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| '''For patient information on this page, click [[Necrotizing fasciitis (patient information)|here]]''' | | '''For patient information on this page, click [[Necrotizing fasciitis (patient information)|here]]''' |
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| {{CMG}} | | {{CMG}}; {{AE}} {{YK}}, {{CZ}} |
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| '''Associate Editor-In-Chief:''' {{CZ}}
| | {{SK}}NF; Phagadena; Phagadena gangrenosum; Meleney’s gangrene; Hemolytic streptococcal gangrene; Flesh eating bacteria; Hospital gangrene; Acute dermal gangrene; Suppurative fasciitis; Synergistic necrotizing cellulitis; Gangrenous ulcer; Malignant ulcer; Putrid ulcer; Necrotizing erysipelas; Nonclostridial gas gangrene; Bacterial synergistic gangrene |
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| ==[[Necrotizing fasciitis overview|Overview]]== | | ==[[Necrotizing fasciitis overview|Overview]]== |
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| ==[[Necrotizing fasciitis risk factors|Risk Factors]]== | | ==[[Necrotizing fasciitis risk factors|Risk Factors]]== |
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| | ==[[Necrotizing fasciitis screening|Screening]]== |
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| ==[[Necrotizing fasciitis natural history, complications and prognosis|Natural History, Complications and Prognosis]]== | | ==[[Necrotizing fasciitis natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| ==Diagnosis== | | ==Diagnosis== |
| [[Necrotizing fasciitis history and symptoms| History and Symptoms]] | [[Necrotizing fasciitis physical examination | Physical Examination]] | [[Necrotizing fasciitis laboratory findings|Laboratory Findings]] | [[Necrotizing fasciitis other imaging findings|Other Imaging Findings]] | [[Necrotizing fasciitis other diagnostic studies|Other Diagnostic Studies]] | | [[Necrotizing fasciitis history and symptoms|History and Symptoms]] | [[Necrotizing fasciitis physical examination|Physical Examination]] | [[Necrotizing fasciitis laboratory findings|Laboratory Findings]] | [[Necrotizing fasciitis electrocardiogram|Electrocardiogram]] | [[Necrotizing fasciitis x ray|X Ray]] | [[Necrotizing fasciitis CT|CT]] | [[Necrotizing fasciitis MRI|MRI]] | [[Necrotizing fasciitis ultrasound|Ultrasound]] | [[Necrotizing fasciitis other diagnostic studies|Other Diagnostic Studies]] |
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| ==Treatment== | | ==Treatment== |
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| ==Case Studies== | | ==Case Studies== |
| [[Necrotizing fasciitis case study one|Case#1]] | | [[Necrotizing fasciitis case study one|Case#1]] |
| ==Causes==
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| *Drugs
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| **[[Panitumumab]]
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| ==Symptoms==
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| The infection begins locally, at a site of [[Physical trauma|trauma]], which may be severe (such as the result of [[surgery]]), minor, or even non-apparent. The affected skin is classically, at first, very painful without any grossly visible change. With progression of the disease, tissue becomes swollen, often within hours. Diarrhea and vomiting are common symptoms as well. Inflammation does not show signs right away if the bacteria is deep within the tissue. If it is ''not'' deep, signs of inflammation such as redness and swollen or hot skin show very quickly. Skin color may progress to violet and blisters may form, with subsequent [[necrosis]] (death) of the subcutaneous tissues. Patients with necrotizing fasciitis typically have a [[fever]] and appear very ill. More severe cases progress within hours, and the [[mortality rate]] is high, about 30%. Even with medical assistance, antibiotics take a great deal of time to react to the bacteria, allowing the infection to progress to a more serious state.<ref>http://www.webmd.com/a-to-z-guides Necrotizing Fasciitis Flesh Eating Bacteria Overview</ref> <ref>Tiu,A et al, ANZ J Surg. 2005 Jan-Feb;75(1-2):32-4 </ref>
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| ==Pathophysiology==
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| “Flesh-eating bacteria” is a misnomer, as the bacteria do not actually eat the tissue. They cause the destruction of skin and muscle by releasing [[toxin]]s (virulence factors). These include streptococcal pyogenic exotoxins and [[Streptococcus pyogenes|other virulence factors]]. ''S. pyogenes'' produces an exotoxin known as a [[superantigen]]. This toxin is capable of activating [[T-cell]]s non-specifically. This causes the over-production of [[cytokines]] that over-stimulate [[macrophage]]s. The macrophages cause the actual tissue damage by releasing oxygen [[free radicals]] that are normally intended to destroy bacteria but are capable of damaging nearly any macromolecule they contact in the body.
