Experience with necrotizing fasciitis at a burn care center.

Abstract: Necrotizing fasciitis is a soft tissue infection that causes necrosis of subcutaneous tissue and fascia but usually spares skin and muscle. Management of this condition consists of early diagnosis, broad-spectrum antibiotic coverage, aggressive surgical debridement, wound closure, and intensive supportive care. Mortality estimates reported in the literature have ranged from 20 to 75%. We report the cases of 12 patients treated al the Joseph M. Still Burn Center in Augusta, GA. Because aggressive surgical debridement combined with medical support is required for successful treatment, we recommend that treatment be administered al a burn care center. We performed a retrospective chart review of all patients admitted to our center with a diagnosis of necrotizing fascitis between May 1, 1995, and June 1, 2000. Patients were managed collaboratively by burn surgeons and critical care intensivists in consultation with other appropriate specialists. The mean time from initial diagnosis until transfer to the burn center was 14 days (range, 0-60 d). Complications included pneumonia, heart failure, metabolic abnormalities, anemia, and sepsis. Four (33%) of the 12 patients died. with the primary cause of death being multiorgan failure. Although our sample size is too small to reach statistical significance, the data suggest that early referral to a burn or wound care center improves patient outcome.

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In an era in which the face of health care is ever-changing, medical conditions still exist that have a longstanding reputation for poor outcome. Necrotizing fasciitis is one such condition. It is a soft tissue infection that usually involves subcutaneous tissue and fascia but spares skin and muscle. Favorable outcomes in cases of necrotizing fasciitis depend in part on early diagnosis and the initiation of proper therapy. An aggressive surgical approach is required. Burn care centers are well equipped to provide this type of care. If the diagnosis is missed in initial patient visits, outcome is adversely affected. In the past 10 years, necrotizing fasciitis has attracted increased attention in the medical community. Elliott et al (1) summarized some of the important issues involved in these cases:

   There was little need to distinguish between various categories
   of necrotizing soft tissue infections because the prognosis
   and the treatment are the same. Necrotizing soft tissue infections
   occur predominantly in patients that are predisposed to
   immune system compromise, and mortality from necrotizing soft
   tissue infections can be reduced by expeditious diagnosis and
   adequate early surgical debridement, and antibiotic support.

Methods

A retrospective chart review of all patients admitted to the Joseph M. Still Burn Center at Doctors Hospital in Augusta, GA, between May 1, 1995, and June 1, 2000, was preformed to identify cases in which necrotizing fasciitis was diagnosed. The Joseph M. Still Burn Center is a 40-bed unit for the treatment of burns and associated skin disorders. Demographic data were collected with regard to patients' age and sex and type of wound sustained. Complications noted before and after transfer were recorded. We noted the number of patient visits to a physician before the diagnosis of necrotizing fasciitis was made and outpatient and in-hospital treatment before transfer. The date of transfer to the burn center was recorded. Patients who were transferred within 24 hours of diagnosis were designated as having been diagnosed early. Wound cultures were obtained at the time of admission and repeated as indicated. Medical management and operations for debridement and wound closure were recorded together with outcome.

Results

Twelve patients with the diagnosis of necrotizing fasciitis were identified. Their mean age was 58 years (age range, 26-90 yr). Predisposing factors that were present in these patients and that might have led to the development of necrotizing fasciitis are shown in Table 1. The mean age of the patients who died was 64 years (age range, 59-72 yr). Before hospitalization, the patients' mean number of outpatient visits with various diagnoses was two. Once hospitalized elsewhere, they underwent a mean of 1.8 surgical procedures (range, 0-61) before transfer. The mean time from the diagnosis of necrotizing fasciitis until transfer was 14 days (range, 1-94 d). Once admitted, patients were cared for collaboratively by the burn team, which included surgeons, intensivists, and appropriate consultant staff. Patients underwent a mean of 3.4 operations (range, 0-10) related to debridement and wound closure. No amputations were required. A mean of 1.08 other procedures, such as biopsy or central line placement, also were performed.

During evaluations of the 12 patients with necrotizing fasciitis, we found that in 4 (33%) of the 12 patients, it occurred after some form of trauma, whereas in 12.5%, it occurred after a surgical procedure. Spontaneous swelling, decreased circulation, calciphylaxis, and a brown recluse spider bite accounted for the remaining cases. The anatomic locations of fasciitis in these 12 patients are listed in Table 2.

