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Centers for Disease Control and Prevention

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Necrotizing fasciitis (NECK-re-tie-zing FASH-e-i-tis) is a rare bacterial infection that spreads quickly in the body and can cause death.

Accurate diagnosis, rapid antibiotic treatment, and prompt surgery are important to stopping this infection.

See a doctor right away if your skin becomes red, warm, swollen, or very painful soon after an injury or surgery.

Group A strep thought to be most common cause

There are many types of bacteria that can cause the "flesh-eating disease" called necrotizing fasciitis. Public health experts believe group A Streptococcus (group A strep) are the most common cause of necrotizing fasciitis. This web page only focuses on necrotizing fasciitis caused by group A strep bacteria.

Bacteria that live in water, including Vibrio vulnificus, can also cause necrotizing fasciitis. Learn about Vibrio wound infections.

How you get necrotizing fasciitis

The bacteria most commonly enter the body through a break in the skin. Different breaks in the skin can include:

Cuts and scrapes

Burns

Insect bites

Puncture wounds (including those due to intravenous [IV] drug use)

Surgical wounds

However, people can also get necrotizing fasciitis after blunt trauma (an injury that does not break the skin).

Necrotizing fasciitis is rarely contagious

Most cases of necrotizing fasciitis occur randomly. It is very rare for someone with necrotizing fasciitis to spread the infection to other people. For this reason, doctors usually do not give preventive antibiotics to close contacts of someone with necrotizing fasciitis.

Necrotizing means causing the death of tissues. Fasciitis means inflammation of the fascia (the tissue under the skin that surrounds muscles, nerves, fat, and blood vessels).

Symptoms can often be confusing and develop quickly

The infection often spreads very quickly.

Early symptoms of necrotizing fasciitis can include:

A red, warm, or swollen area of skin that spreads quickly

Severe pain, including pain beyond the area of the skin that is red, warm, or swollen

Fever

See a doctor right away if you have these symptoms after an injury or surgery. Even though minor illnesses can cause symptoms like these, people should not delay getting medical care.

Later symptoms of necrotizing fasciitis can include:

Ulcers, blisters, or black spots on the skin

Changes in the color of the skin

Pus or oozing from the infected area

Dizziness

Fatigue (tiredness)

Diarrhea or nausea

Some people are at increased risk

While anyone can get necrotizing fasciitis, it is rare.

Other health factors

Most people who get this illness have other health problems that may lower their body's ability to fight infections. Some conditions that weaken the body's immune system include:

Diabetes

Kidney disease

Cirrhosis (scarring) of the liver

Cancer

Diagnosis can be difficult and acting fast is key

There are many infections that look similar to necrotizing fasciitis in the early stages, which can make diagnosis difficult. In addition to looking at the injury or infection, doctors can diagnose necrotizing fasciitis by:

Performing a biopsy (taking a tissue sample)

Looking at bloodwork for signs of infection and muscle damage

Looking at imaging (CT scan, MRI, ultrasound) of the damaged area

However, it is important to start treatment as soon as possible. Therefore, doctors may not wait for test results if they think a patient might have necrotizing fasciitis.

Prompt treatment is key

Necrotizing fasciitis is a very serious illness that requires care in a hospital. Antibiotics and surgery are typically the first lines of defense if a doctor suspects a patient has necrotizing fasciitis.

Doctors treat necrotizing fasciitis with IV antibiotics.

Antibiotics

To try to stop the infection, doctors give antibiotics through an IV, which allows medicine to flow into a vein.

Sometimes, however, antibiotics cannot reach all the infected areas because the bacteria have killed too much tissue and reduced blood flow. When this happens, doctors must surgically remove the dead tissue.

Surgery

Since necrotizing fasciitis can spread so rapidly, patients often must get surgery done very quickly. It is not unusual for someone with necrotizing fasciitis to end up needing multiple surgeries. In serious cases, the patient may need a blood transfusion.

Up to 1 in 5 people with necrotizing fasciitis die from the infection.

