Miller Loren G, Perdreau-Remington Francoise, Rieg Gunter, Mehdi Sheherbano, Perlroth Josh, Bayer Arnold S, Tang Angela W, Phung Tieu O, Spellberg Brad
Division of Infectious Diseases, Harbor-UCLA Medical Center and the Los Angeles Biomedical Institute at Harbor-UCLA, Torrance, California, USA.
N Engl J Med. 2005 Apr 7;352(14):1445-53. doi: 10.1056/NEJMoa042683.
Necrotizing fasciitis is a life-threatening infection requiring urgent surgical and medical therapy. Staphylococcus aureus has been a very uncommon cause of necrotizing fasciitis, but we have recently noted an alarming number of these infections caused by community-associated methicillin-resistant S. aureus (MRSA).
We reviewed the records of 843 patients whose wound cultures grew MRSA at our center from January 15, 2003, to April 15, 2004. Among this cohort, 14 were identified as patients presenting from the community with clinical and intraoperative findings of necrotizing fasciitis, necrotizing myositis, or both.
The median age of the patients was 46 years (range, 28 to 68), and 71 percent were men. Coexisting conditions or risk factors included current or past injection-drug use (43 percent); previous MRSA infection, diabetes, and chronic hepatitis C (21 percent each); and cancer and human immunodeficiency virus infection or the acquired immunodeficiency syndrome (7 percent each). Four patients (29 percent) had no serious coexisting conditions or risk factors. All patients received combined medical and surgical therapy, and none died, but they had serious complications, including the need for reconstructive surgery and prolonged stay in the intensive care unit. Wound cultures were monomicrobial for MRSA in 86 percent, and 40 percent of patients (4 of 10) for whom blood cultures were obtained had positive results. All MRSA isolates were susceptible in vitro to clindamycin, trimethoprim-sulfamethoxazole, and rifampin. All recovered isolates belonged to the same genotype (multilocus sequence type ST8, pulsed-field type USA300, and staphylococcal cassette chromosome mec type IV [SCCmecIV]) and carried the Panton-Valentine leukocidin (pvl), lukD, and lukE genes, but no other toxin genes were detected.
Necrotizing fasciitis caused by community-associated MRSA is an emerging clinical entity. In areas in which community-associated MRSA infection is endemic, empirical treatment of suspected necrotizing fasciitis should include antibiotics predictably active against this pathogen.
坏死性筋膜炎是一种危及生命的感染，需要紧急手术和药物治疗。金黄色葡萄球菌一直是坏死性筋膜炎非常罕见的病因，但我们最近注意到，由社区获得性耐甲氧西林金黄色葡萄球菌（MRSA）引起的此类感染数量惊人。
我们回顾了2003年1月15日至2004年4月15日在我们中心伤口培养出MRSA的843例患者的记录。在该队列中，14例被确定为来自社区的患者，具有坏死性筋膜炎、坏死性肌炎或两者的临床和术中表现。
患者的中位年龄为46岁（范围28至68岁），71%为男性。并存疾病或危险因素包括当前或既往注射吸毒（43%）；既往MRSA感染、糖尿病和慢性丙型肝炎（各21%）；以及癌症和人类免疫缺陷病毒感染或获得性免疫缺陷综合征（各7%）。4例患者（29%）没有严重的并存疾病或危险因素。所有患者均接受了药物和手术联合治疗，无一死亡，但他们出现了严重并发症，包括需要进行重建手术和在重症监护病房长时间住院。86%的伤口培养物中MRSA为单一微生物，10例接受血培养的患者中有4例（40%）血培养结果为阳性。所有MRSA分离株在体外对克林霉素、甲氧苄啶-磺胺甲恶唑和利福平敏感。所有回收的分离株属于同一基因型（多位点序列类型ST8、脉冲场类型USA300和葡萄球菌盒式染色体mec类型IV [SCCmecIV]），并携带杀白细胞素（pvl）、lukD和lukE基因，但未检测到其他毒素基因。
由社区获得性MRSA引起的坏死性筋膜炎是一种新出现的临床实体。在社区获得性MRSA感染流行的地区，对疑似坏死性筋膜炎的经验性治疗应包括对该病原体有可预测活性的抗生素。
