Friday, March 31, 2006

Necrotizing fasciitis and necrotizing cellulitis - Abstracts

Subacute forms of necrotizing fasciitis and necrotizing cellulitis: diagnosis criteria and surgical decision-making

[Article in French]

Chosidow O.

Service de Medecine Interne, GH de la Pitie-Salpetriere, Paris, France.

Subacute cellulitis could be described as intermediary forms between benign erysipelas and life-threatening necrotizing fasciitis with toxic shock syndrome. The key point is to consider any cellulitis a possible indication for surgery. Subacute cellulitis may occur in the elderly or diabetic patients. Local signs (cyanosis, necrosis.) are sometimes isolated. They may occur during the evolution of cellulitis requiring a medical treatment. This emphasizes the importance of carefully following-up any patient treated by antibiotics for cellulitis, i.e. monitoring the extension of erythema (using a felt-pen) and atypical local signs. Complementary investigations are especially helpful when diagnosing cellulitis requiring a surgical treatment: fine-needle aspirations; histology; soft-tissue X-ray; MR imaging that can detect alterations of the cutis and fascia, myositis, and abscesses.

Surgery can be delayed for such patients, allowing for a better preparation. Sometimes, only surgical exploration may confirm cellulitis. Lastly, some cases may mimic surgical cellulitis but a prolonged course of antibiotics is able to control the disease. Abscesses requiring secondary surgical evacuation may complicate all these insidious features.

Publication Types:
Consensus Development Conference

PMID: 11319370 [PubMed - indexed for MEDLINE]

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What data is needed today to deal with cellulitis and necrotizing fasciitis?

Cazorla C.

Service des Maladies Infectieuses, Hopital Bellevue, Saint-Etienne, France.

Cellulitis and necrotizing fasciitis can be distinguished by the depth of the cutaneous lesion and classically by the different bacteria implicated. This classification is not taken into account by the practitioner because of a similar therapeutic strategy. That is why most authors used a single title: necrotizing soft tissue infection. The potential severity of these infections required a quick diagnosis to decrease the risk of mortality and severe functional consequences. The analysis of the literature doesn't allow to establish the incidence of these infections. It was demonstrated that infections due to Streptococcus serogroup A increased over the last few years, thanks to a specific surveillance system. Risk factors leading to these infections are: cutaneous trauma, age, diabetes, varicella in children, contact with people infected by Streptococcus. The most recent studies demonstrated a frequent polymicrobism of the infections, with anaerobes, Streptococcus, Staphylococcus, and gram-negative rods.

At the onset of the disease, the diagnosis is difficult to establish. Pain, induration of tissues, a rapid evolution, the inefficacy of antibiotic treatment suggest the diagnosis of necrotizing infection. MRI, when available, is a good technique to reveal the depth of the infection and necrosis. Surgery will confirm the diagnosis and allow for debridement of necrotized tissues. A delayed surgery increases the mortality risk factor, as stated in numerous studies.

Publication Types:
Consensus Development Conference

PMID: 11319376 [PubMed - indexed for MEDLINE]

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Management of necrotizing cellulitis and fasciitis

Derancourt C.

Service de dermatologie, hopital Robert-Debre, Reims, France.

A literature review did not reveal any controlled study on the management of necrotizing fasciitis.

Treatment protocol includes: - an immediate or early surgical management with debridement of all necrotic tissue and extensive fasciotomy followed by a surgical reexamination of the infected area in the following days; - an initial antibiotic therapy targeting aerobic Gram-positive and Gram-negative organisms and anaerobes (e.g: amoxicilline-clavulanic acid or vancomycin-metronidazole); - an adequate nutritional support, infusion, and resuscitation; - hyperbaric oxygen therapy may be considered as an associated treatment; but there is no randomized, controlled trial demonstrating its efficacy.

Publication Types:
Consensus Development Conference

PMID: 11319377 [PubMed - indexed for MEDLINE]

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Related Links:

Necrotizing soft tissue infections: a primary care review (Complete Article)

Necrotizing fasciitis: a fourteen-year retrospective study of 163 consecutive patients (Abstract)

Necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality (Abstract)

Necrotizing fasciitis: report of 39 pediatric cases (Abstract)


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