Serious complications are common

Necrotizing fasciitis can lead to

It can also result in life-long complications from loss of limbs or severe scarring due to surgically removing infected tissue.

Looking at data from the most recent five years:

Even with treatment, up to 1 in 5 people with necrotizing fasciitis died from the infection

Up to 1 in 3 people who got both necrotizing fasciitis and streptococcal toxic shock syndrome at the same time died from their infections

Prevent necrotizing fasciitis

There are no vaccines to prevent group A strep infections, but there are things you can do to help protect yourself and others.

To help prevent group A step infections, you should:

Wash your hands often

Clean and care for wounds

Clean and care for wounds

If you have an open wound or skin infection, avoid spending time in:

Hot tubs

Swimming pools

Natural bodies of water (e.g., lakes, rivers, oceans)

Care for fungal infections like athlete's foot to help prevent group A strep infections. Learn about athlete's foot (ringworm).

CDC tracks necrotizing fasciitis caused by group A strep bacteria

CDC tracks necrotizing fasciitis caused by group A strep bacteria with a special system called Active Bacterial Core surveillance (ABCs). Since 2010, approximately 700 to 1,150 cases occur each year in the United States. This is likely an underestimate. According to ABCs data, the number of annual group A strep necrotizing fasciitis infections reported to ABCs does not appear to be rising.

Related diseases

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Necrotizing fasciitis is a rare bacterial infection that spreads quickly and can cause death. Accurate diagnosis, rapid antibiotic treatment, and prompt surgery are important to stopping it.

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Necrotizing fasciitis is a subset of aggressive skin and soft tissue infections that cause necrosis of the muscle fascia and subcutaneous tissues( national library of medicine). In other words it is considered Flesh eating bacteria

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It can be caused by many types of bacteria, however the most common is Group A Streptococcus

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Ulcers and blisters

Scarring and disfigurement

Sepsis

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While most signs can be visible to the naked eye, a flesh biopsy is performed to conclude correct hypothesis. Treatments include

1. Surgery to remove damaged tissue

2. Antibiotics to slow the infection

3. Further antibiotic therapy to prevent reoccurance

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1. Wash your hands often

2. Clean all wounds properly

3. Bandage wounds

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This short article talks about the use of a vaccine based inhibitor to prevent group A streptococcus from causing infections with your body

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. 2022 Dec 20;12(24):e4589.

doi: 10.21769/BioProtoc.4589.

Affiliations

¹ Department of Microbiology and Molecular Genetics, The Institute for Medical Research, Israel-Canada (IMRIC), Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem 9112102, Israel.

² School of Life Sciences, Jawaharlal Nehru University, New Mehrauli Road, New Delhi 110067, India.

³ Institute for Drug Research, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem 9112102, Israel.

Free PMC article

Aparna Anand et al. Bio Protoc.

Free PMC article

. 2022 Dec 20;12(24):e4589.

doi: 10.21769/BioProtoc.4589.

Affiliations

¹ Department of Microbiology and Molecular Genetics, The Institute for Medical Research, Israel-Canada (IMRIC), Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem 9112102, Israel.

² School of Life Sciences, Jawaharlal Nehru University, New Mehrauli Road, New Delhi 110067, India.

³ Institute for Drug Research, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem 9112102, Israel.

Abstract

Group A streptococcus (GAS) is a Gram-positive human pathogen that causes invasive infections with mild to life-threatening severity, like toxic shock syndrome, rheumatic heart disease, and necrotizing fasciitis (NF). NF is characterized by a clinical presentation of widespread tissue destruction due to the rapid spread of GAS infection into fascial planes. Despite quick medical interventions, mortality from NF is high. The early onset of the disease is difficult to diagnose because of non-specific clinical symptoms. Moreover, the unavailability of an effective vaccine against GAS warrants a genuine need for alternative treatments against GAS NF. One endoplasmic reticulum stress signaling pathway (PERK pathway) gets triggered in the host upon GAS infection. Bacteria utilize asparagine release as an output of this pathway for its pathogenesis. We reported that the combination of sub-cutaneous (SC) and intraperitoneal (IP) administration of PERK pathway inhibitors (GSK2656157 and ISRIB) cures local as well as systemic GAS infection in a NF murine model, by reducing asparagine release at the infection site. This protocol's methodology is detailed below. This protocol was validated in: Sci Transl Med (2021), DOI: 10.1126/scitranslmed.abd7465.

