References: Lethal Infection; Volume 3 Issue 6

1. AUTHOR	Kaul-R, McGeer-A, Low-D-E, Green-K, Schwartz-B
INSTITUTION	Shared Department of Microbiology, Mount Sinai Hospital, Toronto, Ontario, Canada.
TITLE	Population-based surveillance for group A streptococcal necrotizing fasciitis: Clinical features, prognostic indicators, and microbiologic analysis of seventy-seven cases. Ontario Group A Streptococcal Study.
SOURCE	Am-J-Med 1997 Jul, VOL: 103 (1), P: 18-24, ISSN: 0002-9343.
ABSTRACT	PURPOSE: To determine the incidence of group A streptococcal necrotizing fasciitis in Ontario, Canada, and to describe the clinical features, outcome, and microbiologic characteristics of this infection. PATIENTS AND METHODS: Prospective, population-based surveillance for invasive group A streptococcal infections was conducted in Ontario from November 1991 to May 1995. All 77 patients meeting clinical and/or histopathologic criteria for streptococcal necrotizing fasciitis were included. Demographic and clinical information was obtained by patient interviews and chart review. Group A streptococci were characterized by M-protein and T- agglutination typing, and polymerase chain reaction (PCR) detection of streptococcal pyrogenic exotoxin genes A and C (speA; speC). RESULTS: The incidence of group A streptococcal necrotizing fasciitis increased during the study from 0.085 per 100,000 population in the first year to 0.40 per 100,000 population in the last year (P < 0.001). The median age of cases was 57.5 years and the rate of disease increased with increasing age. Seventy-nine percent of cases were community-acquired, 11% were nosocomial, and 10% were acquired in a nursing home. Forty-seven percent of cases were associated with the presence of streptococcal toxic shock syndrome (Strep TSS) and 46% were bacteremic. Thirty-four percent of cases died and mortality was correlated with increasing age (P = 0.006), presence of hypotension (P = 0.01), and bacteremia (P = 0.03). The most common streptococcal serotypes were M1 (35%) and M3 (25%). Forty-one percent of strains possessed the speA gene and 30% the speC gene. Outcome was not correlated with M-type or the presence of spe genes. CONCLUSIONS: The incidence of necrotizing fasciitis caused by group A streptococcus increased in Ontario between 1992 and 1995. Elderly individuals were more likely to acquire the disease and to die from it. Mortality because of streptococcal necrotizing fasciitis was also associated with the presence of hypotension, Strep TSS, or bacteremia, but not with M-type or the presence of pyrogenic exotoxin genes. Author.

2. AUTHOR	Chelsom-J, Halstensen-A, Haga-T, Hoiby-E-A.
INSTITUTION	Medical Department B, Gade Institute, Oslo, Norway.
TITLE	Necrotising fasciitis due to group A streptococci in western Norway: incidence and clinical features (see comments).
SOURCE	Lancet 1994 Oct 22, VOL: 344 (8930), P: 1111-5, ISSN: 0140-6736.
CM	Comment in: Lancet 1994 Dec 24-31; 344(8939-8940):1770-1; Comment in: Lancet 1994 Dec 24-31; 344(8939-8940):1771.
ABSTRACT	During November, 1992, to May, 1994, 13 patients were treated at Haukeland University Hospital, Norway, for necrotising fasciitis due to group A beta-haemolytic streptococci. 3 patients died, 1 before admission. Mucoid group A streptococci were isolated from affected tissue (12 patients) and/or blood (5). Strains from 11 patients were serotype M-1 (5 patients), M-3 (2), M-6 (2), M-28 (1), and M- untypable (T-1, opacity factor negative) (1). For the 12 patients admitted alive, the following preoperative events were recorded: 8 had clinical signs of shock with systolic blood pressure of 90 mm Hg or less, 8 had impaired renal function, and 7 had biochemical markers of disseminated intravascular coagulation. At least 6 patients fulfilled the criteria for streptococcal toxic shock syndrome. Preoperative C-reactive protein was substantially raised ( > 200 mg /L) in 10 patients. The 12 patients were given high doses of antibiotics and were operated on with aggressive debridement of necrotic skin and fascia, 7 of them within 24 h of admission. The increasing incidence of necrotising fasciitis in western Norway reflects the resurgence of invasive group A streptococcal infections documented in Scandinavia since 1987. The high case-fatality rate can be reduced by early diagnosis and aggressive surgery combined with adequate antibiotic therapy. Author.