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| ==Treatment==
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| The diagnosis is confirmed by either [[blood culture]]s or aspiration of [[pus]] from [[Biological tissue|tissue]], but early medical treatment is crucial and often presumptive; thus, antibiotics should be started as soon as this condition is suspected. Initial treatment often includes a combination of intravenous antibiotics including [[penicillin]], [[vancomycin]] and [[clindamycin]]. If necrotizing fasciitis is suspected, surgical exploration is always necessary, often resulting in aggressive [[debridement]] (removal of infected tissue). As in other maladies characterized by massive wounds or tissue destruction, hyperbaric oxygen treatment can be a valuable adjunctive therapy, but is not widely available. [[Amputation]] of the affected organ(s) may be necessary. Repeat explorations usually need to be done to remove additional necrotic tissue. Typically, this leaves a large open wound which often requires skin grafting. The associated systemic inflammatory response is usually profound, and most patients will require monitoring in an [[intensive care unit]].
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| ===Antimicrobial regimen===
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| * Necrotizing fasciitis<ref name="pmid24947530">{{cite journal| author=Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL et al.| title=Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. | journal=Clin Infect Dis | year= 2014 | volume= 59 | issue= 2 | pages= 147-59 | pmid=24947530 | doi=10.1093/cid/ciu296 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24947530 }} </ref>
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| :* 1. '''Mixed infections'''
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| ::* 1.1 '''Adults'''
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| :::* Preferred regimen (1): [[Piperacillin-tazobactam]] 3.37 g IV q6–8h {{and}} [[Vancomycin]] 30 mg/kg/day IV q12h
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| :::* Note: In case of severe pencillin allergy, use clindamycin or metronidazole with an aminoglycoside or fluoroquinolone
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| :::* Preferred regimen (2): [[Imipenem]]-[[cilastatin]] 1 g IV q6–8h
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| :::* Preferred regimen (3): [[Meropenem]] 1 g IV q8h
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| :::* Preferred regimen (4): [[Ertapenem]] 1 g IV q24h
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| :::* Preferred regimen (5): [[Cefotaxime]] 2 g IV q6h {{and}} [[Metronidazole]] 500 mg IV q6h
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| :::* Preferred regimen (6): [[Cefotaxime]] 2 g IV q6h {{and}} [[Clindamycin]] 600–900 mg IV q8h
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| ::* 1.2 '''Pediatrics'''
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| :::* Preferred regimen (1): [[Piperacillin-tazobactam]] 60–75 mg/kg/dose of the [[Piperacillin]] component IV q6h {{and}} [[Vancomycin]] 10–13 mg/kg/dose IV q8h
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| :::* Note: Severe pencillin allergy, use clindamycin or metronidazole with an aminoglycoside or fluoroquinolone)
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| :::* Preferred regimen (2): [[Meropenem]] 20 mg/kg/dose IV q8h
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| :::* Preferred regimen (3): [[Ertapenem]] 15 mg/kg/dose IV q12h for children 3 months-12 years
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| :::* Preferred regimen (4): [[Cefotaxime]] 50 mg/kg/dose IV q6h {{and}} [[Metronidazole]] 7.5 mg/kg/dose IV q6h
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| :::* Preferred regimen (5): [[Cefotaxime]] 50 mg/kg/dose IV q6h {{and}} [[Clindamycin]] 10–13 mg/kg/dose IV q8h
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| :* 2. '''Streptococcus infection'''
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| ::* 2.1 '''Adults'''
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| :::* Preferred regimen: [[Penicillin]] 2–4 MU IV q4–6h {{and}} [[Clindamycin]] 600–900 mg IV q8h
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| :::* Note: In case of severe pencillin allergy, use vancomycin, linezolid, quinupristin/dalfopristin, daptomycin
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| ::* 2.2 '''Pediatric'''
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| :::* Preferred regimen: [[Penicillin]] 0.06–0.1 MU/kg/dose IV q6h {{and}} [[Clindamycin]] 10–13 mg/kg/dose IV q8h
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| :::* Note: In case of severe pencillin allergy, use vancomycin, linezolid, quinupristin/dalfopristin, daptomycin
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| :* 3. '''Staphylococcus aureus'''
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| ::* 3.1 '''Adults'''
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| :::* Preferred regimen (1): [[Nafcillin]] 1–2 g IV q4h
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| :::* Note: In case of severe pencillin allergy, use vancomycin, linezolid, quinupristin/dalfopristin, daptomycin
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| :::* Preferred regimen (2): [[Oxacillin]] 1–2 g IV q4h
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| :::* Preferred regimen (3): [[Cefazolin]] 1 g IV q8h
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| :::* Preferred regimen (4): [[Vancomycin]] 30 mg/kg/day IV q12h
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| :::* Preferred regimen (5): [[Clindamycin]] 600–900 mg IV q8h
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| ::* '''Pediatrics'''
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| :::* Preferred regimen (1): [[Nafcillin]] 50 mg/kg/dose IV q6h