Keywords: Endoplasmic reticulum stress; GSK2656157; Group A streptococcus; ISRIB; Necrotizing fasciitis murine model; PERK pathway.

PubMed Disclaimer

Conflict of interest statement

Competing interests The authors declare no conflict of interest or competing interests.

Figures

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References

Bisno A. L. and Stevens D. L. ( 1996 . ). Streptococcal infections of skin and soft tissues . N Engl J Med 334 ( 4 ): 240 - 245 . - PubMed

Efstratiou A. and Lamagni T. ( 2016 . ). Epidemiology of Streptococcus pyogenes . Ferretti, J. J., Stevens, D. L. and Fischetti, V. A.(Eds.) Streptococcus pyogenes: Basic Biology to Clinical Manifestations . - PubMed

Aziz R. K. and Kotb M. ( 2008 . ). Rise and persistence of global M1T1 clone of Streptococcus pyogenes . Emerg Infect Dis 14 ( 10 ): 1511 - 1517 . - PMC - PubMed

Nelson G. E. , Pondo T. , Toews K. A. , Farley M. M. , Lindegren M. L. , Lynfield R. , Aragon D. , Zansky S. M. , Watt J. P. , Cieslak P. R. , Angeles K. , Harrison L. H. , Petit S. , Beall B. and Van Beneden C. A. ( 2016 . ). Epidemiology of Invasive Group A Streptococcal Infections in the United States , 2005-2012. Clin Infect Dis 63 ( 4 ): 478 - 486 . - PMC - PubMed

Lynskey N. N. , Jauneikaite E. , Li H. K. , Zhi X. , Turner C. E. , Mosavie M. , Pearson M. , Asai M. , Lobkowicz L. , Chow J. Y. , et al. .( 2019 . ). Emergence of dominant toxigenic M1T1 Streptococcus pyogenes clone during increased scarlet fever activity in England: a population-based molecular epidemiological study . Lancet Infect Dis 19 ( 11 ): 1209 - 1218 . - PMC - PubMed

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national center for biotechnology information

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PERK Pathway Inhibitors Cure Group A Streptococcal Necrotizing Fasciitis in a Murine Model - PubMed

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Group A streptococcus (GAS) is a Gram-positive human pathogen that causes invasive infections with mild to life-threatening severity, like toxic shock syndrome, rheumatic heart disease, and necrotizing fasciitis (NF). NF is characterized by a clinical presentation of widespread tissue destruction du ...

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Joseph was a war surgeon who gave the first description of the infection

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Flesh Eating Bacteria (Necrotizing fasciitis)

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In the most recent five years, the mortality rate of necrotizing fasciitis ranges from 11% to 22%.¹ Coincident necrotizing fasciitis and streptococcal toxic shock syndrome (STSS) have a mortality rate ranging from 16% – 33%.³ Extensive surgical debridement and amputations are not uncommon.

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Etiology

Type II necrotizing fasciitis, known as hemolytic streptococcal gangrene, is characterized by the isolation of S. pyogenes with or without other bacterial species. Staphylococcus aureus is the most common species found in co-infection cases.

S. pyogenes are gram-positive cocci that grow in chains ( see Figure 1). They exhibit β-hemolysis (complete hemolysis) when grown on blood agar plates. They belong to group A in the Lancefield classification system for β-hemolytic Streptococcus. Thus, these bacteria are also called group A Streptococcus or group A strep.

