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Fitzpatrick's Dermatology, 9th Edition (Chapter-based Decks) > 153: Necrotizing Fasciitis > Flashcards

153: Necrotizing Fasciitis Flashcards

1
Q

What characterizes necrotizing fasciitis?

A

Necrotizing fasciitis is characterized by rapid progression of infection, spreading along the fascial plane, leading to progressive necrosis and high mortality rates if not diagnosed and managed promptly.

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2
Q

What are the common predisposing comorbidities associated with necrotizing fasciitis?

A

Common predisposing comorbidities include diabetes, cardiovascular disease, IV drug abuse, peripheral vascular disease, venous stasis, obesity, smoking, alcohol abuse, cirrhosis, malignancy, corticosteroid use, and chronic kidney disease.

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3
Q

What is the typical source of bacterial introduction in necrotizing fasciitis cases?

A

The majority of necrotizing fasciitis cases are community acquired via bacterial introduction through a break in the skin. In some cases, the site of bacterial introduction is never identified.

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4
Q

What are the clinical scenarios where polymicrobial infections are particularly high in necrotizing fasciitis?

A

Polymicrobial infections are particularly high in bowel-associated infections, decubitus ulcers, IV drug users, and spread from genital sites.

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5
Q

What is the most likely source of infection for a patient with necrotizing fasciitis and a history of recent abdominal surgery?

A

The most likely source of infection is bowel-associated, such as a perianal abscess or penetrating abdominal trauma.

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6
Q

How does corticosteroid use predispose to necrotizing fasciitis?

A

Corticosteroid use suppresses the immune system, increasing susceptibility to infections like necrotizing fasciitis.

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7
Q

What is the most likely site of infection for a patient with necrotizing fasciitis and a history of recent episiotomy?

A

The most likely site of infection is along the uterus or at the episiotomy site.

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8
Q

How does alcohol abuse predispose to necrotizing fasciitis?

A

Alcohol abuse impairs immune function and liver function, increasing susceptibility to infections like necrotizing fasciitis.

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9
Q

How does venous stasis predispose to necrotizing fasciitis?

A

Venous stasis leads to poor circulation and tissue hypoxia, creating an environment conducive to infection.

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10
Q

How does smoking predispose to necrotizing fasciitis?

A

Smoking impairs vascular function and immune response, increasing susceptibility to infections like necrotizing fasciitis.

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11
Q

How does malignancy predispose to necrotizing fasciitis?

A

Malignancy can lead to immunosuppression and tissue breakdown, increasing susceptibility to infections like necrotizing fasciitis.

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12
Q

How does chronic kidney disease predispose to necrotizing fasciitis?

A

Chronic kidney disease impairs immune function and wound healing, increasing susceptibility to infections like necrotizing fasciitis.

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13
Q

How does cirrhosis predispose to necrotizing fasciitis?

A

Cirrhosis impairs immune function and liver detoxification, increasing susceptibility to infections like necrotizing fasciitis.

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14
Q

How does obesity predispose to necrotizing fasciitis?

A

Obesity is associated with poor circulation and immune dysfunction, increasing susceptibility to infections like necrotizing fasciitis.

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15
Q

How does peripheral vascular disease predispose to necrotizing fasciitis?

A

Peripheral vascular disease leads to poor circulation and tissue hypoxia, creating an environment conducive to infection.

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16
Q

How does diabetes predispose to necrotizing fasciitis?

A

Diabetes impairs immune function and wound healing, increasing susceptibility to infections like necrotizing fasciitis.

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17
Q

How does cardiovascular disease predispose to necrotizing fasciitis?

A

Cardiovascular disease impairs circulation and tissue oxygenation, increasing susceptibility to infections like necrotizing fasciitis.

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18
Q

How does IV drug use predispose to necrotizing fasciitis?

A

IV drug use introduces pathogens directly into the bloodstream or tissues, increasing the risk of infections like necrotizing fasciitis.

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19
Q

What was the average number of admissions for necrotizing soft-tissue infections in the United States from 1998 to 2010?

A

The average was between 3800 to 5800 admissions annually.

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20
Q

What was the prevalence of pediatric necrotizing fasciitis between 2010 and 2015?

