Summary
Objective
The aim of the study is to report a case of multi-focal necrotising fasciitis, review
research on this subject to identify common aetiological factors and highlight suggestions
to improve management.
Context
Necrotising fasciitis is a severe, life-threatening soft tissue infection that typically
arises from a single area, usually secondary to a minor penetrating injury. Multi-focal
necrotising fasciitis, where there is more than one non-contiguous area of necrosis,
is much less commonly reported. There are no guidelines specific to the management
of multi-focal necrotising fasciitis, and its under-reporting may lead to missed management
opportunities.
Design
A systematic literature review in accordance with the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) protocol.
Data sources
A search of MEDLINE, OLD MEDLINE and the Cochrane Collaboration was performed from
1966 to March 2011 using 16 search terms.
Data extraction
All articles were screened for genuine non-contiguous multi-focal necrotising fasciitis.
Of the papers that met this criterion, data on patient demographics, likely inciting
injury, presentation time-line, microbial agents, sites affected, objective assessment
scores, treatment and outcome were extracted.
Data synthesis
A total of 31 studies met our inclusion criteria and 33 individual cases of multi-focal
necrotising fasciitis were included in the quantitative analysis. About half (52%)
of cases were type II necrotising fasciitis; 42% of cases had identifiable inciting
injuries; 21% of cases developed multi-focal lesions non-synchronously, of which 86%
were type II. Nearly all (94%) of cases had incomplete objective assessment scores.
One case identified inflammatory imaging findings prior to clinical necrosis.
Conclusions
Multifocality in necrotising fasciitis is likely to be associated with type II disease.
We postulate that validated objective tools will aid necrotising fasciitis management
pathways that will identify high-risk groups for multifocality and advise early pre-emptive
imaging. We recommend the adoption of regional multi-focal necrotising fasciitis registers.
Keywords
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References
- Necrotising fasciitis: early awareness and principles of treatment.Isr L Med Sci. 1985; 21: 127-132
- Determinants of mortality or necrotising soft-tissue infections.Ann Surg. 1995; 221: 558-565
- Necrotising fasciitis, hospital gangrene, and phagedena.Lancet. 1994; 344: 1416-1419
- Treatise on surgical infections.Oxford University Press, New York, NY1948 (15)
- Haemolytic streptococcus gangrene.Arch Surg. 1924; 9: 317-364
- Necrotizing fasciitis.Am Surg. 1952; 18: 416-431
- Necrotising fasciitis: review of the literature and case report.Clin Orthop Relat Res. 1987; 216: 187-192
- Necrotising fasciitis.Lancet. 1994; 343: 1427
- Invasive group A streptococcal infections.Clin Infect Dis. 1992; 14: 2-13
- Necrotising fasciitis due to group A streptococci in western Norway: incidence and clinical features.Lancet. 1994; 344: 1111-1115
- Bacteriology of necrotizing fasciitis.Am J Surg. 1977; 134: 52-57
- Diagnosis and management of necrotising fasciitis: a multiparametric approach.J Hosp Infection. 2010; 75: 249-257
- Epidemiology of invasive group A streptococcal necrotizing fasciitis.Clin Infec Dis. 2002; 35: 268-276
- Necrotizing candidal fasciitis following hip surgery.Orthopedics. 1990; 13: 768-770
- Zygomycotic necrotizing fasciitis in immunocompetent patients: a series of 18 cases.Mod Path. 2006; 19: 1221-1226
- Multiple dimensions of caring for a patient with acute necrotizing fasciitis.Dimen Crit Care Nurs. 2006;Jan-Feb; 25: 15-21
- Necrotizing fasciitis: a model nursing plan.MedSurg Nurs. 2002; 11: 37-43
- Necrotizing fasciitis in adults due to group B streptococcus.Arch Inten Med. 1988; 148: 727-729
- The LRINEC (laboratory risk indicator for necrotiszing fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections.Crit Care Med. 2004; 32: 1535-1541
- Tissue oxygen saturation monitoring in diagnosing necrotizing dasciitis of the lower limb: a valuable tool but only for a select few.Ann Emerg Med. 2005; 45: 462
- Clinical relevance of the LRINEC (laboratory risk indictor for necrotizing fasciitis) score for assessment of early necrotizing fasciitis.Crit Care Med. 2005; 33: 1677
- The laboratory risk indicator for necrotizing fasciitis (LRINEC) score: useful tool or paralysis by analysis?.Crit Care Med. 2004; 32: 1618-1619
- Objective criteria may assist in distinguishing necrotizing fasciitis from nonnecrotizing soft tissue infection.Am J Surg. 2000; 179: 17-20
- A simple model to help distinguish necrotizing fasciitis from nonnecrotising soft tissue infection.J Am Coll Surg. 2000; 191: 227-231
- Marine bacteria as a leading cause of necrotizing fasciitis in coastal areas of South Korea.Am J Trop Med Hyg. 2009 Apr; 80: 646-650
- The PRISMA group (2009). Preferred reporting items for systematic reviews and Meta-Analyses: the PRISMA Statement.BMJ. 2009; 339: b2535
