Necrotizing Fasciitis:

A diagnosis you can’t miss

Daniel Schlatterer D. O.
Wellstar, Atlanta Medical Center
Atlanta, GA

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Images are from the personal collection of Daniel Schlatterer D. O.

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Objectives
You will learn:
1) what is necrotizing fasciitis and its clinical consequences
2) how to diagnose NF
3) how to treat NF

To achieve these objectives, you will review the:

a) Clinical & radiographic findings
b) Laboratory risk indicator for necrotizing fasciitis - LRINEC scale
c) Surgical debridement
d) Literature pearls, interesting facts

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Let’s start with a case example
You are called by the medical service to assess the leg of a 56-year-old male admitted for CHF.

No further clinical information is available.

A) What in the picture is consistent with NF?
B) If you suspect NF, what are your next steps?
Keep these questions in mind as you go through this presentation
Return to these questions before viewing the answer and discussion on the last slide

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What is Necrotizing Fasciitis (NF)?
• NF is a rare but serious infection of the subcutaneous tissues and fascia of the
skin
• Widespread fascial necrosis with relative sparing of skin and underlying muscle
• Caused by toxin-producing virulent bacteria
• May occur in any region of the body
• the abdominal wall, perineum, and the extremities
• The causative bacteria thrive in low oxygen level regions
• For example: blunt trauma areas, or post-surgical areas
• Often fatal unless promptly recognized and treated aggressively

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Historical information - 1st Report
• First described by Fournier in 1832
• Remarkable because the classic signs had not yet been established
• Patients being very sick with “disproportionate” pain and only minor skin
changes in the early phases
• Today, we are much better at recognizing sepsis and organ
failure
• More frequently have NF in our differential diagnosis for very sick
patients with skin findings
• Often skin findings are minor
• Diagnosis is paramount to rapid, life saving intervention

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Epidemiology
• Roughly 1-4/100,000 people
• Most orthopaedic departments in trauma centers treat 1-5/year
• An extremity can be involved at any location

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Classification
• By Location
• Fournier’s: perineum
• Ludwig’s angina: floor of the mouth, under the tongue
• Based on Etiology
• Type I-IV

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Classification
• Type I: polymicrobial infection
• most frequent (55–90%)
• Affected patients are often immunodeficient and show comorbidities such as
diabetes mellitus
• Type II: monomicrobial
• Lancefeld group A-streptococcus (Streptococcus pyogenes) but often occurs
in association with Staphylococcus aureus .
• This type is not linked to certain comorbidities, portal of entry are skin lesions
or injections (i.v. drug abuse or iatrogenic)
• The progression can be fulminant with severe systemic toxicity, septic shock
and multi-organ failure Leiblein et al, 2018

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Classification
• Type III: monomicrobial
• clostridium species, Gram-negative bacteria or Vibrio spp. (Vibrio vulnificus)
• fulminant progression with multi-organ failure within 24 h and high mortality
• Mortality 35–44% with treatment
• Type IV: Fungal
• most often with Candida spp. or zygomycetes

Leiblein et al, 2018

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Vibrio vulnificus (VV) and necrotizing fasciitis
• Bacteria found in coastal waters
• People with open wounds may get infected by swimming in waters
with VV leading to NF
• People can get infected by ingesting undercooked shellfish, or raw
oysters. The symptoms of diarrhea, cramping fever, chills and
vomiting appear within 24 hours and often subside within 3 days

Kuo et al, 2007

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How does NF happen?
• Introduction of the pathogen into the subcutaneous space occurs via
disruption of the overlying skin or by hematogenous spread from a
distant site of infection
• Polymicrobial necrotizing fasciitis is usually caused by enteric
pathogens, whereas monomicrobial necrotizing fasciitis is usually due
to skin flora.