A

It was 0.8 per 1 million patient-years.

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21
Q

What role do bacterial enzymes play in necrotizing fasciitis?

A

Bacterial enzymes assist in tissue breakdown and rapid progression of the disease.

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22
Q

What is the significance of polymicrobial infections in necrotizing fasciitis?

A

They are often polymicrobial with up to 5 pathogens identified in many cases.

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23
Q

What are the early cutaneous features of necrotizing fasciitis?

A

Early features include erythema, pain, and surrounding edema that mimic classic cellulitis.

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24
Q

What systemic symptoms may arise as necrotizing fasciitis progresses?

A

Early complaints include malaise, fever, nausea, and vomiting. As the condition worsens, patients may experience tachycardia, disorientation, and lethargy.

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25
Q

What are the four major subtypes of necrotizing fasciitis based on microbial pathogens?

A

Type I: Polymicrobial infections; Type II: Monomicrobial infections; Type III: Infections caused by Vibrio spp.; Synergistic Necrotizing Cellulitis: Type I with necrosis extending to muscle.

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26
Q

What is Fournier Gangrene?

A

Fournier Gangrene is localized to the genitalia, perineum, anus, and occasionally the skin of the lower abdomen.

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27
Q

What is the common age range for patients presenting with Fournier Gangrene?

A

Generally between 50 to 60 years old.

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28
Q

What are the stages of cervical and craniofacial necrotizing fasciitis?

A

Stage 1: Tenderness, erythema, swelling, and heat; Stage 2: Blistering and bullae; Stage 3: Crepitus, anesthesia, and skin necrosis.

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29
Q

What is the significance of the progression from severe pain to anesthesia in necrotizing fasciitis?

A

The progression indicates nerve damage due to tissue necrosis, a hallmark of advanced necrotizing fasciitis.

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30
Q

What is the most common isolate in community-acquired necrotizing soft-tissue infections?

A

Streptococcus pyogenes.

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31
Q

What are the early cutaneous features of necrotizing fasciitis?

A

Early cutaneous features include erythema, pain, and surrounding edema that mimic classic cellulitis.

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32
Q

How do the cutaneous features of necrotizing fasciitis progress as the disease advances?

A

As the disease progresses, more dramatic changes in color occur, development of bullae, and eventually gangrenous or necrotic changes of the skin and subcutaneous tissues.

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33
Q

What systemic symptoms arise as necrotizing fasciitis progresses?

A

Systemic symptoms include malaise, fever, nausea, and vomiting, eventually leading to tachycardia, disorientation, and lethargy.

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34
Q

What is the classification of necrotizing fasciitis based on microbial pathogens?

A

Necrotizing fasciitis is classified into Type I (polymicrobial infections) and Type II (monomicrobial infections).

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35
Q

What are the clinical features and staging of cervical and craniofacial necrotizing fasciitis?

A

Stage 1: tenderness, erythema, swelling, and heat; Stage 2: blistering and bullae; Stage 3: crepitus, anesthesia, and skin necrosis.

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36
Q

What is Fournier gangrene and its typical clinical features?

A

Fournier gangrene is localized to the genitalia, perineum, anus, and occasionally the lower abdomen, typically presenting in patients aged 50 to 60 years.

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37
Q

What is the gold standard for diagnosing necrotizing fasciitis?

A

The gold standard for diagnosis is surgical consultation and exploration of the concerning site.

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38
Q

What are the key clinical features that suggest necrotizing fasciitis?

A

Key clinical features include erythema, edema, and pain involving the genitalia and surrounding skin, along with systemic symptoms.

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39
Q

What is the role of the LRINEC scoring system in necrotizing fasciitis?

A

The LRINEC scoring system helps detect early cases of necrotizing fasciitis, with a score of 6 points or more indicating high suspicion.

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40
Q

What are the mortality rates associated with necrotizing fasciitis?

A

Adult mortality rates range from 20% to 30%, while pediatric mortality rates are approximately 10% to 15%.

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41
Q

What surgical intervention is often considered for patients with extensive rectal involvement in necrotizing fasciitis?

A

For patients with extensive rectal involvement, diverting colostomy can be considered.