3. AUTHOR	Simonart-T, Simonart-J-M, Schoutens-C, Ledoux-M, De-Dobbeleer-G.
INSTITUTION	Service de Dermatologie, Centre Hospitalier Etterbeek-Ixelles, Bruxelles, Belgique.
TITLE	(Epidemiology and etiopathogeny of necrotizing fasciitis and streptococcal shock syndrome). TT Epidemiologie et etiopathogenie des fasciites necrosantes et du syndrome de choc streptococcique.
SOURCE	Ann-Dermatol-Venereol 1993, VOL: 120 (6-7), P: 469-72, ISSN: 0151-9638 43 Refs.
ABSTRACT	A significant increase in the frequency of necrotizing fasciitis caused by streptococci of group A has recently been noted. The disease usually appears in individuals without obvious risk factors. The initial lesion is often quite ordinary, and the evolution towards a toxic shock very swift. This evolution can be summarized as follows: 1) localized infection; 2) bacteraemia with circulating toxins and soft tissue necrosis; 3) production of cytokines by the immune cells of the host, leading to a rapidly irreversible toxic shock. Serotypes 1, 3, 12 and 28 of group A streptococcus are usually involved. The virulence of some serotypes might be explained by the acquisition of a toxic gene. The sensitivity of the host is linked to the genetic expression of the V. beta. elements on the surface of lymphocytes. Antibiotics cannot save the patient when necrotizing fasciitis is installed. Surgery must be massive and performed early. Author.

4. AUTHOR	Kotrappa-K-S, Bansal-R-S, Amin-N-M.
INSTITUTION	University of California, Irvine School of Medicine, USA.
TITLE	Necrotizing fasciitis (published erratum appears in Am Fam Physician 1997 Feb 1; 55(2):448).
SOURCE	Am-Fam-Physician 1996 Apr, VOL: 53 (5), P: 1691-7, ISSN: 0002-838X 18 Refs.
ABSTRACT	Necrotizing fasciitis is a life-threatening, invasive soft-tissue infection that is characterized by widespread, rapidly developing necrosis of the subcutaneous tissue and fascia. It is more likely to occur in patients with a compromised immune system. In type I necrotizing fasciitis, anaerobes and gram-negative bacteria are predominant; in the type II form, the bacterial etiology is group A beta-hemolytic streptococci. The diagnosis must be made on the basis of clinical grounds and is characterized by rapidly developing, painful erythema that progresses to bullous formation and gangrenous necrosis. Author.

5. AUTHOR	Tsai-C-C, Lai-C-S, Yu-M-L, Chou-C-K, Lin-S-D.
INSTITUTION	Department of Surgery, Chung-Ho Memorial Hospital, Kaohsiung Medical College, Taiwan, Republic of China.
TITLE	Early diagnosis of necrotizing fasciitis by utilization of ultrasonography.
SOURCE	Kao-Hsiung-I-Hsueh-Ko-Hsueh-Tsa-Chih 1996 Apr, VOL: 12 (4), P: 235-40, ISSN: 0257-5655.
ABSTRACT	Necrotizing fasciitis is a rare and rapid progression soft tissue infection. The only identifiable feature is tissue necrosis along a single fascia plane. Because the skin is initially spared, it is difficult for early recognition prior to extensive tissue destruction. Ultrasonography was used for early diagnosis of this infection in five cases. All 5 patients presented with severe cellulitis. Under the suspicion of necrotizing fasciitis, ultrasonography was performed before surgical debridement. Tissue biopsy was done for histological confirmation of the diagnosis. Three patients were proven to have necrotizing fasciitis and two cellulitis only. The ultrasonographic findings of necrotizing fasciitis included: 1) irregularity of the fascia; 2) abnormal fluid collections along the fascia plane; and 3) diffuse thickening of the fascia when compared with the control site in the normal limb. However, in severe infectious cellulitis, the above mentioned findings were not observed. Our results indicate the usefulness of the ultrasonography for early diagnosis of necrotizing fasciitis. Author.

6. AUTHOR	Rouse-T-M, Malangoni-M-A, Schulte-W-J.
INSTITUTION	The Department of Surgery, The Medical College of Wisconsin, Milwaukee.
TITLE	Necrotizing fasciitis: a preventable disaster.
SOURCE	Surgery 1982 Oct, VOL: 92 (4), P: 765-70, ISSN: 0039-6060.
ABSTRACT	Twenty-eight cases of necrotizing fasciitis (NF) were treated in 27 patients. Most commonly these infections were caused by perineal disease, operative procedures, and cutaneous ulcers. Associated chronic diseases were present in 21 patients. Postoperative fasciitis occurred when prophylactic antibiotics were omitted or used inappropriately during clean-contaminated or contaminated procedures and when primary skin closure was done in the presence of intra-abdominal contamination. All but four infections were polymicrobial. The overall mortality rate was 73% (20 of 27). Death was due to persistent would sepsis in nine, systemic septic complications despite apparent local control of the infection in nine, and myocardial infarction in two patients. Five of seven survivors had NF limited to one region (leg, perineum, or abdomen). Only 2 of 15 patients survived when more than one debridement was necessary to control ongoing wound necrosis. Eleven of 12 patients who had a delay in treatment for more than 12 hours died. These results suggest that prompt recognition and treatment of NF are essential for survival. The presence of chronic debilitating diseases may contribute to the uncontrollable nature of both local and systemic infection, further emphasizing the need for early diagnosis. Postoperative fasciitis is potentially preventable by strict adherence to the principles for management of contaminated procedures. Author.