Necrotising fasciitis

Epidemiology & Risk:

• Incidence: ~0.7 per 100,000/year; mortality 20–35% despite optimal care.
• Risk factors: diabetes mellitus, immunosuppression, obesity, peripheral vascular disease, trauma, surgery, IV drug use.
• Can occur in previously healthy individuals.

Clinical Features:

• Early: Severe pain out of proportion to findings, erythema, swelling.
• Late: Bullae, ecchymosis, crepitus, anaesthesia, septic shock.
• Common sites: extremities, perineum (Fournier gangrene), trunk.

Classification: Based on microbiology:

• Type I – Polymicrobial (70–90%) – common in immunocompromised patients (diabetes, vascular disease, trauma).
• Type II – Monomicrobial (Group A Streptococcus, sometimes Staphylococcus aureus/MRSA) – typically in otherwise healthy individuals.
• Type III – Vibrio spp., Clostridium spp.
• Type IV – Fungal (rare).

NF is a surgical emergency requiring immediate recognition and intervention. Mortality increases dramatically with delays in surgery beyond 12 hours.

Although NF is primarily a clinical diagnosis, adjunct investigations help confirm suspicion and guide management:

Emergency Investigations

• Laboratory findings:
  • WBC >15,000/mm³
  • Hyponatraemia (<135 mmol/L)
  • Elevated CRP (>15 mg/dL)
  • LRINEC score ≥6 suggests high risk (parameters: CRP, WBC, Hb, Na, Cr, glucose).
• Imaging (use only if it does not delay surgery):
  • CT: fascial thickening, gas in soft tissues (sensitivity ≈80%)
  • MRI: highly sensitive (≈93%) for fascial oedema
  • POCUS: quick bedside tool; look for “STAFF” (Subcutaneous thickening, Air, Fascial Fluid).
• Definitive test: Bedside “finger test” (easy fascial plane dissection under local anaesthetic) + tissue biopsy.

Immediate Management Principles

• Resuscitation: IV fluids, haemodynamic support (vasopressors if needed).
• Empiric antibiotics (start immediately):
  • Broad spectrum:
    • Vancomycin or Linezolid (MRSA coverage)
    • Piperacillin-tazobactam OR carbapenem (Gram-negatives & anaerobes)
    • Clindamycin (to inhibit toxin production).
• Urgent surgical debridement: Do not delay for imaging if suspicion is high. Often requires serial debridement every 12–36 hrs; amputation in severe cases.
• Adjuncts (controversial):
  • Hyperbaric oxygen (limited evidence)
  • IV immunoglobulin for streptococcal toxic shock (uncertain mortality benefit).

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Historical Timeline and Terminology Evolution

c. 500 BCE – Hippocrates describes erysipelas leading to severe tissue necrosis.

…the erysipelas would quickly spread widely in all directions. Flesh, sinews and bones fell away in large quantities. The flux which formed was not like pus but a different sort of putrefaction… The bones were bared and fell away…There were many deaths

Hippocrates Epidemics III

18th–19th Century – Before the American Civil War, common terms included “malignant/putrid/gangrenous ulcer“; “phagedenic ulcer”, “phagedena gangraenosa”, “phagaedena”, and “hospital gangrene”. British naval surgeons and military physicians reported cases of “hospital gangrene” during campaigns recognising this as a rapidly spreading soft-tissue infection.

1871 – Joseph Jones (1833–1896), Confederate Army surgeon, publishes extensive report on hospital gangrene in the American Civil War (2,642 soldiers affected; ~50% mortality):

The skin in the affected spot melted away in twenty-four hours into a grayish and greenish slough…

1883 – Jean Alfred Fournier (1832–1914) describes a fulminant gangrenous infection of the perineum in young men → later termed Fournier’s gangrene.

1924 – Frank L. Meleney (1889–1963) demonstrates β-hemolytic streptococcus as the cause of many cases of hospital gangrene in Hemolytic Streptococcus as Cause of Hospital Gangrene (Ann Surg, 1924). Advocates early surgical debridement.

1952 – Ben J. Wilson (1920–2015) presented during the St. Louis Assembly of The Southwestern Surgical Congress, Sept. 25-26, 1951 and coined the term “necrotizing fasciitis”.

Necrotizing fasciitis is the descriptive term given to a severe, often fulminant, infection which may begin in an operative wound, at the site of a trivial skin wound, or may begin without any obvious inciting lesion. Previously considered rare, the disease has been seen in Dallas in 29 individuals over the last three years.

The essential lesion is necrosis of the fascia and subcutaneous tissue with relative sparing of muscle.

Ben Wilson, 1952

1950s–1970s – Numerous synonyms fall out of use (e.g., Meleney’s gangrene, hemolytic streptococcal gangrene, suppurative fasciitis).

1980s–1990s – Media popularizes the term “flesh-eating bacteria” during clusters of Group A Streptococcus infections. MRSA later emerges as a cause of Type II NF.

2000s–Present – Shift toward umbrella term “Necrotizing Soft Tissue Infections (NSTIs)” in clinical literature to cover all variants (fasciitis, myonecrosis, Fournier’s gangrene) because management principles are similar.

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Associated Persons

• Joseph Jones (1833–1896) – first modern systematic description (hospital gangrene)
• Jean Alfred Fournier (1832–1914) – described perineal gangrene.
• Frank L. Meleney (1889–1963) – established streptococcal cause; early surgical intervention.
• Ben J. Wilson (1920-2015) – – coined term necrotizing fasciitis in 1951

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References

Historical references

• Jones WHS. Hippocrates. (Translated works). 1923
• Jones J. Outline of observations on hospital gangrene : as it manifested itself in the Confederate armies, during the American Civil War, 1861-1865. 1869
• Jones J. Observations upon the losses of the Confederate armies from battle, wounds and disease during the American Civil War of 1861- 1865, with investigations upon the number and character of the diseases supervening upon gun-shot wounds. Richmond and Louisville Medical Journal. 1869; 8(4): 340-358, 8(5): 453-480. and 1870; 9(3): 257-275, 9(6): 635-657.
• Fournier JA. Gangrene foudroyante de la verge. Semaine médicale. 1883; 2: 345-347
• Wilson B. Necrotizing fasciitis. The American Surgeon. 1952 Apr;18(4):416-31.
• Meleney FL. Hemolytic streptococcus gangrene, Archives of Surgery 1924; 9: 317–364.

Eponymous term review

• Descamps V, Aitken J, Lee MG. Hippocrates on necrotising fasciitis. Lancet. 1994 Aug 20;344(8921):556
• Quirk WF Jr, Sternbach G. Joseph Jones: infection with flesh eating bacteria. J Emerg Med. 1996 Nov-Dec;14(6):747-53
• Sarani B, Strong M, Pascual J, Schwab CW. Necrotizing fasciitis: current concepts and review of the literature. J Am Coll Surg. 2009 Feb;208(2):279-88.
• Puvanendran R, Huey JC, Pasupathy S. Necrotizing fasciitis. Can Fam Physician. 2009 Oct;55(10):981-7.
• Guliyeva G, Huayllani MT, Sharma NT, Janis JE. Practical Review of Necrotizing Fasciitis: Principles and Evidence-based Management. Plast Reconstr Surg Glob Open. 2024 Jan 19;12(1):e5533.
• Nickson C. Necrotising fasciitis. CCC