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42
Q

What is the most likely diagnosis for a patient with erythema, edema, and severe pain in the lower extremity?

A

The most likely diagnosis is necrotizing fasciitis, with the next step being immediate surgical consultation.

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43
Q

What is the diagnosis for a patient with erythema, edema, and pain in the genital area who is febrile and hypotensive?

A

The diagnosis is Fournier gangrene, and a CT scan can help delineate the extent of involvement.

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44
Q

What does a LRINEC score of 7 indicate?

A

A LRINEC score of 7 indicates a high likelihood of necrotizing fasciitis, with the next step being immediate surgical intervention.

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45
Q

What additional surgical procedure might be considered for a patient with necrotizing fasciitis involving the perineum?

A

A diverting colostomy might be considered to minimize fecal contamination.

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46
Q

What does a gray, dusky, edematous fascial plane on surgical exploration confirm?

A

This finding confirms the diagnosis of necrotizing fasciitis.

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47
Q

What does a LRINEC score of 4 indicate?

A

A LRINEC score of 4 indicates a low likelihood of necrotizing fasciitis.

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48
Q

What is the mainstay of therapy for necrotizing fasciitis?

A

The mainstay of therapy is rapid surgical intervention.

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49
Q

What is the recommended time frame for surgical intervention to improve clinical outcomes in necrotizing fasciitis?

A

Surgical intervention should occur less than 24 hours following onset.

50
Q

What is a common surgical procedure for patients with limb disease due to necrotizing fasciitis?

A

Amputation may be necessary for patients with limb disease.

51
Q

What is essential for achieving therapeutic success in necrotizing fasciitis treatment?

A

Full surgical debridement of all necrotic areas is essential.

52
Q

What type of antibiotics are recommended for necrotizing fasciitis?

A

Broad-spectrum antibiotics are recommended.

53
Q

What should be monitored closely in patients with necrotizing fasciitis?

A

Fluid resuscitation and electrolyte balance should be monitored closely.

54
Q

What is the role of IV immunoglobulin in the treatment of necrotizing fasciitis?

A

Some benefit is suggested, but data is limited.

55
Q

What is the recovery process like for patients who survive necrotizing fasciitis?

A

The recovery process is often long and laborious.

56
Q

What is the significance of the anatomical location of disease in necrotizing fasciitis?

A

It has not been found to be a risk factor for mortality.

57
Q

What is the importance of fluid resuscitation in the management of necrotizing fasciitis?

A

Fluid resuscitation is crucial due to significant drainage from lesions.

58
Q

What are the defining features of gangrenous or necrotizing cellulitis?

A

Gangrenous or necrotizing cellulitis is characterized by rapidly progressive infection of the skin and subcutaneous tissue.

59
Q

What is the management approach for necrotizing cellulitis?

A

The management includes surgical debridement and antimicrobial therapy.

60
Q

What are the two major infections included in myonecrosis?

A

The two major infections are pyomyositis and clostridial gas gangrene.

61
Q

What is the management approach for necrotizing cellulitis?

A

The management of necrotizing cellulitis includes:
1. Surgical debridement to remove necrotic tissue.
2. Antimicrobial therapy as outlined by the IDSA guidelines, which is essential for effective treatment.

62
Q

What are the two major infections included in myonecrosis?

A

The two major infections included in myonecrosis are:
1. Pyomyositis
2. Clostridial gas gangrene

63
Q

What factors increase the risk of developing pyomyositis?

A

Factors that increase the risk of developing pyomyositis include:
- Immunosuppression (e.g., HIV)
- Diabetes mellitus
- Preceding bacteremia or local skin and soft-tissue infections
- Localized trauma or muscle overuse
- Predilection sites are the lower extremities and pelvic girdle.

64
Q

What is the prevalence of pyomyositis in the developed world?

A

The prevalence of pyomyositis in the developed world ranges from 1 per 1145 to 1 per 4000 hospital admissions, accounting for approximately 1% of all hospital admissions.

65
Q

What does subcutaneous emphysema suggest about the type of infection?

A

Subcutaneous emphysema suggests a gas-forming infection, which could be clostridial or nonclostridial necrotizing cellulitis.

66
Q

What is the most likely causative organism for necrotizing fasciitis after swimming in tropical waters?

