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Introduction   

Necrotizing Fasciitis is a soft tissue infection that causes necrosis to the muscle fascia and subcutaneous tissue. Necrotizing fasciitis is a form of necrotizing soft tissue infections [3]. These infections are considered rare but life threatening [3]. In the United States, this condition affects 0.4 people out of every 100,000 patients (or 1 out of every 250,000) [1].  

Necrotizing fasciitis can affect any part of the body but is most often shown to affect the extremities [2]. This condition rapidly progresses over 24-48 hours and can cause significant damage that could lead to organ failure. This infection most often develops from an open area of the skin but can also be seen after blunt force trauma [2]. 

Necrotizing fasciitis is considered the most common form of the necrotizing soft tissue infections [3]. This course will further examine this infection, the signs and symptoms associated with it, and the treatment for this condition. This course is designed to better inform nurses about this condition to apply this information into their daily practice. 

Definition 

Necrotizing fasciitis belongs to a group of conditions called necrotizing soft tissue infections [3]. As mentioned above necrotizing fasciitis is considered the most common type of these infections [3]. This infection causes necrosis of the subcutaneous tissue and muscle fascia. Fascia is composed of connective tissue that is below the skin [6].  

Some of the roles of these tissues are to separate muscles, encompass organs, and help veins stay patent [6]. The infection spreads through the fascial plane while the overlying tissues are not affected at first [1]. This has been known to cause a delay in diagnosis and a delay in treatment [1]. This infection can ultimately destroy the dermis, epidermis, fascia, and muscle [3].   

Necrotizing fasciitis is classified in two different types: Polymicrobial necrotizing fasciitis (type 1) and Monomicrobial necrotizing fasciitis (type 2). These infections are broken down by the initial bacteria that started the infection. Other classifications are in the beginning stages of being accepted as research continues, however the first two types are the two that are commonly accepted [3].  This infection can be caused by a surgical procedure or a non-invasive procedure, like phlebotomy. Necrotizing fasciitis is considered a rare condition, however because it can be difficult to diagnose it may be underreported [3]. 

Epidemiology 

The prevalence of necrotizing fasciitis is 0.3 to 15 cases per 100,000 people [3]. There are certain risk factors that are thought to increase the incidence of developing necrotizing fasciitis [3]. These risk factors include individuals that have had a surgical procedure or a noninvasive procedure where there is a break in the skin or mucosa [3]. Also, individuals with certain comorbidities such as diabetes mellitus, peripheral vascular disease, obesity, and alcoholism are at an increased risk [3]. Individuals who are immunocompromised also are at an increased risk of developing this infection [2].  

Type I polymicrobial necrotizing fasciitis is typically seen in aging adults with comorbidities [3]. This type of necrotizing fasciitis is the result of both aerobic and anaerobic bacteria [3]. Because both aerobic and anaerobic bacteria are involved, it causes tissue necrosis and hemodynamic instability [3]. 

Type II monomicrobial necrotizing fasciitis is not tied to a specific age group of individuals [3]. The bacteria that cause these infections are group A streptococcus [2]. Individuals that are considered healthy can develop streptococcal necrotizing fasciitis [2]. Corticosteroid use and cirrhosis have also been linked to an increased risk for this infection [2]. This infection can be caused by a break in the skin or blunt force trauma [2]. 

Pathophysiology 

In this type of infection, the bacteria quickly move into the muscle fascia [1]. It can take several days for the superficial tissue to visibly looked affected [1]. When the infection is caused by group A streptococcus it can come from various routes such as straight from the environment from a penetrating trauma or from a previous streptococcal infection [2]. After the initial spread of the infection the bacteria die and produce endotoxins (waste from the bacteria) [4]. This in turn causes tissue ischemia and produces lesions that are filled with pus and fluid from dead tissue [4].  

The blood supply to these tissues is impaired which limits the ability of antibiotics (or the body alone) to fight the infection [4]. Surgical intervention then becomes necessary to remove the necrotic tissue [4]. Polymicrobial necrotizing fasciitis is gas gangrene as the bacteria causes gaseous infiltration in the subcutaneous tissue [3]. Due to the severity and speed of this infection, if treatment is not initiated a patient may develop toxic shock, which can lead into multiple organ failure and even death [4]. 

Etiology 

The cause of necrotizing fasciitis is dependent on the bacteria that initiates the infection. About 80% of cases of necrotizing fasciitis are caused by bacteria introduced to the body from a break in the skin [1]. Infections that are from a single site are typically from staphylococcus aureus and streptococci, which are gram positive cocci organisms [1]. 

