have been found to predispose patients to the risk of infection. Most of these conditions cause immunosuppression and include diabetes, malignancy, drug abuse, and chronic renal disease.[5]

The progression of the infection begins with the introduction of bacteria to the site and typically a result of trauma to the skin, however, trauma is not a necessary component. Once the infection is seeded locally, the bacteria spreads through deep fascial planes causing widespread tissue damage and infection. The spread of bacteria can cause ischemia to the area due to thrombosis occurring in blood vessels which can eventually result in gangrene.[6]

Epidemiology[edit | edit source]

Necrotizing fasciitis in some regions of the world is as common as one in every 100,000 people, compared to about 0.4 in every 100,000 people per year in the United States.[4]  Necrotizing fasciitis is considered a rare condition, however, the mortality rate remains high. Evidence has estimated the mortality rate to be at 20-40%, increasing with the delay in initial diagnosis.[2][7]

Etiology[edit | edit source]

Necrotizing fasciitis is caused as a direct sequela of bacterial infection that enters the body through a break in the skin (in roughly 80% of all cases).The most common bacteria associated with necrotiing fasciitis after minor trauma is Group A Streptococcus. When necrotizing fasciitis develops after surgery, it is likely a mix of bacteria. Upon entering the body, it rapidly reproduces and emits toxins/enzymes that damage fascia and soft tissue. The bacteria will shield itself from the body's immune system which speeds up the proliferation along tissue planes.[8]

Early presentation

Characteristics/Clinical Presentation[edit | edit source]

Erythmia and necrosis of the left leg

The patient may initially present with:

  • increasing pain,
  • tenderness to palpation to the local area and periwound,
  • purpura, erythema, swelling.[9]
  • , crepitus, purulent drainage and usually a history of some type of trauma.[2]
  • Complaints of flu-like symptoms (nausea, vomiting, fever, malaise etc.) are also common.
  • Patients can present with symptoms of sepsis that include fever, tachycardia, altered mental state and diabetic ketoacidosis that typically accompanies trauma to the skin.[6]
  • Progressive symptoms include subcutaneous bleeding, gangrene and necrosis, which can lead to systemic inflammatory response syndrome (SIRS), septic shock and even death.[2]

Clinical presentation of necrotizing fasciitis varies and can typically be mistaken for other pathologies, such as cellulitis and superficial skin infections. Awareness of the presentation of necrotizing fasciitis clinically is critical due to the rapid progression of the disease. Evidence has shown that accurate diagnosis is difficult with only 15% to 34% of patients with necrotizing fasciitis having the appropriate admittion diagnosis.[6] Misdiagnosis often occurs due to the vague symptoms that may be present (i.e. erythema, fever, pain), or the lack thereof. 

Types[edit | edit source]

Necrotizing fasciitis can be classified into 2 types:

  1. Type 1: is defined as necrotizing fasciitis caused by both aerobic and anaerobic bacteria,
  2. Tpe 2 :is caused by group A betahaemolytic Streptococcus and Staphylococcus aureus.[2]

Systemic Involvement[edit | edit source]

There are multiple systems that are compromised as the result of necrotizing fasciitis. If untreated, necrotizing fasciitis can lead to multi-system organ failure. Specific systems involved include:[10]

  • Integumentary system: Tissue decay spawned from the infection
  • Cardiovascular system: Implicated from the hypotension that occurs as a sign of necrotizing fasciitis. In addition, heart failure can result from advancement of the condition. 
  • Pulmonary system: Can be compromised from eventual respiratory failure that can occur in later stages
  • Gastrointestinal system: Common sign of nausea and vomitting
  • Genitourinary system: Can lead to renal failure
  • Immunologic system: Comon sign of fever

Risk Factors:[edit | edit source]

Diagnostic Procedures:[edit | edit source]

  • CT scans: Deep fascial thickening, enhancement, fluid and gas in the soft tissue planes in and around superficial fascia are indicators of necrotizing faciitis.
NecFasc CT1.jpg
NecFasc CT.jpg
NecFasc CT3.jpg
  • Ultrasound: Thickening and distortion of deep fascia, and fluid collections along deep fascia are denoted
  • MRI: Deep fascial thickening, deep fascial fluid collections, and hyperintense T2W signal within muscles
    • Controversial topic as some authors state that fascial enhancement is an indicator, while other authors state that lack of fascial enhancement is a positive finding.
  • Laboratory tests: (same as ones used for severe soft tissue infections)
    • Full blood count
    • Electrolytes
    • Erythrocyte sedimentation rate
    • C-reactive protein
  • Frozen section biopsy: Limited due to high costs involved[2]

