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Necrotizing fasciitis

Infection identification and management

Brennan, Mary R., MBA, BSN, RN, CWON; LeFevre, Florence, MSN, RN, CCRN

doi: 10.1097/01.CCN.0000549627.98688.e2
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Abstract: Necrotizing fasciitis is a life-threatening infection that can affect anyone. Early identification and intervention implementation are key to managing the infection's progression. An effective plan of care includes immediate assessment, antibiotic stewardship, and surgical intervention.

Necrotizing fasciitis (NF) is a life-threatening infection that is best managed through early identification and intervention. This article will help critical care nurses recognize, assess for, and treat NF. An effective plan of care may include antibiotic therapy and surgical debridement.

Mary R. Brennan is an assistant director of wound and ostomy care at North Shore University Hospital, Manhasset, N.Y.

Florence LeFevre is an assistant director of nursing education at North Shore University Hospital, Manhasset, N.Y.

The authors have disclosed no financial relationships related to this article.

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Necrotizing fasciitis (NF), also known as necrotizing soft-tissue infection, is a life-threating infection of the subcutaneous tissue, fascia, and muscles.1 The CDC estimates that 700 to 1,200 cases of NF emerge each year but cautions that these numbers may be an underestimate.2 Most data are collected from statistical reporting on Group A Streptococcus.2 In Fournier gangrene, a form of NF, incidence estimates are 10 times higher in men than women; estimates show an incidence rate of 1.6 men per 100,000.3 The diagnosis and treatment of NF is complex and warrants careful assessment and treatment to improve healthcare outcomes for patients with this potentially fatal infection.

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Pathophysiology

NF is an aggressive bacterial infection that primarily affects the superficial fascia, subcutaneous fat, and deep fascia. The disease begins with inflammation and progresses to skin necrosis that may cause extensive tissue destruction in the end stages. The most common cause of NF is Gram-positive bacteria, such as Escherichia coli (E. coli) and Klebsiella.1,4 Additional bacterial organisms include Group A streptococcal infections, methicillin-resistant Staphylococcus aureus, and methicillin-sensitive Staphylococcus aureus; some cases are caused by fungal infection (Candida).1,4 NF produced by a fungal infection is most often seen in immunocompromised patients.1 Once the bacterial or fungal infection enters the local tissue, it quickly produces a widespread inflammatory response leading to tissue death. The patient experiences systemic toxicity with multiorgan failure that may ultimately result in death.

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Risk factors

In the Cochrane Database of Systematic Reviews, diabetes mellitus was the most commonly cited comorbidity, occurring in 44.5% of patients with NF.1 Liver cirrhosis also has been identified as a major comorbidity.5,6 Each of these disease states contributes to increased mortality. A review of the literature also cites the following as NF risk factors: smoking, I.V. drug use, underlying malignancy, kidney impairment, obesity, malnutrition, peripheral vascular disease, alcohol use, and varicella infections (a risk factor in pediatric patients).4,7 Patients on nonsteroidal anti-inflammatory drugs (NSAIDs) should be closely evaluated and monitored as the NSAIDs may suppress any signs and symptoms of inflammation.7,8 Precipitating events that may contribute to NF include animal and insect bites, childbirth, burns, soft-tissue infections, minor invasive procedures, traumatic injury, and gastrointestinal perforation. In addition, contact with marine life (Vibrio vulnificus, a bacterium found in seawater) and seafood consumption (Aeromonas, a bacterium found in fresh and brackish water) may be considered additional precipitating risk factors.5 Although NF is rarely seen in children, immunosuppression and diabetes may be prominent risk factors in pediatric populations. Aside from patients with Fournier gangrene, gender and advanced age are not cited as risk factors for NF. Patients who present with sepsis, hypotension, chronic kidney disease, or an extension of gangrene to the abdominal wall have been cited with higher mortality.