Clinical features

Necrotizing fasciitis can affect any part of the body, but most commonly affects extremities, particularly the legs. Necrotizing fasciitis begins with pain in the affected area accompanied by the following signs:

Spread within subcutaneous tissue with relative sparing of the overlying skin

Absence of lymphadenitis and lymphangitis

Swelling progresses to brawny edema and then to dark-red induration. Within 24 to 48 hours, the overlying skin may turn dusky, indicating small vessels in the dermal papilla have thrombosed. Cutaneous ischemia also develops. Bullae form and are filled with straw colored fluid that progressively turns to hemorrhagic fluid. Affected tissues progressively darken from red to purple to blue to black. As gangrene sets in, skin becomes anesthetized due to destruction of superficial nerves.

Indications of advanced disease include:

Transmission

Risk factors

Healthy people can get streptococcal necrotizing fasciitis. However, it is most commonly found in the setting of systemically or locally immunocompromised individuals. Classically, these are adults with underlying disease, such as diabetes mellitus, peripheral vascular disease, or neoplasm. In the past, retrospective reports linked nonsteroidal anti-inflammatory drugs to necrotizing fasciitis; however, prospective studies have not confirmed this linkage. Cirrhosis and corticosteroid therapy have also been shown to be predisposing factors. Furthermore, the streptococcal strain may influence the development of necrotizing fasciitis. The most commonly involved strains contain M protein types 1, 3, 12, and 28 (usually elaborating pyrogenic exotoxin A). Necrotizing fasciitis may also occur as a superinfection complicating varicella lesions.

Diagnosis and testing

Differentiating cellulitis and necrotizing fasciitis can be difficult when presenting symptoms are non-specific (e.g., unexplained fever, pain, edema, erythema). Where there is low suspicion for necrotizing fasciitis, imaging may be helpful, but can delay diagnosis. Suspicion based upon clinical findings (e.g., profound pain, areas of decreased sensation, crepitation, bullae, skin necrosis) should lead to:

Prompt surgical exploration

Gram stain

Culture

Likewise, in patients whose systemic findings are out of proportion to local findings, surgical exploration or biopsy should be expeditious.

Computed tomography (CT) scanning or magnetic resonance imaging (MRI) can detect subcutaneous and fascial edema or tissue gas. This information can be helpful early in the process when pain and swelling are present without cutaneous changes. However, these are not definitive studies and may delay the diagnosis. In the case of streptococcal necrotizing fasciitis, abscess formation or gas in the tissues are usually not seen on imaging. Muscle tear, hematoma, or prior surgery can complicate interpretation of imaging studies; therefore, these studies should never delay surgical exploration.

Labs such as leukocytosis, thrombocytopenia, and azotemia are common. Gram stain can be highly informative to determine whether the etiology is group A strep.

Treatment

Primary treatment of necrotizing fasciitis is early and aggressive surgical exploration and debridement of necrotic tissue. Surgery is coupled with appropriate broad-spectrum parenteral antibiotic therapy. Upon first exploration, extensive incisions that go beyond the area of apparent involvement are usually necessary. The wound should be left open and re-inspected 24 hours later to ensure adequacy of the initial debridement. Antibiotic therapy is based upon Gram stain findings. Once group A strep is confirmed to be the etiology, high dose penicillin or ampicillin and clindamycin (which interferes with toxin production) should be given. Intravenous immunoglobulin may be considered in cases of severe necrotizing fasciitis, although efficacy has not been proven.

Prognosis and complications

In the most recent five years, the mortality rate of necrotizing fasciitis ranges from 11% to 22%. Coincident necrotizing fasciitis and streptococcal toxic shock syndrome (STSS) have a mortality rate ranging from 16% - 33%.Extensive surgical debridement and amputations are not uncommon.

Prevention

Epidemiology and surveillance

CDC tracks necrotizing fasciitis caused by group A strep with a special system called Active Bacterial Core surveillance (ABCs). Since 2010, approximately 700 to 1,150 cases occur each year in the United States. This is likely an underestimate. According to ABCs data, the number of annual group A strep necrotizing fasciitis infections reported to ABCs does not appear to be rising.

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Get clinical information about necrotizing fasciitis caused by Streptococcus pyogenes. Primary treatment includes surgery and antibiotics.