A numerical score sheet, called the laboratory risk indicator for necrotizing fasciitis (LRINEC), was devised from lab parameters as a possible indicating tool for detection of necrotizing fasciitis. Score of ≥6 has a positive predictive value of 92% and a negative predictive value of 96%.[11]

Scoring of the LRINEC of less than 5 is indicative of a low risk of <50%; a score of 6-7 of an intermediate risk and a score of 8 and more indicates an high risk of more than 75%. The scoring is based on the following criteria:

Parameter Range Score
Hb (g/dl) >13.5

11.0 - 13.5

<11

0

1

2

White cells (10^9/L) <15

15 - 25

>25

0

1

2

Sodium (mmlo/L) <135 2
Creatinine (μmol/L) >141 2
Glucose >10 1
C-reactive protein >150 4

In addition, blood and pus cultures could be examined and surgical exploration may be indicated to confirm the diagnosis of necrotizing faciitis.[12] . However,the LRINEC scoring system lacked diagnostic sensitivity. Elevated serum lactate was supported as both a diagnostic and prognostic indicator[13]

Differential Diagnosis :[edit | edit source]

  • Cellulitis[14]
  • Superficial skin infections
  • Acute epididymitis
  • Gas gangrene
  • Hernias
  • Orchitis
  • Testicular torsion
  • Toxic shock syndrome

Medical Management:[edit | edit source]

Surgical debridement

An aggressive form of treatment for necrotizing fasciitis is necessary due to the rapid progression of the infection once contracted. The typical management includes intravenous broad-spectrum antibiotics and early surgical debridement in order to remove the necrotic tissue.[6] Until surgical debridement has occurred, tissue hypoxia limits the efficacy of intravenous antibiotics.[6] A high dose antibiotic regimen is critical in the treatment of the infection in order to limit the amount of tissue damage that may occur. The inflammation that is associated with the infection causes intense pain and discomfort that is unrelieved by analgesic medications.[14] These two clinical findings present in necrotizing fasciitis assist to differentiate it from cellulitis. Early recognition is vital for successful treatment. If detected during the early stages, surgical debridement can be minor and more localized to the infected epidermis, subcutaneous and adipose tissue.[15] 

Wound care is of utmost importance following surgical debridement[16]. Depending on the extent of the pathology, extensive debridement might be needed, resulting in big operative wounds. This holds a subsequent risk for further wound infections, and optimal wound care is of utmost importance. Vacuum dressings or negative pressure wound therapy might be used to facilitate the process of wound healing, by enhancing blood perfusion and promote granulation tissue, especially in the depth of the wound. This removes exudate, which decreases the inhibitory mediators and matrix metalloproteinases that interfere with the healing process.[17]

In the later stages of necrotizing fasciitis, systemic shock can occur resulting in failure of many organ systems. Respiratory failure, heart failure, low blood pressure and renal failure may occur in this stage. Limb amputation is necessary once the infection begins to spread to other organ systems.

Hyperbaric oxygen therapy has been proposed as an adjunct therapy for the treatment of necrotizing fasciitis. However, evidence has found conflicting results on the efficacy of this treatment. The main advantages of hyperbaric oxygen therapy in addition to standard regimes are tissue preservation and decreased mortality.[7] In another study by Golger et al, it was found that the addition of hyperbairc oxygen therapy showed no improvement in mortality rate.[18] A need exists for higher levels of research to be conducted for more conclusive results.

Physiotherapy Management:[edit | edit source]

Physiotherapy management will primarily occur after surgical debridement, and mainly focus on maintenance, prevention and management of secondary complications. Physiotherapy does not play a role in the curative management of this pathology. Patients with necrotizing fasciitis have an increased risk for the loss of endurance and strength.

  • Prevention:
    • Prophylactic chest physiotherapy to prevent atelectasis, as these patients often spend the most of their time in bed
    • Loss of muscle power and range of motion: By incorporating exercise program
    • Loss of function: Mobility program
    • Pressure sores: Positioning and mobilization
  • Maintenance: Of chest, function and range of motion
  • Management of secondary complications:
    • Pneumonia/chest infections/respiratory failure with the incorporation of chest physiotherapy
    • Effects of immobility - Graded strengthening exercise program; transfer training; gait re-education; improve independence; address functional limitations
    • Pressure sores: Positioning and mobilization
    • Amputation rehabilitation[19][20]

References[edit | edit source]