Multiple cultures were obtained from each patient. Eleven (98%) of 12 patients had polymicrobial infections. Antibiotic administration was adjusted with regard to type, dose, and frequency according to the MICs and serum blood levels required. The mean number of bacteriologic pathogens isolated from each infection site was 3.3. Enterococcus species and Pseudomonas aeruginosa were the most commonly recovered organisms, as shown in Table 3. In one patient, no organisms were recovered from the wound. All of the patients evaluated were stabilized on arrival at the burn center. Debridement and wide excision of the necrotic tissue was performed. Dressings were changed daily, and serial surgical debridements continued until it was evident that all necrotic tissue had been removed, alter which the wounds were closed.

In the patient group transferred to the burn center early in the infection course, various complications were observed, including fluid overload, cellulitis, depression, and anxiety. There were no deaths in this group. In the group of patients referred late in the infection course, more severe complications were encountered, including pneumonia, acute respiratory distress syndrome, respiratory failure, seizure, anemia, sepsis, electrolyte imbalance, and multisystem organ failure. Six (75%) of the eight women and two (50%) of the for men included in this study survived. Four (33%) of the 12 patients died. Three patients were classified as early transfers, all of whom survived. Four (44%) of the nine patients transferred late died. Multisystem organ failure was the primary cause of death. Autopsies were not performed. The average length of hospital stay for the entire group of patients was 21 days (range, 1-94 d).

Discussion

Necrotizing fasciitis is a serious wound complication that has a variety of causes. Cases of this infection have been recognized for many years. Green et al (2) provided a historical review of the topic. When necrotizing fasciitis involves the male genitalia, it is referred to as Fournier's gangrene, named for Jean Alfred Fournier, who described cases of scrotal gangrene in 1843. In 1871, Dr. Joseph Jones, a Confederate army surgeon in the U.S. Civil War, recorded the first study involving a large number of patients. In 1924, Dr. Frank Meleney documented approximately 20 such patients in his practice in Beijing. In 1952, Dr. Ben Wilson released a study conducted in Dallas, TX, regarding his observations of this disease. He introduced the present name of necrotizing fasciitis.

The death rate associated with this condition is high. Rouse et al (3) recorded a mortality rate of 73% in 1982. In a 1999 article, Mohammedi et al (4) documented an improved overall mortality rate of 15%. The death rate in our series is 33%. In this report, there were various predisposing factors noted before the development of necrotizing fasciitis (Table 1). Diabetes mellitus, cardiovascular disease, and renal disorders were the most common. In a 1998 Taiwanese study, Hsiao et al (5) reported that diabetes mellitus was present in 50% of the 34 patients treated. Intense pain, fever, swelling and redness at the point of origin characterized the onset of the disease. Necrotizing fasciitis was mistaken for cellulitis, or erysipelas, and treated conservatively. Ultimately, the disease progressed to gangrene of the skin, and the diagnosis of "wet" gangrene was made. Amputation was then often required, without recognition of the true nature of the process. Namias et al (6) noted that the most common initial diagnosis in such cases is cellulitis or deep vein thrombosis. In our series, most of the infections were found to be of polymicrobial origin, although Group B Streptococcus with associated toxic shock syndrome has been reported in some cases. (7) We did not encounter that entity.

Improvement in the prognosis for patients with necrotizing fasciitis is based on early recognition and appropriate treatment. In many situations, patients are judged to have benign complaints and the appropriate diagnosis is missed. Therefore, it is only after repeat visits that an accurate diagnosis is made and appropriate treatment is begun. Often this delay adversely affects outcome and adds to morbidity. An aggressive operative approach is essential. In a report of surgical debridement, Bilton et al (8) wrote, "Prompt wide surgical debridement along with supportive care and antibiotics serves to decrease morbidity and mortality of necrotizing fasciitis." These investigators reported that when two patient groups were compared, they found that the best results were achieved with the use of early debridement.

Because of the nursing skills and collaborative medical and surgical management required, care delivered in a burn or wound care setting is thought to be desirable. In examining early versus late referral to the burn center, patients in the early group experienced lower rates of morbidity than did those in the late group. There were no deaths in the early group. Interestingly, the length of bum center stay was significantly longer in the early group than in the late group, even when adjusted for mortality. Although our sample size is too small for our results to have statistical significance, our study suggests that early referral and treatment such as that available at a multidisciplinary burn center reduces patient morbidity and mortality.