A

The most likely causative organism is Vibrio vulnificus.

67
Q

What is gangrenous or necrotizing cellulitis?

A

A type of necrotizing infection localized to the skin and subcutaneous tissue, not extending deep enough to involve the underlying fascia or muscles.

68
Q

What is a defining feature of nonclostridial necrotizing cellulitis?

A

Subcutaneous emphysema.

69
Q

What is the cornerstone of therapy for necrotizing infections?

A

Surgical debridement in conjunction with antimicrobial therapy.

70
Q

What role does Panton-Valentine leukocidin play in pyomyositis?

A

It is thought to play a role in the development of pyomyositis and the ability to create intramuscular infections.

71
Q

What are the defining features of Clostridial crepitant cellulitis?

A

Clostridial crepitant cellulitis is characterized by:
- Limited, superficial, and focal infections of the skin.
- Often presents without severe systemic symptoms.
- Extensive subcutaneous emphysema with minimal overlying skin changes.
- Tissue necrosis is limited to superficial skin and subcutaneous tissue.

72
Q

What are the common predilection sites for pyomyositis infections?

A

Lower extremities and pelvic girdle, often following localized trauma or muscle overuse.

73
Q

What is the gold standard for diagnosing pyomyositis?

A

MRI is the gold standard for diagnosing pyomyositis, as it can show muscle inflammation and intramuscular abscess formation.

74
Q

What are the stages of clinical progression in pyomyositis?

A

Stage | Description |
|——-|————-|
| I | Inflammation and pain surrounding the infected muscle with associated leukocytosis; mild induration of subcutaneous tissue; cutaneous changes typically absent. |
| II | Suppuration with abscess formation within the muscle belly; severe focal pain, fever, and swelling over the affected muscle; lasts 1 to 3 weeks. |
| III | Progression to systemic disease with septic physiology, shock, and multifocal abscess formation. |

75
Q

What factors increase the risk of mortality in pyomyositis?

A
  • Septic physiology
  • Hypotension
  • Tachycardia
  • Lower Glasgow coma score
  • Higher Sequential Organ Failure Assessment (SOFA) score
  • Elevated laboratory markers, including blood urea nitrogen, creatinine, bilirubin, and serum glutamic pyruvate transaminase.
76
Q

What is the initial antimicrobial treatment for pyomyositis?

A
  • Start broadly with vancomycin.
  • For patients with multiple comorbidities, immunocompromised status, or developed infection, add Piperacillin-tazobactam, ampicillin-tazobactam, or carbapenem to vancomycin.
77
Q

What distinguishes clostridial gas gangrene from clostridial crepitant cellulitis?

A

Clostridial gas gangrene is a much deeper infection characterized by severe necrosis of skeletal muscle, rapidly progressive, and often accompanied by severe systemic symptoms, with a risk for progression to multiorgan system shock.

78
Q

What are the common pathogens associated with pyomyositis?

A

S. pneumoniae or Gram-negative enteric bacteria, and less commonly viral, parasitic, or fungal pathogens.

79
Q

What are the clinical features of clostridial myonecrosis?

A

The clinical features include:
- Acute abdominal pain followed by localized pain in the limb.
- Rapid progression of lesions over 24 hours with color changes in the skin.
- Severe pain and gas collection in tissue manifesting as crepitus.
- Brownish discharge with a foul smell, described as ‘dishwater exudate.’
- Symptoms resembling an influenza-like prodrome followed by tachycardia, fever, diaphoresis, and hypotension.

80
Q

What is the triad of symptoms that is thought to be diagnostic of clostridial myonecrosis?

A

The triad of symptoms includes:
1. Soft-tissue crepitus
2. Severe pain
3. Tachycardia disproportionate to fever

81
Q

What is the mainstay of therapy for patients with clostridial myonecrosis?

A

The mainstay of therapy includes:
- Surgical debridement
- Multiple surgical debridements and amputations as necessary
- Intensive care unit-level care
- Broad-spectrum antibiotics based on IDSA guidelines, typically clindamycin plus high-dose penicillin.

82
Q

What are the mortality rates associated with clostridial myonecrosis?