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Of note, the FDA issued a safety announcement in August 2018 warning that cases of Fournier gangrene have been reported in patients with type 2 diabetes mellitus who are taking sodium-glucose cotransporter-2 (SGLT2) inhibitors. The safety announcement is available on the FDA website, www.fda.gov/Drugs/DrugSafety/ucm617360.htm.

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Clinical presentation and diagnosis

This disease may follow an escalation of symptoms. Initially, a patient with NF will present with intense pain, erythema, and swelling. The pain may be uncharacteristically intense and more than what one would expect with the initial assessment of the wound or identified trauma. Commonly, the areas affected include the trunk or lower extremities whereas the head and neck are considered very unusual locations. (See NF of the foot and calf.)

Fournier gangrene, a form of NF occurring in the perineum, genital, or perianal region, is most commonly seen in men but may also be seen in women and children. In some patients, there may be no discernable wound, but medical history may indicate a recent trauma. Tenderness of the skin or the area surrounding the wound may extend into the borders of the wound. The patient may also experience fever and tachycardia followed by hypotension and tachypnea as the tissue destruction progresses. Initial patient history should focus on the etiology of the wound and concurrent medical history, especially involving comorbidities such as diabetes and liver disease. As the tissue destruction progresses, which may occur rapidly, tenderness and pain intensity may indicate disease progression into the surrounding tissue.

Diagnosis at this stage is vital in controlling tissue destruction. Blood work, including a complete blood cell count, basic metabolic panel, and blood cultures, should be ordered. Imaging studies ordered may include an MRI, computed tomography scan, and ultrasound. In patients with Fournier gangrene, the Fournier's Gangrene Severity Index, which monitors levels of body temperature, heart rate, respiratory rate, sodium, creatinine, hematocrit, white blood cell (WBC) count, bicarbonate, and potassium may be implemented to identify patient mortality risk stratification and need for debridement.9 The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) tool was established in 2004 to distinguish NF from soft-tissue infections (see Laboratory Risk Indicator for Necrotizing Fasciitis).10 A misdiagnosis of soft-tissue infection (cellulitis) could dangerously delay treatment for patients with NF. The tool consists of a scoring system using hemoglobin, WBC count, blood glucose, sodium, creatinine, and C-reactive protein. The results of each level are assigned a score, and the total score is used to evaluate response to severe infections. The potential total score ranges from 0 to 13; scores of 6 or higher indicate a high suspicion of an early diagnosis of NF and may assist the practitioner with initiating a rapid response and escalation of acuity. Later, a modified LRINEC score was introduced; this version includes fibrinogen levels and erythrocyte counts with added clinical symptoms, such as pain, fever, tachycardia, and signs of acute kidney injury that rendered a higher predictive value for diagnosis.11

Table

Table

NF may occur in the pediatric population, but it is an infrequent event in children and early diagnosis is difficult. (See NF in the pediatric population.)

Many physicians will make a clinical diagnosis based on visual symptoms and may include a “finger test,” performed by a surgeon. The finger test involves injecting a local anesthetic into the affected area and creating a 2-cm incision down to the deep fascia. Dishwater-like fluid may be observed upon entry. If inserting the index finger dissects the subcutaneous tissue off from the deep fascia plane, the test is considered positive for NF.7 A positive result indicates the need for emergency surgical debridement.

If left untreated, the infectious process will continue expeditiously and further skin necrosis will occur. Crepitus, hemorrhagic bullae, and a dusky discoloration progressing to frank gangrene may become apparent. Definite symptoms of sepsis are evident, and the patient's clinical presentation deteriorates quickly. In the Cochrane Database of Systematic Reviews, mortalities of 23% were identified with NF; however, various articles in the literature cite rates of 8.7% to 76%.1,4-7

