t has many names: hemolytic streptococcal gangrene, Meleney ulcer, acute dermal gangrene, hospital gangrene, Fournier gangrene (which is localized in the scrotum and perineal area), suppurative fasciitis and synergistic necrotizing cellulitis. The formal name medical science has given it is necrotizing fasciitis (NF). Its common name, flesh-eating bacteria, which carries a 30-80 percent mortality rate, most closely describes what it does and the fear it engenders.
The family of Crystal Spencer, 33, knows the horrors of NF. Spencer, of Farmingdale, MI, died in July after being hospitalized for a month with NF.1
Twenty-four-year-old Aimee Copeland just barely survived her ordeal with NF. The Georgia resident lost both her hands, her left leg and her right foot as a result of the bacteria. After months of rehabilitation, she was released from the hospital in August. She acquired her infection after cutting her leg on a rock on the banks of the Tallapoosa River, where she and friends were relaxing.2 Copeland's was one of several cases in Georgia and South Carolina this year.
NF is a bacterial infection that attacks soft tissue and the fascia, the sheath of tissue covering muscle. Although it is a single disease, the condition can be precipitated by more than one type of bacteria. Group A streptococcus (Streptococcus pyogenes), Staphylococcus aureus, Clostridium perfringens, Bacteroides fragilis and Aeromonas hydrophila have been identified in NF patients. Group A strep, the most common bacteria causing NF, appears to be associated with the most rapid disease progression.
According to Ziad K. Mirza, MD, medical director of the outpatient Wound Care & Hyperbaric Medicine Centers at Greater Baltimore Medical Center, Towson, MD, those at risk of contracting NF are "immunocompromised; obese; diabetic; have cancer, HIV, renal disease; take long-term immunotherapy agents or are on anti-rejection drugs."
The incidence of NF is low - anywhere from 500 to 2,000 cases a year in the U.S., depending on the source. The CDC, which spearheaded the Active Bacterial Core Surveillance Emerging Infections Program Network to monitor incidence of organisms that cause NF, report the number of cases remains steady.
NF usually starts as a small bump, a cut or abrasion or as a result of surgery. It was after surgery in 1993 that Jacqueline Rommelle, executive director and co-founder of the National Necrotizing Fasciitis Foundation (NNFF), met her troubles with the disease.
"After I gave birth to my twins via Cesarean section, I needed surgery to repair ventral incisional hernias," Roemmele told ADVANCE. "Soon after the surgery I developed a fever and the incision began to drain copious amounts of yellow fluid. I also experienced a lot of pain, which the doctor attributed to the surgery. However, after I developed holes or gaping wounds in the area of the incision, when my skin began to literally die, I knew something was very wrong."
However, her physician continued to diagnose her symptoms as the flu. It took a nurse who examined the wound and recommended a visit to the emergency department before the condition was diagnosed as NF. Her recovery included numerous surgeries that left her with "shark-bite-like scars and muscle spasms," among other deficits. With asymmetry on one side of her body, her body image was shattered and eventually her marriage ended.
Roemmele's case illustrates one of the critical problems with NF - it often is misdiagnosed.
"The basic presentation in most patients is a puncture or cut in the skin, followed by severe pain," Mirza said.
Roemmele, co-author with Diane Batdorff of the book Surviving the Flesh-eating Bacteria: Understanding, Preventing, Treating, and Living with the Effects of Necrotizing Fasciitis, stresses "a major clue to physicians and nurses is pain out of proportion to the injury. For example, if someone comes to the ER with a slight sprain but is screaming in pain, it could be a sign of NF."
Accurate, fast diagnosis is critical because NF progresses rapidly, Mirza cautioned.
"The first thing that happens is induration, a hardening of the skin and underlying tissue," he said. "That is followed by redness that progresses quickly. The initial puncture or injury site becomes discolored and can become bluish or darkish black."
Mirza, who has treated many NF patients with hyperbaric therapy, said gas may collect under the skin in some cases.
According to the NNFF website (www.nnff.org) there are early, advanced and critical symptoms of NF.3
Early symptoms include:
• a minor trauma or skin opening;
• some pain in the general area of the injury, but not necessarily at the site of the injury;
• pain disproportionate to the injury;
• flu-like symptoms that can include diarrhea, nausea and fever; and
• intense thirst.
Advanced symptoms include:
• swelling and purplish rash of the limb or area of the body experiencing pain;
• large, dark marks on the affected limb that may become blackish, fluid-filled blisters; and
• the wound becomes necrotic with bluish, white or dark mottled flaky appearance.
Critical symptoms are:
• severe drop in blood pressure;
• development of toxic shock; and
Diagnosis is confirmed with laboratory testing and by CT scan or MRI.
Once the diagnosis is made, standard treatment is four-pronged.
"Topical agents, IV or oral antibiotics, surgical debridement and hyperbaric oxygen therapy are prescribed," Mirza said. "Most patients receive at least three of the four."
Sources said it is rare a patient with NF doesn't require surgery to excise all dead tissue. Debridement may occur many times until all infection is removed. At times, patients will lose limbs because the infection has progressed too far.
"Mortality can be as high as 60 percent, but with hyperbaric therapy that goes down to 30 percent," Mirza said.
A number of things happen when a patient is put under pressure in a hyperbaric chamber, Mirza told ADVANCE. "Patients breathe 100 percent oxygen under 2-3 times atmospheric pressure, which brings a great number of oxygen- and nitrogen-reactive radicals to help fight infection. Besides the high oxygenation of the tissue, neutrophils, part of the immune system, are sensitized to go where the infection is. Some antibiotics, like cephalosporins, are enhanced by hyperbaric therapy, which can minimize the inflammation that occurs when the immune system is activated."
Roemmele is excited about a new skin and wound cleanser to be used in combination with negative pressure wound therapy for the management of NF. A case study on the product was presented in September at the 2012 Fall Symposium on Advanced Wound Care in Baltimore.4
Caring for patients with NF requires contact precautions and fastidious handwashing before and after seeing the patient.
"The infection is not airborne; you must come in contact with it," Mirza explained. "As long as there is food for the bacteria and the area isn't clean, the bacteria will live on any surface."
Prevention & Research
This kind of education is one of the reasons Roemmele and Batdorff founded the NNFF. "After we both battled NF, we discovered there isn't much information out there about this horrible disease," Roemmele said.
"We want to raise awareness, educate people about the disease and teach prevention, as well as encourage research and provide camaraderie for people affected by NF," Roemmele said. "The foundation has worked with top-level physicians in infectious diseases, most recently on a retrospective study of people who contracted NF more than once, many years apart."
Preventing NF is critical. Mirza said.
"Any cut, no matter how minor, should be taken seriously and cleansed thoroughly," he explained. He advises against using antibacterial soaps regularly because it may contribute to bacterial resistance.
References for this article can be accessed at www.advanceweb.com/Nurses. Click on Resources, then References.
Gail O. Guterl is a frequent contributor to ADVANCE.