A

Mortality rates for clostridial myonecrosis are reported to be as high as 100%, particularly among patients who initially present in shock.

83
Q

What is the significance of ‘dishwater exudate’ in clostridial myonecrosis?

A

The ‘dishwater exudate’ is a characteristic feature of clostridial myonecrosis, indicating severe tissue necrosis.

84
Q

What does the presence of bullae filled with red-blue fluid indicate in necrotizing fasciitis?

A

The presence of bullae filled with red-blue fluid indicates advanced disease with significant tissue necrosis.

85
Q

What systemic complications should be anticipated in a patient with necrotizing fasciitis who is febrile and hypotensive?

A

Systemic complications include septic shock, multiorgan failure, and disseminated intravascular coagulation.

86
Q

What is ‘water exudate’?

A

‘Water exudate’ is a characteristic feature of clostridial myonecrosis, indicating severe tissue necrosis.

87
Q

What systemic complications should be anticipated in a febrile and hypotensive patient with necrotizing fasciitis?

A

Systemic complications include septic shock, multiorgan failure, and disseminated intravascular coagulopathy.

88
Q

What are the most likely causative organisms in a patient with necrotizing fasciitis who has a history of IV drug use?

A

The most likely causative organisms are Clostridium sordellii and Clostridium novyi.

89
Q

What are the most common causative organisms of clostridial myonecrosis?

A

Clostridium perfringens, Clostridium novyi, Clostridium histolyticum, Clostridium septicum, and Clostridium sordellii.

90
Q

What is a prominent feature of clostridial myonecrosis?

A

Severe pain.

91
Q

What is the triad of symptoms thought to be diagnostic of clostridial myonecrosis?

A

Soft-tissue crepitus, severe pain, and tachycardia disproportionate to fever.

92
Q

What is the mainstay of therapy for clostridial myonecrosis?

A

Surgical debridement.

93
Q

What is the mortality rate for clostridial myonecrosis among patients who initially present in shock?

A

As high as 100%.

94
Q

What can progressive myonecrosis lead to?

A

Myoglobinuria and subsequent renal failure.

95
Q

What is the recommended antibiotic therapy for clostridial myonecrosis?

A

Clindamycin plus high-dose penicillin.

96
Q

What is a significant risk factor for developing spontaneous clostridial myonecrosis?

A

Underlying gastric malignancy or neutropenic gastritis.

97
Q

What is the clinical significance of gas collection in clostridial myonecrosis?

A

It manifests as overlying crepitus and indicates severe infection.

98
Q

What are the common causative organisms of spontaneous clostridial myonecrosis?

A

Clostridium perfringens, Clostridium novyi, Clostridium histolyticum, Clostridium septicum, and Clostridium sordellii.

99
Q

What are the clinical features indicative of clostridial myonecrosis?

A

Key clinical features include:
- Acute abdominal pain followed by localized limb pain.
- Rapid progression of lesions within 24 hours, with color changes in the skin.
- Severe pain and crepitus in the affected area.
- Brownish discharge with a foul smell, described as ‘dishwater exudate.’
- Symptoms resembling an influenza-like prodrome followed by tachycardia, fever, and hypotension.
- High risk for compartment syndrome and potential progression to shock and multiorgan failure.

100
Q

What is the triad of symptoms that is thought to be diagnostic of clostridial myonecrosis?

A

The triad of symptoms indicative of clostridial myonecrosis includes:
1. Soft-tissue crepitus
2. Severe pain
3. Tachycardia disproportionate to fever.

101
Q

What is the mainstay of therapy for patients with clostridial myonecrosis?

A

The mainstay of therapy for clostridial myonecrosis includes:
- Surgical debridement
- Multiple surgical interventions as needed
- Broad-spectrum antibiotics based on IDSA guidelines, typically clindamycin plus high-dose penicillin.
- Intensive care unit-level care is often required.

102
Q

What are the mortality rates associated with clostridial myonecrosis, and what factors influence these rates?

A

Mortality rates for clostridial myonecrosis can be as high as 100%, particularly among patients who present in shock. Factors influencing these rates include:
- Delay in surgical intervention
- Severity of the initial presentation
- Presence of comorbid conditions.

103
Q

What are the first-line antimicrobial agents for mixed infections in adults and their dosages?

