Anaerobic and Necrotizing Infections
Basics
Basics
Basics
Description
Description
Description
- Necrotizing soft tissue infections (NSTI) are rare and rapidly progressing infections involving any layer of soft tissue, including skin, subcutaneous fat, fascia, and/or muscle (1).
- NSTI can affect any part of the body but are more commonly seen in extremities and abdominal wall (1).
- NSTI are associated with extensive tissue destruction, systemic toxicity, limb loss and are potentially fatal.
- NSTI represent a medical emergency. Early diagnosis, prompt surgical consultation, and initiation of broad-spectrum antibiotics are essential in improving outcomes (2).
- Associated terms: necrotizing fasciitis, progressive bacterial synergistic gangrene, synergistic necrotizing cellulitis, gas gangrene, nonclostridial anaerobic cellulitis, Fournier gangrene, Ludwig angina, “flesh-eating” infections
Epidemiology
Epidemiology
Epidemiology
- Predominant age: any age
- Predominant sex: male = female
Incidence
- 4 per 100,000
- Increased incidence in patients >50 years
Etiology and Pathophysiology
Etiology and Pathophysiology
Etiology and Pathophysiology
- Type I NSTI—most common
- Polymicrobial, typically a combination of aerobic and anaerobic species (1)
- More common in patients with specific risk factors (see below), although no specific inciting event is identified in 20–50% of patients (3)
- Type II NSTI
- Monomicrobial infection
- Tends to occur in otherwise healthy individuals (3)
- Most commonly caused by group A β-hemolytic streptococci (Streptococcus pyogenes), followed by methicillin-resistant Staphylococcus aureus (MRSA) (2)
- Type III NSTI
- Vibrio vulnificus—associated with exposure to marine environments, especially in patients with severe liver disease
- Aeromonas hydrophila—associated with exposure to freshwater environments
- Clostridium perfringens
- Bacteria enter the soft tissue after trauma causing skin or mucosal breach. Bacterial invasion may also occur without definite site of entry in a host with transient bacteremia after deep tissue trauma (2).
- Bacterial toxins and surface proteins cause a local inflammatory response. Vascular occlusion follows leading to deep tissue ischemia and necrosis (2).
- Bacterial toxins may trigger a systemic inflammatory response, leading to multiorgan failure or sepsis (2).
Risk Factors
Risk Factors
Risk Factors
- Can occur in young, healthy persons without risk factors
- Predisposing risk factors (3)
- Advanced age
- Obesity
- Diabetes, cirrhosis, end-stage renal failure
- Malnutrition
- Immune suppression (HIV, malignancies, alcoholism, corticosteroid use)
- History of cellulitis or impaired venous and lymphatic drainage (4)
- Peripheral vascular disease
- Precipitating risk factors
- IV drug abuse
- Trauma, burns
- Skin ulceration
- Herpes zoster
- Human, animal, or insect bites (4)
- Surgical risk factors
- Prior operations
- Hypoalbuminemia
General Prevention
General Prevention
General Prevention
- Management of predisposing risk factors (4)
- Diabetics should have regular foot examinations (4).
- Appropriate wound care after trauma involving irrigation, foreign body removal, and débridement of devitalized tissue (4)
- Sterile surgical procedures and skin closure (2)
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