Group A streptococci are one of the most typical causes of necrotizing fasciitis. They are a common type of organism often found in an individual’s skin, nose, and throat [4]. Often times it can go unnoticed and not cause any symptoms [4]. This is the same bacteria that can cause strep throat [4]. Necrotizing fasciitis may also combine with varicella lesions causing a superinfection [2]. 

Necrotizing fasciitis can also be caused by staphylococcus aureus which is another gram-positive cocci [4]. Individuals can test positive for this bacteria and may not experience any symptoms [4]. Methicillin-resistant staphylococcus aureus is a common bacterium that can cause hospital acquired infections [4]. Escherichia coli and klebsiella are both gram negative cocci that have been known to cause necrotizing fasciitis [4]. 

Polymicrobial infections are a combination of anaerobic organisms with gram negative cocci [1]. There are numerous forms of bacteria that can cause necrotizing fasciitis and as research expands on the subject, more organisms are identified [4].  

Dependent on the bacteria causing the initial infection, there can be specifications explaining how the infection impacts the body [3]. Regardless of the bacteria, damage is done to the superficial tissue and moves deep into the muscular fascia [3]. 

Clinical Signs and Symptoms 

The clinical signs and symptoms of necrotizing fasciitis can present similarly to cellulitis initially. It is imperative that healthcare providers thoroughly assess the patient’s history and physical as this infection can be life threatening. Necrotizing fasciitis and cellulitis both present with erythema, edema, and warmth of the skin [3]. Cellulitis can also cause a fever, however patients with cellulitis are most likely hemodynamically stable [3].  

Pain 

A characterizing symptom of necrotizing fasciitis is pain that is unproportioned to the symptoms that are experienced [1]. With the initial infection, the superficial tissue may not appear like the infection is severe enough to produce the pain the patient experiences [1]. However, in patients that have diabetic neuropathy they may not experience this pain due to the existing nerve damage, which may delay diagnosis [3]. Patients with preexisting conditions can have more severe systemic symptoms such as lactic acidosis and severe sepsis [3]. In the later stages of the infection, usually 24-48 hours into the infection, the pain may subside as the tissue dies [4]. 

Inflammation and Ischemia 

On assessment patients present with warmth, erythema, tenderness, and edema to the site of the infection [3]. If the infection is caused by certain organisms that produce gas subcutaneous crepitus may be noted [3].  As the infection progresses, the swelling increases and the color of the skin turns from red to dusky, then to purple and eventually black [2]. The skin changes color due to ischemia of the cutaneous tissue [2]. In the late stages of the infection blisters and crepitus may form [2]. The skin may slough off and can look as if the patient experienced a third-degree burn [2].  

Systemic Features 

As the infection progresses systemic signs and symptoms appear [2]. Hypotension, tachycardia, and confusion can be present in the later stages of the disease [4]. Patients may become delirious and incontinent of bowel and bladder [4]. The area of the infection can split open in the late stages and leak cloudy fluid, although not common [4]. Black necrotic lesions then form, and the patient may lose feeling in the area [4]. At this stage, organ failure can ensue from toxic shock which can lead to death [4]. 

Case Study  

A 52-year-old male presents to an emergency department with fever and severe pain to the right lower extremity. The patient states that his right lower leg was swollen, reddened, and warm to the touch when he woke up that morning. He reports the pain is 9/10. The patient has a history of chronic hypertension, type II diabetes, and alcohol use. The patient recalls scratching his leg while working on his car earlier in the week. Upon assessment erythema, edema, and tenderness with palpation are noted. The patient states the pain is worsening and is sharp. The patient’s vital signs are temperature 101 F, blood pressure 101/52, heart rate 108, oxygen saturation level 96%, and respiratory rate 20.  

• What laboratory tests would most likely be ordered for this patient? 

• What are risk factors this patient may have for developing necrotizing fasciitis? 

• Does this patient require any imaging studies? 

• What are some signs and symptoms that might suggest necrotizing fasciitis? 

After lab tests are drawn, pain medication and antibiotics are administered, the patient is admitted to a medical surgical unit overnight for observation. The day shift nurse begins their assessment. Upon assessment the patient’s right lower extremity is now dusky and swelling has increased. The site of the infection is now turning a shade of purple. The patient states the pain has decreased. The patient’s vital signs are now temperature 101.2F, blood pressure 78/42, heart rate 110, oxygen saturation level 92%, and respirations 22. 

• After these findings, what are the nurse’s next steps? 

• What type of treatment does this patient require? 

• Why might the patient’s pain have decreased? 