Green et al, 1996

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Who gets Necrotizing Fasciitis ?
• Any patient can get NF
• More frequently occurs in
• diabetics
• alcoholics
• immunosuppressed patients
• IV drug users
• patients with peripheral vascular disease,
• May also occur in young, healthy individuals

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Atypical etiologies
1) Necrotizing fasciitis as a complication of botulinum toxin injection
Patient received botox for cosmetic reasons (Eye. January 1998)
2) Necrotizing fasciitis of the breast
(British Journal of Plastic Surgery. January 2001)
3) Necrotizing fasciitis and cellulitis after traditional Samoan tattoo
4) Necrotizing fasciitis in a patient receiving infliximab for rheumatoid
arthritis
5) Necrotizing fasciitis following etanercept treatment for dermatomyositis
6) Treatment with any immune or disease modulating medication

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What are the common sites for NF?
Can occur anywhere on the body
• Perineum (36%),
• Lower extremities (15.2%)
• Postoperative wounds (14.7%)
• Abdomen, oral cavity, and neck

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Diagnosis: History
• Pain out of proportion to the visible findings
• Relatively unresponsive to pain medications
• History of minor trauma, needle puncture or extravasation of
drugs, an insect bite, scratch, or abrasion
• In many cases no identifiable cause can be found
• Symptoms may develop over a period of hours to several days

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 Diagnosis: Physical Examination
• Initially there may be only slight skin changes
• An open wound or sore with surrounding erythema
• Progressive changes
• Skin becomes increasingly tense and erythematous with indistinct margins.
• Color can change from a red-purple to a dusky blue before progressing to necrosis and
formation of bullae and eventually becoming hemorrhagic
• Crepitus of the affected area may be palpated and may even be seen as soft
tissue air on a plain radiograph or CT scan

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 Diagnosis: Physical Examination
• Strongly recommend serial physical examination by same individual
• Surgical skin marking pen to outline borders to help track progression
objectively or photographic documentation per hospital protocol
• Tenderness beyond the apparent margin of infection is diagnostic and present
in 98% patients

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What does Necrotizing Fasciitis look like?

A benign appearing soft tissue wound.

This was the start of a tattoo On examination, crepitus would be felt, The surrounding erythema may cause
Several days before presentation and multiple bullae would be noted. one to only consider cellulitis
This does not appear worse than many The most concerning aspect of this
of the traumatized legs seen by wound is tissue at the margins which
orthopaedic surgeons, but it is limb and appears separated from deeper tissue
life threatening and able to be easily pulled away. In a
matter of hours this will be limb and
life threatening.

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Non-orthopaedic case
This patient had a C-section several days prior
to presentation

This case is included because it nicely

illustrates
- the bullae that form,
- the wound weeping,
- the epidermal loss

Left untreated, this patient will become septic

and likely progress to organ failure, or even
death.

Lost in the clinical picture is the intolerable

wound malodor.

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Diagnosis: Imaging
• Subcutaneous air or gas is a hallmark finding on plain radiographs and
CT scans, which gives rise to crepitus on examination. All three of
these patients need to be seen immediately.

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Ultrasound and MRI imaging
• Subcutaneous air or gas is the universal finding on any imaging
modality
• US has the advantage of being rapid, portable and even connected to
smart-phone applications
• NF requires immediate diagnosis and emergent surgical intervention
• DO NOT DELAY for advanced imaging such as MRI
• diagnosis should be obtainable from the history and physical examination.
• Imaging is not a mainstay of diagnosis,
• be aware of subcutaneous gas especially incidental finding on another study.
For example on a calf US to rule-out a DVT.