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Treatment

Patients presenting with suspected NF should be triaged for an immediate assessment with the surgical team. Initial care consists of blood work, oxygen therapy, and fluid resuscitation. Blood cultures are drawn and the patient may be placed on broad-spectrum empiric antibiotic therapy until results of the sensitivity are identified. Infectious-disease physicians should be consulted, as NF is a polymicrobial organism and broad-spectrum antibiotics will be prescribed in conjunction with specific Gram-negative antibiotics, which are administered by I.V. infusion. Imaging studies may be ordered and should be done immediately. In some hospitals, the OR is contacted to plan for an emergency surgical procedure. Surgical options, which may consist of serial debridements, will be done. In 2015, the Cochrane Collaboration completed a systematic review of the literature and failed to locate any clinical studies supporting hyperbaric oxygen therapy (HBOT) as an adjunctive treatment, although a study published in 2016 discussed use of HBOT to preserve limbs and stabilize wounds.14,15

Fournier gangrene requires immediate debridement of the affected tissue, antibiotic therapy, and an intensive care setting to monitor a patient's hemodynamic functions. Patients may require temporary or permanent urinary and/or fecal diversion. Skin grafting, negative pressure wound therapy, and reconstructive surgery may be needed depending on the initial and subsequent debridements that were necessary in the management of this infection. Pain management is an important consideration for these patients, especially during dressing changes and potential treatment options. Multiple surgical debridements, potential skin grafting, loss of limbs, and alterations to bodily functions (fecal or urinary diversions) may be undertaken, and pain management should be part of the plan of care.3,7,8,16

For NF in the lower extremities, amputation rates are variable, with 15% to 72% of patients requiring amputation. The amputation rate may be higher in patients with diabetes.17

Cosmetic surgery may be pursued after recovery to reduce unsightly scarring and/or deformities. Patients who undergo amputations may need short- or long-term rehabilitation and prosthetic devices. Patients may require additional support with mental health counseling to accept any disabilities or activity restrictions that may have occurred; for some, the needed additional counseling and support may be in the form of financial funding to cover the costs of rehabilitative care and medical devices.

When considering the care needs of a patient presenting with NF, critical care nurses may need to focus on early detection, pain management, nutrition, and emotional support. The table provided summarizes key nursing considerations when caring for a patient with NF or Fournier gangrene. (See Nursing considerations.)

Former patients may fear an NF recurrence. In the review of the literature for this article, there were no articles noting recurrence in a patient. Nurses may need to remind high-risk patients to seek immediate care for any wounding event.

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Conclusion

In summary, a patient's survival requires immediate NF diagnosis and treatment. Initial assessment of patients presenting with wounds or trauma and reporting pain out of proportion to the injury should be fast-tracked for surgical consultation. Nursing care is essential to support the patient and family, as further care may involve multiple surgeries/procedures and perhaps lifestyle adjustments.

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NF in the pediatric population

Research has shown immunosuppression may be a significant risk factor in pediatric patients presenting with NF.12 Malnutrition was noted as another risk factor in some pediatric patients. Initiating factors in the newborn population are omphalitis, circumcision, and electrode placement.12 Typical adult presentation of fever, erythema, and bullae may be late manifestations of the disease in the pediatric population. In one study, a modified version the LRINEC used in adults, the P-LRINEC, was evaluated for diagnostic accuracy in children. In pediatric patients, using only the values of a CRP > 20 mg/L as the most sensitive and sodium < 135 mEq/L were the most specific lab values for diagnosis and appeared to improve accuracy in diagnosing NF in children. This tool will need further validation, but it does appear to aid in more accurately forming an early diagnosis.13

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Nursing considerations

  • Perform a detailed skin assessment to detect distinct features associated with NF, such as pain, bullae, inflammation, and erythema.
  • Educate high-risk patients (patients with comorbidities of diabetes mellitus and liver disease) on the importance of seeking medical care for any injury.
  • Notify the physician of any patient who presents with intensely severe pain disproportionate to visual presentation and tenderness at the wound site and its surrounding tissue for a surgical opinion.
  • Closely monitor patients on NSAIDs because their symptomology may be subdued.
  • Monitor symptoms and notify the physician with changes in the patient's medical status.
  • Consider the presentation of bullae a surgical emergency.
  • Ensure appropriate nutrition support for the patient because his or her healing needs are increased after a surgical incision, drainage, and debridement.
  • Be aware that the patient may require multiple surgical procedures such as management efforts at controlling the infection and after recovery for cosmetic repairs.
  • Develop a pain management plan of care during the patient's hospitalization and postprocedure process.
  • Provide extensive emotional support to the patient and family.
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REFERENCES

