Käch K, Kossmann T, Trentz O
Departement Chirurgie, Universitätsspital Zürich.
Unfallchirurg. 1993 Apr;96(4):181-91.
Necrotizing soft tissue infections are a group of life- and limb-threatening infections. They are caused by aerobic and anaerobic bacteria occasionally in a synergistic polymicrobial combination. The literature describing necrotizing soft tissue infections is controversial and often contradictory. Depending on their clinical appearance, tissue level and microbiological findings, necrotizing soft tissue infections are classified into two major groups, infections within the subcutaneous/fascia niveau and within the muscle level. Necrotizing infections of the subcutaneous level are further differentiated in hemolytic streptococcal gangrene, necrotizing fasciitis, clostridium fasciitis, and anaerobic nonclostridium fasciitis. In particular, necrotizing fasciitis is a rapidly progressing process, which is characterized by suppurative fasciitis, following by vascular thrombosis and cutaneous gangrene and is often accompanied by severe systemic toxicity, seen as septic-toxic shock and progressive (multi-) organ failure. Nineteen cases of necrotizing soft tissue infections were treated at the Department of Surgery, University Hospital of Zurich, between 1989 and 1992. These infections originated from "neglected trauma" in 9 (9/19), drug injections in 4 (4/19), acute infections in 3 (3/19), operative wounds in 2 (2/19) and perforation of the intestine in 1 case (1/19). Most of the patients (13/19) suffered from chronic debilitating diseases and were compromised by a suppressed immune system. We treated two groups of patients, one with septic-toxic clinical course and the other without. Eleven patients (11/19) belonged to group one and four of them, showing necrotizing fasciitis of the trunk, died as a result of multiorgan failure (MOF). Furthermore, three patients in this group had a limb amputated. In the other group without septic-toxic signs, no one died or lost a limb. The two groups differed also in length of hospital stay, an average of 60 days in group one (23 days intensive care) and 25 days in group two. Our results suggest that prompt recognition and treatment of necrotizing soft tissue infections are essential for the patient's survival. Often the full extent of the infections is underestimated initially, resulting in delayed surgical therapy. To control the rapidly spreading necrosis, early diagnosis and radical debridement of the affected tissue are essential and should be done without compromise, even if the affected limb must be amputated.
坏死性软组织感染是一组危及生命和肢体的感染。它们由需氧菌和厌氧菌引起，偶尔为协同性多微生物组合。描述坏死性软组织感染的文献存在争议且常常相互矛盾。根据临床表现、组织层次和微生物学检查结果，坏死性软组织感染分为两大组，即皮下/筋膜层感染和肌肉层感染。皮下层的坏死性感染进一步分为溶血性链球菌坏疽、坏死性筋膜炎、梭状芽孢杆菌性筋膜炎和非梭状芽孢杆菌性厌氧菌性筋膜炎。特别是，坏死性筋膜炎是一个快速进展的过程，其特征为化脓性筋膜炎，继之血管血栓形成和皮肤坏疽，且常伴有严重的全身毒性，表现为脓毒性休克和进行性（多）器官衰竭。1989年至1992年间，苏黎世大学医院外科治疗了19例坏死性软组织感染患者。这些感染的起因如下：9例（9/19）源于“被忽视的创伤”，4例（4/19）源于药物注射，3例（3/19）源于急性感染，2例（2/19）源于手术伤口，1例（1/19）源于肠道穿孔。大多数患者（13/19）患有慢性消耗性疾病，免疫系统受到抑制。我们治疗了两组患者，一组临床病程为脓毒性，另一组无此表现。11例患者（11/19）属于第一组，其中4例躯干出现坏死性筋膜炎，死于多器官功能衰竭（MOF）。此外，该组有3例患者截肢。在另一组无脓毒性体征的患者中，无人死亡或截肢。两组患者的住院时间也不同，第一组平均为60天（23天重症监护），第二组为25天。我们的结果表明，及时识别和治疗坏死性软组织感染对患者的生存至关重要。感染的实际范围最初常常被低估，导致手术治疗延迟。为控制迅速蔓延的坏死，早期诊断和对受影响组织进行彻底清创至关重要，且应毫不妥协地进行，即使必须截肢受影响的肢体。