A

The first-line antimicrobial agents for mixed infections in adults are:
- Piperacillin-tazobactam: 3.37 g q6h IV; 30 mg/kg/day in 2 divided doses
- Vancomycin: 30 mg/kg/day IV in 2 divided doses.

104
Q

What is the pediatric dosage for meropenem in patients with necrotizing soft-tissue infections?

A

The pediatric dosage for meropenem is:
- Children 3 months to 12 years: 20 mg/kg/dose q8h IV.

105
Q

What are the recommended agents for patients with severe penicillin allergy when treating Staphylococcus aureus infections?

A

For patients with severe penicillin allergy, the recommended agents for treating Staphylococcus aureus infections are:
- Vancomycin, Linezolid, Quinupristin/Dalfopristin, Daptomycin.

106
Q

What is the adult dosage for clindamycin in treating necrotizing soft-tissue infections?

A

The adult dosage for clindamycin in treating necrotizing soft-tissue infections is:
- 600 to 900 mg q8h IV.

107
Q

What is the pediatric dosage for doxycycline in treating Aeromonas hydrophila infections?

A

The pediatric dosage for doxycycline in treating Aeromonas hydrophila infections is:
- Not recommended for children; may need to use in life-threatening situations.

108
Q

What is the first-line antimicrobial agent for mixed infections in adults according to the 2014 guidelines?

A

Piperacillin-tazobactam or vancomycin.

109
Q

What is the recommended adult dosage for meropenem in treating necrotizing soft-tissue infections?

A

1 g q8h IV.

110
Q

What is the pediatric dosage for piperacillin compared to the adult dosage?

A

60 to 75 mg/kg/dose q8h IV for pediatric patients, compared to 30 mg/kg/day in 2 divided doses for adults.

111
Q

What is the first-line antimicrobial agent for treating Streptococcus infections?

A

Penicillin plus clindamycin.

112
Q

What is the adult dosage for vancomycin for resistant strains?

A

30 mg/kg/day in 2 divided doses IV.

113
Q

What is the pediatric dosage for clindamycin in treating necrotizing soft-tissue infections?

A

10 to 13 mg/kg/dose q8h IV.

114
Q

What is the recommended treatment for Clostridium spp. infections?

A

Clindamycin plus penicillin.

115
Q

What is the adult dosage for doxycycline in treating Aeromonas hydrophila infections?

A

100 mg q12h IV; 500 mg q12h IV; 1 to 2 g q24h IV.

116
Q

What is the recommended treatment for Vibrio vulnificus infections?

A

Doxycycline plus ceftriaxone or cefotaxime.

117
Q

What are the first-line antimicrobial agents recommended for treating mixed infections in patients with necrotizing soft-tissue infections, and what are their adult dosages?

A

The first-line antimicrobial agents for mixed infections are:
- Piperacillin-tazobactam: 3.375 g q6h IV; 30 mg/kg/day in 2 divided doses
- Vancomycin: 20 mg/kg/dose q8h IV.

118
Q

What is the recommended dosage for meropenem in pediatric patients with necrotizing soft-tissue infections?

A

The recommended dosage for meropenem in pediatric patients is:
- Children 3 months to 12 years: 20 mg/kg/dose q8h IV.

119
Q

What are the alternative agents for patients with severe penicillin allergy when treating Staphylococcus aureus infections?

A

For patients with severe penicillin allergy, the alternative agents for treating Staphylococcus aureus infections include:
- Vancomycin, linezolid, quinupristin/dalfopristin, daptomycin.

120
Q

What is the pediatric dosage for clindamycin in treating infections caused by Clostridium spp. in children?

A

The pediatric dosage for clindamycin in treating infections caused by Clostridium spp. is:
- Children 1 to 13 years: 10 to 13 mg/kg/dose q8h IV.

121
Q

What is the recommended adult dosage for doxycycline in treating infections caused by Aeromonas hydrophila?

A

The recommended adult dosage for doxycycline in treating infections caused by Aeromonas hydrophila is:
- 100 mg q12h IV; 500 mg q12h IV.

Fitzpatrick's Dermatology, 9th Edition (Chapter-based Decks) (48 decks)

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