Necrotizing fasciitis
Overview
For more than a century, many authors have described soft tissue infections. Their occurrence has been on the rise because of an increase in immunocompromised patients with diabetes mellitus, cancer, alcoholism, vascular insufficiencies, organ transplants, HIV, or neutropenia. Necrotizing fasciitis can occur after trauma or around foreign bodies in surgical wounds, or it can be idiopathic, as in scrotal or penile necrotizing fasciitis. Necrotizing fasciitis has also been referred to as hemolytic streptococcal gangrene, Meleney ulcer, acute dermal gangrene, hospital gangrene, suppurative fascitis, and synergistic necrotizing cellulitis. Fournier gangrene is a form of necrotizing fasciitis that is localized to the scrotum and perineal area. Necrotizing fasciitis is a progressive, rapidly spreading, inflammatory infection located in the deep fascia, with secondary necrosis of the subcutaneous tissues. Because of the presence of gas-forming organisms, subcutaneous air is classically described in necrotizing fasciitis. This may be seen only on radiographs or not at all. The speed of spread is directly proportional to the thickness of the subcutaneous layer. Necrotizing fasciitis moves along the deep fascial plane. These infections can be difficult to recognize in their early stages, but they rapidly progress. They require aggressive treatment to combat the associated high morbidity and mortality. The causative bacteria may be aerobic, anaerobic, or mixed flora, and the expected clinical course varies from patient to patient.
Symptoms
Often, a newborn baby is feeding well, healthy, and growing before he or she develops any symptoms of necrotizing enterocolitis. A baby's symptoms depend on how severe the condition is. If your baby has necrotizing enterocolitis, he or she may: Have a swollen, tender, red, or shiny belly. Not want to eat, or may be throwing up (vomiting). Be constipated. Have dark, black, or bloody stools. Have low or unstable body temperature. Not be very active, or may have little energy.
Causes
Surgical procedures may cause local tissue injury and bacterial invasion, resulting in necrotizing fasciitis. These procedures include surgery for intraperitoneal infections and drainage of ischiorectal and perianal abscesses. IM injections and IV infusions may lead to necrotizing fasciitis. Minor insect bites may set the stage for necrotizing infections. Streptococci can be introduced into the wounds, but the bacteriologic pattern changes from hypoxia-induced proliferation of anaerobes. Local ischemia and hypoxia can occur in patients with systemic illnesses (eg, diabetes). Host defenses can be compromised by underlying systemic diseases favoring the development of these infections. Illnesses such as diabetes or cancer have been described in over 90% of cases of progressive bacterial gangrene. The number of diabetic patients has been reported to be 20-40%. As many as 80% of Fournier gangrene cases occur in people with diabetes. In some series, as many as 35% of patients were alcoholics. Recent studies have shown a possible relationship between the use of nonsteroidal anti-inflammatory agents (NSAIDs), such as ibuprofen, and the development of necrotizing fasciitis during varicella infections. Additional studies are needed to establish whether ibuprofen use has a causal role in the development of necrotizing fasciitis and its complications during varicella infections. This has not previously been described
Diagnosis
Necrotizing enterocolitis is diagnosed from a newborn's symptoms, medical history, and test results. Tests may include an abdominal X-ray to provide a picture of your newborn's intestines; a test to check for blood in the stool (fecal occult blood test); and other tests to check for bacteria in the stool, blood, urine, or spinal fluid.
Treatment
f your newborn has necrotizing enterocolitis, he or she will need to be treated in a hospital, often in a neonatal intensive care unit (NICU). In newborns who have mild to moderate necrotizing enterocolitis, treatment consists of intravenous (IV) feeding, antibiotics, and removing extra fluids and gas from the intestine. This treatment usually lasts between 3 and 10 days. If your newborn does not improve with treatment, or if he or she gets a hole in the intestines, surgery to remove damaged parts of the intestines may be necessary. Up to half of newborns with necrotizing enterocolitis need surgery.1 Many newborns who have surgery for necrotizing enterocolitis survive and go on to live healthy lives