[The therapeutic approach to necrotizing fasciitis]

Necrotizing fasciitis are characterized by the necrosis of fascias, and their severe consequences in terms of morbidity and mortality. An early diagnosis, based on sometimes subtle cutaneous lesions (associated to a sepsis syndrome) allows to start resuscitation and decide on a probable surgery. 3 major forms can be distinguished: streptococcal fasciitis, due to beta-hemolytic streptococci, often following minor trauma, and increasingly associated to a streptococcal toxic shock syndrome (STTS); clostridial gangrene (often polymicrobial when developed on a open wound or after surgery); and synergistic gangrene due to a mixed aerobic-anaerobic flora. Other apparently "primitive" necrotizing fasciitis, caused by specific organisms, may occur in debilitated patients. The prognosis depends on age, comorbidity, and above all on the severity of the sepsis syndrome. Initial resuscitation involves controlling the hypotension and organ dysfunction associated with severe sepsis, and is usually dominated by a severe hypovolemia. Penicillin G remains the key antibiotic for streptococcal and clostridial fasciitis, with a broad spectrum including enterobacteriaceae, streptococci and enterococci, and anaerobes (including Bacteroides spp.) in other types or when the etiology is unknown. In patients presenting with STSS, a combination of clindamycin (or rifampin) to penicillin is recommended, because of their effect on exotoxin production; administration of non-specific immunoglobulins also appears to improve the outcome of patients affected. Hyperbaric oxygen therapy has not proved effective. Early surgical debridement largely influences the prognosis. The prevention of complications associated with long-term intensive care, including early nutritional support and prevention of a thromboembolic disease, is also important.