  1. ↑ Shupak A, Oren S, Goldenberg I, Barzilai A, Moskuna R, Bursztein S. Necrotizing fasciitis: an indication for hyperbaric oxygenation therapy? Surgery 1995;118(5):873-8.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Bechar J, Sepehripour S, Hardwicke J, Filobbos G. Laboratory risk indicator for necrotising fasciitis (LRINEC) score for the assessment of early necrotising fasciitis: a systematic review of the literature. The Annals of The Royal College of Surgeons of England 2017 May 27;99(5):341-6.
  3. ↑ Schroder̈ A, Gerin A, Firth GB, Hoffmann KS, Grieve A, von Sochaczewski CO. A systematic review of necrotising fasciitis in children from its first description in 1930 to 2018. BMC infectious diseases. 2019 Dec;19(1):317.
  4. ↑ 4.0 4.1 Wallace HA, Perera TB. Necrotizing fasciitis. InStatPearls [Internet] 2021 Jul 27. StatPearls Publishing.Available:https://www.ncbi.nlm.nih.gov/books/NBK430756/ (accessed 2.2.2023)
  5. ↑ Hsiao C-T, Weng H-H, Yuan Y-D, Chen C-T, Chen I-C. Predictors of mortality in patients with necrotizing fasciitis. American Journal of Emergency Medicine 2008; 26: 170–75.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 6.5 Puvanendran R, Huey JC, Pasupathy S. Necrotizing fasciitis. Canadian family physician 2009;55(10):981-7.
  7. ↑ 7.0 7.1 Jallali N, Withey S, Butler PE. Hyperbaric oxygen as adjuvant therapy in the management of necrotizing fasciitis. The American Journal of Surgery 2005;189(4):462-6.
  8. ↑ The National Necrotizing Fasciitis Foundation. What is NF? Available from: http://www.nnff.com/what-is-nf.html (accessed 1 April 2012).
  9. ↑ Kiat HJ, Natalie YH, Fatimah L. Necrotizing fasciitis: How reliable are the cutaneous signs?. Journal of emergencies, trauma, and shock. 2017 Oct;10(4):205.
  10. ↑ Goodman C, Snyder T. Differential Diagnosis for Physical Therapists Screening for Referral. 4th ed. St. Louis: Saunders Elsevier, 2007.
  11. ↑ 11.0 11.1 Wong CH, Chang HC, Pasupathy S, Khin LW, Tan JL, Low CO. Necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality. J Bone Joint Surgery Am 2003;85-A(8):1454-60.
  12. ↑ Fazeli M, Keramati M. Necrotizing fascitis: an epidemiologic study of 102 cases. Indian Journal Of Surgery 2007;69:136-139.
  13. ↑ Hodgins N, Damkat-Thomas L, Shamsian N, Yew P, Lewis H, Khan K. Analysis of the increasing prevalence of necrotising fasciitis referrals to a regional plastic surgery unit: a retrospective case series. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2015 Mar 1;68(3):304-11.
  14. ↑ 14.0 14.1 Bisno AL, Cockerill FR, Bermudez CT. The Initial Outpatient-Physician Encounter in Group A Streptococcal Necrotizing Fasciitis. Clinical Infectious Diseases 2000 Aug; 31:607–8.
  15. ↑ El-khani U, Nehme J, Darwish A, Jamnadas-Khoda B, Scerri G, Heppell S, Bennett N. Multifocal necrotising fasciitis: an overlooked entity?. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2012 Apr 1;65(4):501-12.
  16. ↑ Corona PS, Erimeiku F, Reverté-Vinaixa MM, Soldado F, Amat C, Carrera L. Necrotising fasciitis of the extremities: implementation of new management technologies. Injury. 2016 Sep 1;47:S66-71.
  17. ↑ Baharestani M. Negative pressure wound therapy in the adjunctive management of necrotizing fascitis: examining clinical outcomes. Ostomy Wound Management 2008;54:44-50.
  18. ↑ Golger A, Ching S, Goldsmith CH, Pennie RA, Bain JR. Mortality in patients with necrotizing fasciitis. Plast Reconstr Surg 2007; 119(6): 1803-7.
  19. ↑ Duffin M, Farist K, Novak M. The impact of physical therapy on necrotizing fasciitis: A case report. Georgia Regent University. 2014.
  20. ↑ Vaughn A. Physical therapy intervention for in acute care for an adolescent with extensive muscle destruction follwoing necrotizing fasciitis: A case report [dissertation]. The Faculty of the Marieb College of Health and Human Services Florida Gulf Coast University. 2017.
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