7/26/2011

Left Lower Leg

• First described by Hippocrates in 5th centry as a complication from erysipelas

•  "...the erysipelas would quickly spread widely in all directions. Flesh, sinews and bones fell away in large quantities...Fever was sometimes present and sometimes absent...There were many deaths. The course of the disease was the same to whatever part of the body it spread." 

NECROTIZING FASCIITIS

• Incidence (low end) – 500-1000 per year nationally

• Predisposing factors – immunosuppression, DM, malignancy, drug abuse (IVDU), CKD

• 50% of patients have hx of skin injury• 25% have blunt trauma• 70% have one ore more chronic illnesses

NECROTIZING FASCIITIS

• Systemic signs – fever, tachycardia, hypotension• NF more commonly seen in extremities; can be

seen on any part of body• Other findings include erythema, induration,

tenderness, fluctuance, skin necrosis and bullae

PHYSICAL DIAGNOSIS

• Leukocytosis• Elevated BUN and Cr• Elevated CK• Elevated CRP• Hyponatremia commonly seen

LAB FINDINGS

• Type I – Polymicrobial infection with aerobic and anaerobic bacteria; tends to affect the chronically ill – DM, immuncompromised, etc.

• Type II – Tends to be Group A Strep and can affects people indiscriminately

NECROTIZING FASCIITIS

• Implicated organisms• Group A Strep• S. aureus• A. hydrophila• E. coli• Klebsiella• Clostridium perfringens• Vibrio vulnificus

NECROTIZING FASCIITIS

• Immediate surgical consult

• If you suspect Type I • Ampicillin/Sulbactam + Clinda/Metronidazole• Can substitute Piperacillin/Tazobactam for Amp/Sul

• If you suspect Type II• Clindamycin and/or Penicillin • Vancomycin in areas where community-acquired MRSA is

prevalent

TREATMENTS

• Understand the signs and symptoms that make one suspect necrotizing fasciitis

• Get appropriate specialists involved quickly – Surgery, ID

• Recognize higher risk of chronically ill patients to get this disease

• Know causative organisms and treatments

TAKE HOME POINTS