壊死性筋膜炎

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  • Necrotizing Fasciitis

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Bacterial resistance to antimicrobial agents increases rapidly outside as well as in hospitals. Antimicrobials may remove sensitive organisms from the bacterial flora, but they also foster the establishment of a resistant strain, not only inducing infection by bacteria which had not previously been considered pathogens, but also preventing spontaneous healing. Although necrotizing fasciitis has been seen in the past 20 years throughout the world, it remains unclear which cases are attributable to new forms of infectious disease because no data are available on their incidence. Regional clusters of cases of necrotizing fasciitis in England and Norway suggest the differential geographic distribution of certain bacteria with high toxicity, such as beta-hemolytic Streptococcus (mainly invasive group A Streptococcus). For the most part, gram-negative rods and anaerobes were simultaneously isolated from tissue fluid cultures. Necrotizing fasciitis occurs within 24 hours after the onset of cellulitis. The progression of necrotizing fasciitis is usually rapid, resulting in widespread gangrene of the subcutaneous fat and fascia around the scalp and into the deep neck spaces. Crepitus, cutaneous anesthesia due to gas bubbles in the soft tissues, and foul-smelling gray watery discharge are found. Some cases are seen as post-operative infection after maxillofacial surgery. Frequently, septic shock, mediastinitis and multiple organ failure are associated with necrotizing fasciitis, leading to a fatal outcome. Some patients have a history of systemic diseases, particularly those associated with compromised status, accounting for the increased risk of necrotizing fasciitis. In some cases, however, there is no such history. This suggests that the toxicity of the bacteria influences the onset of this disease in addition to the widely accepted risk factor of compromised host. Computed tomography can be diagnostic when there is evidence of gas bubbles in the deep tissue even in the absence of crepitation, foetor, and anesthesia of the skin. Abnormally elevated C-reactive protein concentration is a sensitive quantitative measure of the inflammatory response associated with necrotizing fasciitis. Necrotizing fasciitis requires prompt surgical referral for immediate debridement to reduce necrotic tissue and expose anaerobes to oxygen, followed by antibiotics such as clindamycin. The precription of antibiotics alone is not helpful because of the ischaemic focus in necrotic tissue. One of our patients developed septicemia, but all of our patients including the one with septicemia recovered fully without skin grafting. Our findings point to the clinical significance of the computed tomographic findings and débridement associated with eradication of gas bubbles. The patient without objective findings may be misdiagnosed as having a form of cellulitis, such as Ludwigs angina. Any patient with cellulitis should be referred for an early surgical evaluation to prevent the development of the disease and dyspnea due to pharyngeal edema. Prompt evaluation and surgical treatment might reduce the overall mortality in necrotizing fasciitis. It was recently noted that invasive streptococcal infection is associated with a substantial risk of transmission in households and health care institutions. Infections seen throughout the world should be continuously and carefully reviewed.

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  • 松本歯学

    松本歯学 22 (3), 233-244, 1996-12-31

    松本歯科大学学会

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