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Diagnostic tools:
Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC)
Metric
CRP <15mg/dl (0 points) >15mg/dl (4 points)

WBC 15-25 (1 point) >25 (2 points)

Hemoglobin 11-13.5 (1 point) <11 (2 points)
Sodium >/=135 (0 points) <135 (2 points)
Creatinine </= 1.6 mg/dl (0 points) >1.6 mg/dl (2 points)
Glucose </=180 mg/dl ( 0 points) >180 mg/dl (1 point)
Point system cut-off is 6
< 6 points does not override physical exam findings, or rule-out the diagnosis
> 6 points, in general rules in NF
Sepsis parameters are not part of the formula and should be considered separately
Non-survivors had sodium levels <127.7

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Diagnostic tools- LRINEC
** Scoring and classification systems are not fool-proof
A case of NF reported with score = 0

• They guide us on things to look for and assess only

• Must have a high index of suspicion
• clinical suspicion trumps any score
• Confer with experienced colleagues when in doubt

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Beware the elderly
• May show signs of systemic shock and sepsis

• Often pose diagnostic difficulties since they may be

confused, agitated, or even have a reduced level of
consciousness such as intubated and sedated (ICU pts for
example).

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Management
• Emergent surgical consultation
• Fluid resuscitation as needed
• Start IV antibiotics aerobic and anaerobic coverage
• Infectious disease consultation
• If convinced NF is present, then proceed to surgery
• Do not delay for lab results

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Antibiotics
• NF infections can be polymicrobial
• Usually group A streptococcus
• The antibiotic regime often includes
• Penicillin G
• Clindamycin
• Vancomycin
• Aminoglycoside if renal function permits
• IV immunoglobulin therapy has been reported
• Fluids and blood products as indicated
• Transfer to an ICU can be done post-operatively

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Surgical Management
• Extremity fascial planes are continuous
• from the fingers to the axilla
• from the toes to the groin and beyond
• Surgical debridement requires excising to healthy margins
which often extends proximal to the elbow and the knee
• Healthy margins noted surgically by bleeding skin and skin
adherent to the underlying fascia
• Obtain multiple fluid and tissue samples for culturing

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Surgical Management
• The indications and technical aspects of negative pressure wound
therapy (NPWT) have not been studied for NF after a
debridement which is often circumferential
• The surgical team must be prepared for urgent repeat
debridements extending into the thorax, abdominal, or back
regions.
• Limb disarticulation is a surgical decision based upon limb
salvage potential
• “Life over Limb”

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Treatment adjuncts and wound closure
• Negative pressure wound therapy (NPWT) does not have a defined
role in treating NF
• Hyperbaric oxygen therapy (HBO) has been shown to be beneficial
(Riseman, 1990)
• Intravenous immunoglobulin treatment is investigational
• In general, since NF does not involve muscle, the need for muscle or
fasciocutaneous flaps is rarely required
• The debridement of NF involves large areas of skin and fascia
• In cases of extremity NF, consider NPWT over the debrided areas for
3-5 days and then returned for split thickness skin grafting for wound
closure.
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Treatment Pearls and adjuncts
• Fascial involvement beyond the boundaries of skin redness, blistering
or other visual demarcations
• Intraoperatively, may be able to run hands under the skin in all
directions with very little to no resistance
• The fascial area soft with mixture of purulence and watery soft tissue
• Purulence may have odd smell or color
• Skip lesions may be noted, where purulence not continuous under
the fascia
• Be sure to evaluate/debride circumferentially

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Treatment pearls and adjuncts
• The extent of NF under the skin is hard to determine

#1 Assume that the fascial extent is much further than the boundaries
of skin redness, blistering or other visual differences
#2 Extend the 1st debridement widely beyond the suspected margins of
involvement
#3 Serial operating room debridements until
A) the patient stabilizes clinically
B) advancement of the infection beyond its initial borders has ceased

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Outcomes
Angoules et al, 2007
• 451 patients reviewed
• rapidly progressive, life threatening soft tissue infection. the
extremities are involved as a result of
• Minor blunt or penetrating trauma, needle puncture or extravasation of
drugs,
• 22.3% underwent amputation or limb disarticulation following failure
of multiple debridements to control infection
• Mortality rate was 21.9%. Angoules, 2007

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 Outcomes
Leiblein et al, 2018
• 15 patients with necrotizing fasciitis over a 21-month time period
• Two patients underwent limb amputation;
• diabetes mellitus was assigned with a significant higher risk for
amputation.
• The mean hospitalization was 32 days, including 8 days on
intensive care unit.

