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Rapid Responses: Rapid Responses published:
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High index of suspicion is key
- Iain Varley (11 April 2005)
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Presence of skip lesions is an additional clue
- Venkata Sreekanth Sampath (14 April 2005)
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Necrotising fasciitis of the head and neck region
- Ricardo Persaud (17 April 2005)
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Necrotising fasciitis. BMJ 330 April 2005 830-833
- Jacqueline Rees-Lee, Marina Morgan, Consultant Microbiologist , Vikram Devaraj, Consultant Plastic Surgeon (19 April 2005)
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Necrotising Fasciitis: Always use the finger.
- Richard R Clark, David J McGill (21 April 2005)
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Iain Varley, SHO Plastic Surgery Northern General Hospital, Herries Road, Sheffield, S5 7AU
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The excellent review article on necrotising fasciitis (1) highlighted the use of diagnostic aids in reaching a diagnosis promptly, as has been previously discussed (2). As the authors state, "Diagnosis is often delayed because of the paucity of symptoms and the unfamiliarity of the condition among clinicians." Education is therefore a key component of improving the rapidity of diagnosis, and the authors' introduction of a diagnostic protocol may well be successful simply by reminding clinicians of the possibility of the diagnosis. 1) Hasham S, Matteucci P, Stanley PRW, Hart NB. Necrotising fasciitis. BMJ 2005; 330: 830-833 2) Poromanski I, Andriessen A. Developing a tool to diagnose cases of necrotising fasciitis. J Wound Care 2004 Sep;13(8):307-10. Competing interests: None declared |
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Venkata Sreekanth Sampath, Critical Care Fellow Christie Hospital NHS Trust, Manchester M20 4 BX
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In addition to the clinical features described in this excellent review, the presence of skip areas of tissue necrosis is an important clinical clue suggesting necrotising fasciitis.The pathophysiology of this is-organisms spread from the subcutaneous tissue along the superficial and deep fascial planes, presumably facilitated by bacterial enzymes and toxins. This deep infection causes vascular occlusion, ischemia, and tissue necrosis at sites distant from the initial site of infection. Competing interests: None declared |
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Ricardo Persaud, ENT SpR Lister Hospital, Stevenage SG1 4AB
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Re: Clinical review - Necrotising fasciitis I enjoyed reading the clinical review ‘Necrotising Fasciitis’ by Hasham et al. (BMJ 2005; 330:830-3). Any opportunity to raise awareness of this life-threatening condition is welcomed. Furthermore, the need for a multidisciplinary team approach in the management of necrotising fasciitis cannot be over-emphasised. The review is well written and informative. I would be very grateful if the authors could comment on necrotising fasciitis of the head and neck region, especially with regards to the notion that the pathological process of such infective disease occurring this region, with its exceptionally rich vascular and lymphatic systems, may be somewhat different from the same condition affecting other parts of the body. In addition, some authors have suggested that cervical necrotising faciitis is a different clinicopathological entity to craniofacial necrotizing fasciitis, with the former being associated with a 4-times higher mortality rate.1 Since necrotizing fasciitis spreads along fascial planes, secondarily affecting muscle, subcutaneous tissue and skin, I wonder whether the authors would agree that early detection and prompt treatment of the condition could result in the skin being minimally affected and therefore allowing 'loose' closure, with an in situ drain.2 With kind regards Yours sincerely Ricardo Persaud MPHIL DOHNS MRCS ENT Specialist Registrar Lister Hospital, Stevenage Herts, SG1 4AB. England. Email: ricardopersaud@yahoo.co.uk References 1 Banerjee AR, Mutty GE, Moir AA. Cervical necrotizing fasciitis: a distinct clinicopathological entity? J Laryngol Otol 1996;110:81-6. 2 Al-Ammar A, Mir SM. Cervical necrotizing fasciitis with facial nerve paralysis. J Laryngol Otol 2004;118: 573-5. Competing interests: None declared |
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Jacqueline Rees-Lee, SHO Plastic Surgery Royal Devon & Exeter NHS Trust, Exeter, EX2 5DF, Marina Morgan, Consultant Microbiologist , Vikram Devaraj, Consultant Plastic Surgeon