- Necrotising fasciitis in both calves caused by Aeromonas caviae following aesthetic liposuction.J Plast Reconstr Aesthet Surg. 2010 Sep; 63: e695-e698
- Multifocal necrotizing fasciitis - case report.Adv Med Sci. 2010 Jun; 55: 103-107
- Necrotizing fasciitis caused by Streptococcus pneumoniae.J Dermatol. 2009 May; 36: 298-305
- Exploring the pathogenesis of necrotizing fasciitis due to Streptococcus pneumoniae.Scand J Infect Dis. 2002; 34: 639-644
- A rare trifocal presentation of Clostridium septicum myonecrosis.Orthopedics. 2008 Mar; 31: 274
- Klebsiella oxytoca necrotizing fasciitis after orthotopic heart transplant.J Heart Lung Transplant. 2008 Nov; 27: 1265-1267
- Case 2: an 18-month-old child with necrotic lesions on the limbs.Acta Paediatr. 2006 Nov; 95: 1506-1508
- Multi-limb necrotizing fasciitis in a patient with rectal cancer.World J Gastroenterol. 2006 Aug 28; 12: 5256-5258
- Necrotizing fasciitis in an immunocompetent patient with multiple sites of involvement.J Coll Physicians Surg Pak. 2006 Feb; 16: 145-147
- Rapidly progressive necrotizing fasciitis caused by Staphylococcus aureus.Microbiol Immunol Infect. 2005 Oct; 38: 361-364
- Unusual etiology of simultaneous deep space hand infection and necrotizing fasciitis of the foot.Plast Reconstr Surg. 2005 Jul; 116: 10e-13e
- Bacteremic necrotizing fasciitis caused by Vibrio cholerae serogroup O56 in a patient with liver cirrhosis.J Formos Med Assoc. 2004 Dec; 103: 935-938
- Nosocomial infection of Aeromonas hydrophila presenting as necrotizing fasciitis.J Formos Med Assoc. 2004 Jan; 103: 53-57
- Cryptococcal necrotizing fasciitis with multiple sites of involvement in the lower extremities.Dermatol Surg. 2003 Nov; 29: 1158-1160
- Subacute necrotizing fasciitis caused by gas-producing Staphylococcus aureus.Eur J Clin Microbiol Infect Dis. 2003 Oct; 22: 612-614
- Necrotizing fasciitis secondary to chickenpox infection in children.Can J Surg. 2003 Feb; 46: 9-14
- Necrotizing fasciitis: report of 39 pediatric cases.Arch Dermatol. 2002 Jul; 138: 893-899
- Multifocal necrotizing fasciitis in varicella.Pediatr Emerg Care. 1989 Mar; 5: 31-33
- Fatal necrotizing fasciitis following suction-assisted lipectomy.Ann Plast Surg. 1988 Jun; 20: 562-565
- Multifocal community-acquired necrotizing fasciitis caused by a Panton-Valentine leukocidin-producing methicillin-sensitive Staphylococcus aureus.Infection. 2010 Jun; 38: 223-225
- Necrotizing infection of the spine.Spine (Phila Pa 1976). 2006 May 15; 31: E3E42-4
- Multifocal cutaneous mucormycosis complicating polymicrobial wound infections in a tsunami survivor from Sri Lanka.Lancet. 2005 Mar 5–11; 365: 876-878
- Acute kidney injury due to rhabdomyolysis-associated gangrenous myositis.Acta Biomed. 2008 Dec; 79: 246-250
- Gas gangrene without wound: both lower extremities affected simultaneously.Am J Emerg Med. 2008 Oct; 26: 970.e3-970.e4
- Clostridium tertium isolated from gas gangrene wound; misidentified as Lactobacillus spp initially due to aerotolerant feature.Anaerobe. 2007 Jun–Aug; 13 (Epub 2007 Mar 12): 161-165
- Bilateral gas gangrene of the hand - a unique case.Ann R Coll Surg Engl. 2003 Nov; 85: 408-409
- Spontaneous bifocal Clostridium septicum gas gangrene.J Bone Jt Surg Br. 2001 Jan; 83: 115-116
- Pneumorachis caused by metastatic gas gangrene.Diagn Microbiol Infect Dis. 2009 Jan; 63: 108-110
- Group B streptococcal necrotizing fasciitis and streptococcal toxic shock-like syndrome in adults.Arch Intern Med. 1998 Aug 10–24; 158: 1704-1708
- Massive infectious soft-tissue injury: diagnosis and management of necrotizing fasciitis and pupura fulminans.Plast Reconstr Surg. 2001; 107: 1025-1034
- Necrotizing soft tissue infections.Arch Surg. 1996; 131: 846-854
- Magnetic resonance imaging differentiates between necrotizing and non-necrotizing fasciitis of the lower extremity.J Am Coll Surg. 1998; 187: 416-421
- Necrotizing soft tissue infection masquerading as cutaneous abscess following ollicit drug injection.Arch Surg. 1998; 133: 812-818
- Necrotizing soft tissue infections.Arch Surg. 1996; 131: 846-854
- Differentiation of necrotizing fasciitis and cellulitis using MR imaging.AJR. 1998; 170: 615-620
- Gadopentetate dimeglumine-enhanced MR imaging of the musculoskeletal system.AJR. 1991; 156: 457-466
- Diagnosis of osteomylelitis: utility of fat-suppressed contrast enhanced MR imaging.Radiology. 1993; 189: 251-257
- Imaging of musculoskeletal soft tissue infections.Skeletal Radiol. 2010; 39: 957-971
- Severe group A strepococcal infection and streptococcal toxic shock syndrome.Can J Anaesth. 2000; 47: 1129-1140
- Clinical experience with 20 cases of group A streptococcus necrotizing fasciitis and myonecrosis:1995 to 1997.Plast Reconstr Surg. 1999; 103: 1567-1573
- Epidemiology of severe Streptococcus pyogenes disease in Europe.J Clin Microbiol. 2008; 46: 2359-2367
Article info
Publication history
Published online: September 26, 2011
Accepted:
September 1,
2011
Received:
May 25,
2011
Identification
Copyright
© 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Inc. All rights reserved.
