TAILIEUCHUNG - Chapter 115. Approach to the Acutely Ill Infected Febrile Patient (Part 6)

Necrotizing Fasciitis This infection may arise at a site of minimal trauma or postoperative incision and may also be associated with recent varicella, childbirth, or muscle strain. The most common causes of necrotizing fasciitis are group A streptococci alone (Chap. 130) and a mixed facultative and anaerobic flora (Chap. 119). Diabetes mellitus, peripheral vascular disease, and intravenous drug use are associated risk factors. Use of NSAIDs has been reported to allow progression of skin or soft tissue infections; however, prospective studies have not shown that NSAIDs increase the risk of disease or exacerbate established infection. The patient may have. | Chapter 115. Approach to the Acutely III Infected Febrile Patient Part 6 Necrotizing Fasciitis This infection may arise at a site of minimal trauma or postoperative incision and may also be associated with recent varicella childbirth or muscle strain. The most common causes of necrotizing fasciitis are group A streptococci alone Chap. 130 and a mixed facultative and anaerobic flora Chap. 119 . Diabetes mellitus peripheral vascular disease and intravenous drug use are associated risk factors. Use of NSAIDs has been reported to allow progression of skin or soft tissue infections however prospective studies have not shown that NSAIDs increase the risk of disease or exacerbate established infection. The patient may have bacteremia and hypotension without other organ-system failure. Physical findings are minimal compared with the severity of pain and the degree of fever. The examination is often unremarkable except for soft tissue edema and erythema. The infected area is red hot shiny swollen and exquisitely tender. In untreated infection the overlying skin develops blue-gray patches after 36 h and cutaneous bullae and necrosis develop after 3-5 days. Necrotizing fasciitis due to a mixed flora but not that due to group A streptococci can be associated with gas production. Without treatment pain decreases because of thrombosis of the small blood vessels and destruction of the peripheral nerves an ominous sign. The mortality rate is 25-30 overall 70 in association with TSS and nearly 100 without surgical intervention. Life-threatening necrotizing fasciitis may also be due to Clostridium perfringens Chap. 135 in this condition the patient is extremely toxic and the mortality rate is high. Within 48 h rapid tissue invasion and systemic toxicity associated with hemolysis and death ensue. The distinction between this entity and clostridial myonecrosis is made by muscle biopsy. Necrotizing fasciitis caused by community-acquired methicillin-resistant S. aureus MRSA was recently

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