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Dear Sir, We disagree that the initial management of necrotising fasciitis (NF) is the same regardless of aetiology (1). NF due to Group A beta haemolytic streptococci (GAS) needs fundamentally different management. Firstly, non-steroidal anti-inflammatory drugs (NSAIDs) should be stopped. NSAIDs mask clinical signs, and depress the “respiratory burst” essential for killing organisms inside the polymorph survivors of streptococcal toxin attack. Evidence is increasing that NSAIDs are detrimental in invasive GAS infection (2). In Exeter, we strive to ensure clinical staff “think strep” and are aware of the protean manifestations of GAS NF. Thus in a patient with agonising severe pain out of proportion to the physical signs with evidence of a soft tissue infection an early referral to an intensivist, microbiologist and plastic surgeon is expected. This multi-disciplinary approach results in optimal resuscitation, antimicrobial therapy and early aggressive plastic surgical debridement. The diagnosis is primarily clinical and surgical debridement should not be delayed pending investigations such as ultrasound and MRI, which produce false negatives. With this approach, mortality from GAS NF in Exeter fell from 25% (1995-2000), to < 7% in the last 5 years- the lowest in world literature. For suspected NF, the Exeter protocol comprises empirical intravenous clindamycin 1.2gm qds plus imipenem 1gm qds, pending Gram staining of tissues. In suspected streptococcal toxic shock syndrome, 2 gm/kg of intravenous immunoglobulin (IVIG)2 is added for the immune modulating and anti-toxin effects, improving survival from 36% to 67% (3). This may be effective even in the absence of clindamycin (4). Clindamycin and linezolid prevent toxin formation, retaining activity against non-dividing (“stationary phase”) streptococci immune to beta- lactams (5). Finally, if staphylococci are seen on Gram staining, with the emergence of NF due to Panton Valentine leukocidin producing MRSA (6), we suggest adding linezolid until sensitivity results are available. References: 1 Hasham DS, Matteucci P, Stanley PRW Hart NB Necrotising fasciitis BMJ 2005; 330; 830-3 2 Laupland KB. Polyclonal intravenous immunoglobulin for the prophylaxis and treatment of infection in critically ill adults. Can J Infect Dis 2002; 13: 100-106 3 Kaul R, McGreer A, Low DE, Schwartz B. Population based surveillance for Group A streptococcal necrotizing fasciitis: clinical features, prognostic indicators, and microbiologic analysis of 77 cases. Am J Med 1997; 103: 18-24 4 Cawley MJ, Briggs M, Haith LR, Reilly KJ, Guilday RE, Braxton GR, Patton ML. Intravenous immunoglobulin as adjunctive treatment for Streptococcal toxic shock syndrome associated with necrotising fasciitis: case report and review. Pharmacotherapy 1999 19; 9: 1094-98 5 Cockerill FR, Thompson RL, Musser JM, Schlievert PM, Talbot J, Holley KE, Harmsen WS, Ilstrup DM, Kohner PC, Kim MH et al. Molecular serological and clinical features of 16 consecutive cases of invasive streptococcal disease. Clin Infect Dis. 1998 Jun;26(6):1448-58. 6 Miller LG, Pendreau-Remington F, Rieg G, Mehdi S, Perlroth J, Bayer AS, Tang AW, Phung TO, Spellberg B. Necrotizing fasciitis caused by community acquired methicillin staphylococcus aureus in Los Angeles New Engl J Med 2005; 352: 1445-53 Competing interests: None declared |
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Richard R Clark, Research Fellow Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, Glasgow G31 2ER, David J McGill
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Re: Clinical review - Necrotising fasciitis We read this recent article with interest and we feel that the authors have omitted a valuable diagnostic tool. The need for surgical debridement in these patients is based upon the diagnosis of tissue or fascial necrosis. This is most easily diagnosed by a combination of visual inspection and digital examination of the tissue. The 'Finger Test' is an established, quick and easy method for doing this.(1,2) The test can be easily carried out in the A&E, the ward or theatre under local or general aneasthesia. The traditional method is to make a test incision in the suspect area of approximately 2cm once anaesthesia has been applied. The tissues can then be examined visually. The absence of normal blood flow, dirty 'dishwater' coloured fluid and discolouration of the fat would favour the diagnosis. A rapid finger sweep at the level of the fascia can then be carried out. If the tissues dissect with minimal resistance this again favours the diagnosis and the need for formal debridement. Fluid and tissue samples can also be obtained at this stage for microbiological analysis. The authors have stressed in the article the need for a high index of suspicion in making the diagnosis and subsequent institution of rapid treatment. In our unit we routinely use the 'Finger Test' to confirm or refute the diagnosis in any case where we have a high index of suspicion and we promote its value in confirming the diagnosis. References: 1. Andreasen TJ, Green SD, Childers BJ. Massive infectious soft- tissue injury: diagnosis and management of necrotizing fasciitis and purpura fulminans.[see comment]. Plastic & Reconstructive Surgery 2001: 107: 1025-35. 2. Childers BJ, Potyondy LD, Nachreiner R, et al. Necrotizing fasciitis: a fourteen-year retrospective study of 163 consecutive patients. American Surgeon 2002: 68: 109-16. Competing interests: None declared |
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