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 Outcomes
Leiblein et al, 2018
The authors concluded:
• Surgical therapy is indicated if necrotizing fasciitis is suspected.
• Aminopenicillin ± sulbactam in combination with clindamycin
and/or metronidazole is recommended as initial antibiotic
treatment.

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NF versus Cellulitis, or Gangrene
• Both can have erythema, swelling, fever, and pain
• NF confirmed when followed by
• Bullae
• Skin sloughing
• Tissue necrosis
• Gangrene similar in presentation but slower to progress
than NF

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Is NF contagious? Precautions for physicians
• NF is a bacterial infection, not a virus (unlike Ebola).
• The bacterial endotoxins cause the rapid decline for
patients and for their organs to fail.
• Transmission via a needle stick or splash exposure is
remotely possible.

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Is NF contagious? Precautions for physicians
• Theoretically, a needle stick during a surgical procedure on
a patient with NF could lead to NF in the surgeon
• This event has never been reported
• Always use universal precautions when treating any
infection or patient.

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Back to our case example
You are called by the medical service to assess the leg of a 56-year-old male admitted for CHF.

No further clinical information is available.

A) What in the picture is consistent with NF?
B) If you suspect NF, what are your next steps?
Keep these questions in mind as you go through this presentation
Return to these questions before viewing the answer and discussion on the last slide

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Case example - Discussion
Answer:
A) This is a classic presentation before the wound progresses and the patient becomes septic or experiences organ failure.
The leg is erythematous, edematous with multiple bullae that could probably be easily separated from the deeper dermis

B) If NF is suspected, call an attending surgeon who can manage NF

Better yet consider calling the attending surgeon before seeing the patient ( to confirm availability!)
Again if NF is suspected pre-op the patient (NPO, consent, type and screen, call the OR ).
Don’t waste time checking, ordering labs, or calculating the LRINEC.

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Maintain High Index of Suspicion
Successful outcomes rely on two important factors:
1) Awareness of the disease, despite its rare occurrence
2) Immediate therapy

Leiblein et al, 2018

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 Summary
• Always have a high index of suspicion for all traumatized
areas that are exquisitely painful in sick patients
• LRINEC not absolute but helpful
• IV antibiotics
• Aggressive debridement is the key
• Worry about soft tissue reconstruction later – life over limb

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References
• 1. Kuo, Y. L., Shieh, S. J., Chiu, H. Y., & Lee, J. W. (2007). Necrotizing fasciitis caused by Vibrio vulnificus: epidemiology, clinical findings, treatment
and prevention. European Journal of Clinical Microbiology & Infectious Diseases, 26(11), 785-792.
• 2. Leiblein, M., Marzi, I., Sander, A. L., Barker, J. H., Ebert, F., & Frank, J. (2018). Necrotizing fasciitis: treatment concepts and clinical
results. European Journal of Trauma and Emergency Surgery, 44(2), 279-290.
• 3. Diab, J., Bannan, A., & Pollitt, T. (2020). Necrotizing fasciitis. Bmj, 369.
• 4. Riseman, J. A., Zamboni, W. A., Curtis, A., Graham, D. R., Konrad, H. R., & Ross, D. S. (1990). Hyperbaric oxygen therapy for necrotizing fasciitis
reduces mortality and the need for debridements. Surgery, 108(5), 847-850.
• 5. Ronald J., Green, R.J., Dafoe, D., Rajfin, T. Necrotizing Fasciitis. CHEST. Volume 110, Issue 1, July 1996, Pages 219-229.
• 6. Angoules AG, Kontakis G, Drakoulakis E, Vrentzos G, Granick MS, Giannoudis PV. Necrotizing fasciitis of upper and lower limb: a systematic review. Injury. 2007
Dec;38 Suppl 5:S19-26. doi: 10.1016/j.injury.2007.10.030. Epub 2007 Nov 28.
• Images: all images were obtained after searching for “images of necrotizing fasciitis” on Google.

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