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Flesh-Eating Diseases



Flesh-Eating Diseases

Necrotizing Fasciitis (NF)

Necrotizing fasciitis (NF) - is a life-threatening infection of the soft tissues of the 3rd level by the anatomical classification of Ahrenholz, and is characterized by rapidly progressive necrosis of the superficial fascia and surrounding tissues, accompanied by endotoxemia with the outcome in severe sepsis and multiple organ failure (Ahrenholz, 1991). At its core, necrotizing fasciitis is a form of infectious gangrene or cellulitis, which is rapidly progressing with lesions of the skin, subcutaneous tissue, and superficial fascia. According to Wilson, fascial necrosis is the main feature of the pathognomonic disease. According to the literature, the incidence of NF was 0.4 per 100,000 populations (Kaul, McGeer & Low, 1997).

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Mortality statistics by Mc Henry's team are 33% (McHenry, Piotrowsky & Petrinick, 1995). It is believed that the source of infection is damaged skin (abrasions, wounds, including operational, burns, scrapes) and purulent diseases. Among the most published in foreign and domestic journals of articles number of patients with HF is not more than 7-10, and are often limited to a description of 1-2observations, highlighting the importance of this relatively rare but life-threatening disease, the frequency of which in recent years has increased markedly.

NF diagnosis is difficult, first, because of the lack of specific symptoms, and secondly, due to the lack of awareness of physicians about this disease. Symptoms of strep infection start with fever and intense local pain. Microvascular thrombosis causes ischemic necrosis, leading to the rapid spread of infection and disproportionately increasing intoxication. Guiliano highlighted two forms of necrotizing fasciitis (Giuliano, Lewis & Hadley, 1979).

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Streptococcus Pyogenes

On the one hand, infection is presented by A hemolyzed (Streptococcus pyogenic) bacteria, the other - mixed infection anaerobes and facultative anaerobic bacteria (Escherichia coli, Proteus mirabilis, Enterobacteria cloacae, Klebsiella pneumonia, Serratia marcescens) (Fink, 2002). The greatest danger about the prognosis of the clinical course of the disease is the first variant of necrotizing fasciitis with a high risk of developing the syndrome of streptococcal septic shock.

Streptococcus pyogenes due to the evolution of exotoxin leads to severe endotoxemia with the outcome in severe sepsis and multiple organ failure, and is referred to as streptococcal septic shock, which is the clinical sign of pain in the areas of local manifestations, systolic blood pressure below 90 mm Hg, which develops adult respiratory distress syndrome, generalized erythematous rash, possibly with formation of bubbles (Wilson, 1952) (Gregoro, Alliffi & Bollo, 1999).

NF risk factors include children, old age people, and people diagnosed with diabetes, obesity, cancer, alcoholism, drug abuse, and the use of non-steroidal anti-inflammatory drugs as well. The pathogenesis of necrotizing fasciitis is microvascular thrombosis of the skin and underlying tissues, which explains the necrosis progression rapidity of the superficial fascia. It is not limited to the particular section of it and strikes a spectacular wide region, the corresponding area of the microvascular circulation. At the same morphological changes in the fascial formations is not initially inflammatory and gangrenous character.

Poor prognosis and aggressive nature, lead to the need for immediate, radical surgery, which is considered in the literature undisputed and should give extra time, (Dalal, Sterne & Murray, 2003). The main goal of surgery is the excision of necrotic tissue and the reduction of microbial contamination. Excision of infected necrotic tissue to clean, healthy fascia is always shown to stop the infection. According to many authors, only fast radical debridement may reduce mortality among these patients. According to these authors, mortality among patients who had an admitted delay in surgical treatment, was 38%, whereas in patients who underwent immediate neurectomy - 4.2%.

In cases of necrotizing fasciitis without surgical intervention, mortality was 100%. This principle should be applied to so-called lampas sections, which are ineffective due to their palliative nature. After the sanitation, necrotic areas are cared for after thorough washing of wounds with antiseptics and loose grouting gauze soaked in an antiseptic solution. The first dressing is done under general anesthesia in 12-24 hours to audit the wound, and if necessary, re-neurectomy, the purpose of which is reducing the high risk of developing severe sepsis.

Anti-bacterial, detoxification, immunomodulatory therapy, as well as respiratory, hemodynamic, and Nutrition Support should be carried out in the intensive care unit. It is difficult to overestimate the role of antibiotic therapy in the treatment of NF, but the choice of starting an antibiotic is challenging. Given that in the NF often found S. Pyogenes and S.Aureus and high sensitivity to streptococcus B-lactam antibiotics, a standard therapy of streptococcal NF is the use of penicillin (12 million units intravenously over 4 hours) or clindamycin (1.2 g intravenously over 6 hours).

In addition, the use of ceftriaxone is recommended, and in the case of mixed microflora - clindamycin can inhibit the formation of toxin streptococci. A significant factor, positively affecting survival, will be possibly a short interval over before diagnosis in combination with an immediate, uncompromising debridement.

Surveillance of Streptococcal Infection

The program (system) of surveillance of streptococcal infection consists of three independent subsystems:

  1. Information and analysis.
  2. Diagnosis.
  3. Management.

Information and analytical subsystem is the base section of surveillance and includes registration of different clinical forms of streptococcal infection, tracking the dynamics of morbidity, mortality, and the carrier.