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| :::* Note: In case of severe pencillin allergy, use vancomycin, linezolid, quinupristin/dalfopristin, daptomycin
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| :::* Preferred regimen (2): [[Oxacillin]] 50 mg/kg/dose IV q6h
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| :::* Preferred regimen (3): [[Cefazolin]] 33 mg/kg/dose IV q8h
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| :::* Preferred regimen (4): [[Vancomycin]] 15 mg/kg/dose IV q6h
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| :::* Preferred regimen (5): [[Clindamycin]] 10–13 mg/kg/dose IV q8h (bacteriostatic; potential cross-resistance and emergence of resistance in erythromycin-resistant strains; inducible resistance in MRSA)
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| :* 4. '''Clostridium species'''
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| ::* 4.1 '''Adults'''
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| :::* Preferred regimen: [[Clindamycin]] 600–900 mg IV q8h {{and}} [[Penicillin]] 2–4 MU IV q4–6h
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| ::* 4.2 '''Pediatrics'''
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| :::*Preferred regimen: [[Clindamycin]] 10–13 mg/kg/dose IV q8h {{and}} [[Penicillin]] 0.06-0.1 MU/kg/dose IV q6h
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| :* 5. '''Aeromonas hydrophila'''
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| ::* 5.1 '''Adults'''
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| :::* Preferred regimen (1): [[Doxycycline]] 100 mg IV q12h {{and}} [[ciprofloxacin]] 500 mg IV q12h
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| :::* Preferred regimen (2): [[Doxycycline]] 100 mg IV q12h {{and}} [[ceftriaxone]] 1 to 2 g IV q24h
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| ::* 5.2 '''Pediatrics'''
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| :::* Not recommended for children but may need to use in life-threatening situations
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| :* 6. '''Vibrio vulnificus
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| ::* 6.1 '''Adults'''
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| :::* Preferred regimen (1): [[Doxycycline]] 100 mg IV q12h {{and}} [[ceftriaxone]] 1 g IV qid
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| :::* Preferred regimen (2): [[Doxycycline]] 100 mg IV q12h {{and}} [[cefotaxime]] 2 g IV tid
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| ::* 6.2 '''Pediatrics'''
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| :::* Not recommended for children but may need to use in life-threatening situation
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| ==Prognosis==
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| This disease is one of the fastest-spreading infections known, as it spreads easily across the [[fascia]]l plane within the [[subcutaneous]] tissue. For this reason, it is popularly called the “flesh-eating disease,” and, although rare, it became well-known to the public in the 1990s. Even with today's modern medicine, the [[prognosis]] can be bleak, with a [[mortality rate]] of approximately 25% and severe disfigurement common in survivors.
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| ==Other bacterial strains==
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| In February 2004, a rarer but even more serious form of the disease has been observed in increasing frequency, with several cases found specifically in California. In these cases, the bacterium causing it was a strain of ''[[Staphylococcus aureus]]'' (i.e. ''[[Staphylococcus]]'', not ''[[Streptococcus]]'' as stated above) which is [[Antibiotic resistance|resistant]] against [[methicillin]], the [[antibiotic]] usually used for treatment (see [[Methicillin-resistant Staphylococcus aureus|Methicillin-resistant ''Staphylococcus aureus'']] for details).
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| “Super Strep” appeared in Ohio and Texas in 1992 and 1993 and was contracted by approximately 140 people. It took under 12 hours to incapacitate most and caused 3 days of very high fevers. The death rate in 1993 was reported to be 10%, with a majority of the victims having mild to severe brain damage.
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| ==See also== | | ==See also== |
| * [[Mucormycosis]], a rare fungal infection which can present like necrotizing fasciitis | | * [[Mucormycosis]], a rare fungal infection which can present like necrotizing fasciitis |
| * [[Toxic shock syndrome]] | | * [[Toxic shock syndrome]] |
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| ==References==
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| {{reflist|2}}
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| {{Diseases of the musculoskeletal system and connective tissue}} | | {{Diseases of the musculoskeletal system and connective tissue}} |
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| [[Category:Bacterial diseases]]
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| [[Category:Diseases involving the fasciae]]
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| [[Category:Dermatology]] | | [[Category:Dermatology]] |
| [[Category:Infectious skin diseases]]
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| [[Category:Rheumatology]] | | [[Category:Rheumatology]] |
| [[Category:Infectious Disease Project]] | | [[Category:FinalQCRequired]] |
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| [[de:Nekrotisierende Fasziitis]]
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| [[es:Fascitis necrotizante]]
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| [[fr:Fasciite nécrosante]]
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| [[nl:Necrotiserende fasciitis]]
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| [[tr:Nekrotizan fasiit]]
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