Diagnostic Tests and procedures 

As mentioned earlier in the course, diagnosing necrotizing fasciitis may be difficult in the early stages and can present like other infections. This infection is rare, but it is important for providers to rule it out as soon as they can [4].  

In 2004, the Laboratory Risk Indicator for Necrotizing Fasciitis, a laboratory diagnostic tool, was created to help providers differentiate necrotizing fasciitis from other tissue infections [1]. This tool uses the patient’s lab results to identify their risk of necrotizing fasciitis. The tool screens for the likelihood of the patient having this infection by evaluating six lab results: c-reactive protein, total white blood cells, hemoglobin, sodium, creatinine, and glucose [1]. Depending on the patient’s results, they are given a percentage of probability of having necrotizing fasciitis [5]. There have been studies and debates if this tool accurately screens for necrotizing fasciitis [3]. Wound cultures can identify the organism causing the infection; however, it must be collected in the deep muscle tissue [3]. A culture from superficial tissue may not identify the organism due to the organism being in the deeper tissue [3]. 

Imaging may be used during the diagnostic phase; however clinical findings should be the primary diagnostic tool [1]. Plain x-rays are not recommended as they do not add any useful information for diagnosis [1]. A computed tomography (CT) scan can show edema in the fascial plane, but this isn’t present until the late states of the infection [3] A magnetic resonance imaging (MRI) scan is more respected than a CT; however, it is harder to emergently obtain an MRI versus a CT [3]. Surgical intervention should not be delayed waiting on imaging [3].

Management and Treatment 

Management and treatment for necrotizing fasciitis should be started as quickly as possible as this infection progresses rapidly. Patients are commonly transferred into the intensive care unit if they are not already there [1]. The patient should be placed on a NPO (nothing by mouth) diet until the surgical team can assess the patient to determine if surgical intervention is necessary [1]. Fluid resuscitation and vasopressors may be needed for septic shock [3]. Broad spectrum antibiotics are started until finalized cultures with the specific causative organism is identified [3].   

Control of the infection is important and is done by surgical intervention. The main treatment for necrotizing fasciitis is prompt surgical intervention. Drainage of abscesses and debridement is necessary to remove all the necrotic tissue [1]. Often, if the tissue is questionable, it is removed [1]. Several surgeries may be needed to ensure all the necrotic tissue is gone [1].  

Hemolytic stability will return once the necrotic tissue is removed [1]. Amputations may be needed if the necrotic tissue is not removed [3]. The surgical wound needs to be kept open and is usually packed with wet gauze [1]. Daily dressing changes are needed to keep the wound clean [1]. After the necrotic tissue is removed and the patient begins to stabilize, reconstructive surgery may be necessary [1].  

In some cases, the surgical wound cannot be closed, and a plastic surgeon may be consulted for reconstruction [1]. A grafted skin flap may be needed to close the wound [1]. This would be done in subsequent surgeries [1]. Necrotizing fasciitis requires a multidisciplinary care team for treatment and management [1]. 

Nursing Roles 

Necrotizing fasciitis is a rare infection; however, nurses working in an acute care setting may care for these patients. It is important to consider our role and the changes we can put in place in our practice to give high quality care. Assessment is critical in the acute care setting especially as nurses spend more time with the patient.  

Nurses should assess for erythema, edema, and warmth [3]. Any changes to skin color or an increase in edema should be reported to the provider [3]. Vital signs and signs of septic shock should be monitored closely [3]. Nurses should be prepared to give antibiotics and intravenous fluids quickly [3]. Vasopressors may be needed for patients in shock [3]. Nurses should also prepare their patients for surgery [3].  

In the recovery phase of the infection, nurses need to change surgical dressings, help their patients adequately manage pain, and monitor vital signs [3]. As the patient returns to a stable condition, enteral feeds should begin to promote wound healing [3]. Nurses also must educate their patients and family members in the recovery process [3].  

Nurses may have to teach families about wound care when they are approaching discharge from the hospital. Nurses must educate their patients and families on signs of normal wound healing and complications [3]. This can be a traumatic experience for the patient and their family and they may need reinforcement in their education as it can be overwhelming. 

Conclusion

Necrotizing fasciitis is a rare yet serious rapidly progressing infection. The presenting signs and symptoms can be likened to other less serious infections. It is important for necrotizing fasciitis to be ruled out quickly with clinical, laboratory, and imaging findings. 

Nurses should know the signs and symptoms as oftentimes we are the first ones that see the patient whether in an emergency department or hospital. As nurses we are the ones that spend the most time with our patients. It is imperative that we monitor our patient closely and report any abnormal findings immediately. By using this information, we can improve quality outcomes for our patients.  

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