The diagnostic subsystem surveillance aims to produce real ideas about the epidemiology of streptococcal infection. To do this, personnel should:

  1. Identify patterns of spread of disease in time, the territory, and among different age and social groups.
  2. Define the conditions which increase morbidity.
  3. Implement a retrospective epidemiological and operational analysis.
  4. Conduct a daily assessment of the epidemiological situation in organized groups, the analysis of the incidence of acute respiratory movements, sore throat, and scarlet fever, followed by the implementation of an appropriate set of control activities (early detection and isolation of patients with high-grade isotropic treatment and medical monitoring-exposed). All of these actions are carried out by health care workers;
  5. Microbiological monitoring includes monitoring the latitude circulation of the pathogen population, the definition of group A streptococci and the study of their biological properties, sensitivity to antibiotics and disinfectants;
  6. Plan emergency immunological control, which is conducted to identify the time and the risk level of infection among the population, implementation of operational and retrospective evaluation of the epidemiological situation, and to decipher the causes of domestic outbreaks of streptococcal infection in organized groups, and health care facilities.

The results obtained are the basis of adequate planning and implementation of prevention measures for intervention during the epidemic process. The main prerequisites worsening epidemic situation of streptococcal infection is the "mixing", created in the formation and renewal of organized groups, conditions for the existence of these groups, promote the exchange of strains of the pathogen, and the harbingers - the growth of the number of pathogen carriers, emergence erased forms of streptococcal infection, diagnosed as acute respiratory infections, circulation defined (virulent) type and identification of molecular biological markers (clones) streptococcus. The determination of activation of the epidemic process and should be carried out based on serological tests.

The management subsystem: management functions are performed by medical centers. The main functional activities of officials of the centers are epidemiology, diagnostic, and supervision (control). These functions are performed by a physician-epidemiologist, who oversees an exact group and ensures the organization of activities for the prevention of streptococcal infection among the population in the service area. Depending on the epidemiological situation, epidemiologists and specialists of the health department and other departments of the Sanitary Inspection Center stress the importance of hygiene of children and adolescents.

One of the most important sections of the surveillance is a retrospective analysis. Retrospective analysis is the study of the epidemiological situation in the past to obtain the necessary data for planning and forecasting the anti-epidemic levels of disease in the future. In the process of retrospective analysis it is important to identify the patterns of manifestation of the epidemic process of respiratory streptococcal infection (sore throat, scarlet fever, and acute respiratory infections) in time, space and among different population groups and cracked "risk factors", i.e. the conditions that determine the risk of infection and the risk of various population groups.

Stages of the retrospective analysis:

  1. Identification of areas of research.
  2. Collection and primary processing.
  3. The study of information in key areas.
  4. Statement of the epidemiological diagnosis.

The objectives of the retrospective analysis are:

  1. Evaluation of the structure and dynamics of morbidity levels of streptococcal infection on its clinical manifestations.
  2. A separate analysis of morbidity.
  3. Evaluation of the effectiveness and quality of the work on the prevention of streptococcal infection.

The analysis of streptococcal infection provides:

  1. Analysis of the cumulative incidence of long-term dynamics of the population.
  2. Analysis of the annual (monthly, intra-annual) aggregate population dynamics of the disease.
  3. Analysis of morbidity in populations selected on epidemiological grounds and some organized groups.
  4. Analysis of the quality and effectiveness of control activities.

Analysis of the structure and dynamics of disease streptococcal infection in the service area is based on the official records of materials available in the centers of state sanitary, health centers, preschools, regional health authorities, and characterize the incidence of all clinical signs of infection. Annual and monthly incidence is analyzed among the following populations:

  1. Total population.
  2. Children of pre-school educational institutions (nursery).
  3. Students.
  4. The adult population of the service area.

More detailed analysis of the incidence held in each of the mentioned groups. Annual (monthly) disease dynamics in the analyzed were estimated about the annual dynamics of disease, calculated based on mean data for all groups of the population. It also analyzes the long-term dynamics of the disease.

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The result of the retrospective analysis is to establish the incidence of "time risk", "risk areas", "risk", and inside them - specific risk groups, "risk factors" and the forecast of the epidemiological situation. Information provision retrospective analysis involves the following steps:

  • to provide information on the incidence of the total population and selected groups;
  • to provide demographic information;
  • to provide information on the number of organized groups of children and adults, hygienic characteristics, conditions of work and life, and others;
  • focus control activities and their effectiveness, especially in organized groups;
  • the primary statistical analysis: checking the completeness and accuracy of the information, and a summary of the primary group.

Before proceeding to the analysis of baseline information necessary to assess its completeness and accuracy. To verify the completeness and accuracy of the initial information, medical personnel can use the following methods:

  1. Roll-comparison of cases identified in various accounting and reporting documents: a journal of infectious diseases, charts with the development of children, emergency notifications, etc.;
  2. A comparison of the characteristics identified in the literature (the severity of the clinical course of the disease, the manifestations of the epidemic process, etc.).


Thus, in conclusion, we must admit that necrotizing fasciitis is a severe condition of soft tissues. Because of its rarity, low awareness of physicians, timely diagnosis presents great difficulties. The main method of treatment of this disease is early radical nephrectomy against intensive antibiotic therapy. Timely diagnosis, adequate surgical benefit, rational antibiotic therapy, full intensive care, including nutrition and immune correction play a major role in the successful treatment of severe infections of soft tissue, which is essential for a proper understanding of the anatomical and pathophysiological features of the flow of microbial infections in soft tissues.

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