Table 1. Predisposing factors for the development of
necrotizing fasciitis

Patient
no.                            Predisposing factors

 1         Poor nutrition, alcohol abuse, chronic anticoagulation
 2         Poor nutrition, chronic renal insufficiency, venous stasis
             ulcer
 3         Brown recluse spider bite
 4         Acquired immunodeficiency syndrome, congestive heart
             failure, cardiomyopathy, rheumatoid arthritis
 5         Burns on 4% of total body surface, cellulitis, alcohol abuse
 6         Abscess on left hand, acute renal failure, hypertension,
             emphysema
 7         Cellulitis of a vascular graft, peripheral vascular disease,
             hypertension, end-stage renal disease, coronary artery
             disease, mitral valve regurgitation, diabetes mellitus
 8         Diabetes mellitus, cardiovascular thrombosis
 9         Motor vehicle accident, hip and pelvic fractures
10         Emboli to ulnar artery
11         Psychiatric disorders, chronic candidial esophagitis
12         End-stage renal disease, malnutrition, calciphylaxis

Table 2. Anatomic area of involvement

                                 No. of
Body part affected              patients

Upper extremities                  3
Buttocks and legs                  3
Lower extremities                  3
Perineum and legs                  1
Perineum, buttocks, and legs       1
Abdomen, chest, and perineum       1

Table 3. Organisms recovered from wounds

                                                No. of
Type of organism                               patients

Enterococcus species                              4
Pseudomonas aeruginosa                            4
Candida albicans                                  3
[beta]-hemolytic Group A Streptococcus            2
Enterobacter cloacae                              2
Morganella morganii                               2
Methicillin-resistant Staphylococcus aureus       2
Staphylococcus species (not S. aureus)            2
Vancomycin-resistant Entrerococcus species        2
Serratia marcescens                               1
Clostridium difficile                             1
Cryptococcus neoformans                           1
Escherichia coli                                  1
Klebsiella pneumoniae                             1
Staphylococcus haemolyticus                       1
Proteus mirabilis                                 1
Staphylococcus species                            1
Streptococcus species                             1

References

(1.) Ellion DC, Kufera JA, Myers RA. Necrotizing soft tissue infections: Risk factors for mortality and strategies for management. Ann Surg 1996;224: 672-683.

(2.) Green RJ, Dafoe DC, Raffin TA. Necrotizing fasciitis. Chest 1996;110: 219-229.

(3.) Rouse TM, Malangoni MA, Schulte WJ. Necrotizing fasciitis: A preventable disaster. Surgery 1982;92:765-770.

(4.) Mohammedi I, Ceruse P, Duperret S, Vedrinne J, Bouletreau P. Cervical necrotizing fasciitis: 10 years' experience at a single institution. Intensive Care Med 1999;25:829-834.

(5.) Hsiao GH, Chang CH, Hsiao CW, Fanchiang JH, Jee SH. Necrotizing soft tissue infections: Surgical or conservative treatment? Dermatol Surg 1998; 24:243-248.

(6.) Namias N, Martin L, Matos L, ct al. Symposium: Necrotizing fasciitis. Contemp Surg 1996;49:167-178.

(7.) Holmstrom B, Grimsley EW. Necrotizing fasciitis and toxic shock-like syndrome caused by Group B Streptococcus. South Med J 2000;93:1096-1098.

(8.) Bilton BD, Zibari GB, McMillan RW, Aultman DF, Dunn G, McDonald JC. Aggressive surgical management of necrotizing fasciitis serves to decrease mortality: A retrospective study. Am Surg 1998;64:397-401.

Key Points

* Necrotizing fascitis is an infection of subcutaneous tissue and fascia that carries a high mortality rate.

* Aggressive surgical and medical care is essential.

* Early transfer to an appropriate care facility is advised.

From the Joseph M. Still Burn Center, Doctor's Hospital, Augusta, GA. Reprint requests to Joseph M. Still. MD, Physicians Multispecialty Group, 1220 George (;. Wilson Drive, Augusta, GA 30914-3726.

Accepted June 4, 2002.

Copyright [c] 2003 by The Southern Medical Association

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