Necrotising fasciitis

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Abstract
Introduction Despite the impression that may have been gained from the British media, necrotising soft tissue infections have been recognised and reported for centuries, the earliest dating back to Hippocrates in the 5th century BC.1 Such infections represent a large spectrum of clinical entities, ranging from mild pyodermas to life threatening necrotising fasciitis. Although these infections are most commonly caused by streptococcal and staphylococcal species, a multitude of other organisms have also been implicated.2 The term necrotising fasciitis was first used by Wilson3 in 1952 to describe the most consistent feature of the infection, necrosis of the fascia and subcutaneous tissue with relative sparing of the underlying muscle. It can progress rapidly to systemic toxicity and even death if not promptly diagnosed and treated. Once suspected, management should consist of immediate resuscitation, early surgical debridement, and administration of broad spectrum intravenous antibiotics. As plastic surgeons, we receive several referrals each year from other specialties to diagnose or exclude the possibility of necrotising fasciitis. Since it is part of a spectrum of necrotising soft tissue infections, diagnosis can certainly be difficult for people who are unfamiliar with the condition and treatment may be delayed. This may be compounded by the relative lack of clinical signs and symptoms during the early course of the infection and because surgical consultation is sought only once the diagnosis is obvious and the signs of sepsis are readily apparent. Unfortunately, most adverse outcomes result from this delay in diagnosis.4 Fortunately, necrotising fasciitis is rare. The actual incidence in the United Kingdom is estimated at 500 new cases each year but is difficult to record. This in part is due to the confusion that arises by the numerous eponyms given to describe the same condition. A further attempt to classify it according to location (for example, Fournier's gangrene), clinical presentation, or bacteriology only complicates the issue since there is little to distinguish between these entities, and their initial management is the same.5 6 This article aims at eradicating this confusion and looks at the measures that can be taken to increase awareness of necrotising fasciitis among clinicians, with the hope that this will result in earlier referral of patients and improve their overall survival. Summary points Necrotising fasciitis is an uncommon but potentially fatal condition and can affect any part of the body The aetiology is not fully understood but most patients who develop necrotising fasciitis have pre-existing conditions that render them susceptible to infection Diagnosis is often delayed because of the paucity of symptoms and the unfamiliarity of the condition among clinicians Laboratory findings and other diagnostic tests may be useful adjuncts, but the diagnosis is still primarily a clinical one and a high index of suspicion is required Management should consist of immediate resuscitation, early surgical debridement, and administration of broad spectrum intravenous antibiotics We obtained the information for this article from various sources. References came from medical journal databases such as Medline and PubMed. Clinical photographs came from PRWS and NBH and their vast personal archives.

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