1. Hua C, Bosc R, Sbidian E, et al Interventions for necrotizing soft tissue infections in adults. Cochrane Database Syst Rev. 2018;5:CD011680.
2. Centers for Disease Control and Prevention. Acting fast is key with necrotizing fasciitis. 2018. http://www.cdc.gov/Features/NecrotizingFasciitis.
3. Oguz A, Gümüş M, Turkoglu A, et al Fournier's gangrene: a summary of 10 years of clinical experience. Int Surg. 2015;100(5):934–941.
4. Waldron C, Solon JG, O'Gorman J, Humphreys H, Burke JP, McNamara DA. Necrotizing fasciitis: the need for urgent surgical intervention and the impact of intravenous drug use. Surgeon. 2015;13(4):194–199.
5. Park KH, Jung SI, Jung YS, Shin JH, Hwang JH. Marine bacteria as a leading cause of necrotizing fasciitis in coastal areas of South Korea. Am J Trop Med Hyg. 2009;80(4):646–650.
6. Goh T, Goh LG, Ang CH, Wong CH. Early diagnosis of necrotizing fasciitis. Br J Surg. 2014;101(1):e119–e125.
7. Harrington DH, Lenahan CM, Sanders RM. A practitioner's guide to necrotizing fasciitis. Nurse Pract. 2015;40(4):48–54.
8. Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A. Current concepts in the management of necrotizing fasciitis. Front Surg. 2014;1:36.
9. Lin TY, Ou CH, Tzai TS, et al Validation and simplification of Fournier's gangrene severity index. Int J Urol. 2014;21(7):696–701.
10. Wong CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004;32(7):1535–1541.
11. Borschitz T, Schlicht S, Siegel E, Hanke E, von Stebut E. Improvement of a clinical score for necrotizing fasciitis: ‘pain out of proportion’ and high CRP levels aid the diagnosis. PLoS One. 2015;10(7):e0132775.
12. Fustes-Morales A, Gutierrez-Castrellon P, Duran-Mckinster C, Orozco-Covarrubias L, Tamayo-Sanchez L, Ruiz-Maldonado R. Necrotizing fasciitis: report of 39 pediatric cases. Arch Dermatol. 2002;138(7):893–899.
13. Putnam LR, Richards MK, Sandvall BK, Hopper RA, Waldhausen JH, Harting MT. Laboratory evaluation for pediatric patients with suspected necrotizing soft tissue infections: a case-control study. J Pediatr Surg. 2016;51(6):1022–1025.
14. Levett D, Bennett MH, Millar I. Adjunctive hyperbaric oxygen for necrotizing fasciitis. Cochrane Database Syst Rev. 2015;1:CD007937.
15. Harrison WD, Kapoor B. Necrotizing soft tissue infection: principles of diagnosis and management. Orthop Trauma. 2016;30(3):223–231.
16. Chennamsetty A, Khourdaji I, Burks F, Killinger KA. Contemporary diagnosis and management of Fournier's gangrene. Ther Adv Urol. 2015;7(4):203–215.
17. Menichetti F, Giuliano S, Fortunato S. Are there any reasons to change our behavior in necrotizing fasciitis with the advent of new antibiotics. Curr Opin Infect Dis. 2017;30(2):172–179.
Keywords:

antibiotics; bullae; Fournier gangrene; Group A Streptococcus; Laboratory Risk Indicator for Necrotizing Fasciitis; necrotizing fasciitis; necrotizing soft-tissue infection; skin necrosis

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