NECROTIZING SOFT-TISSUE INFECTIONS OF THE EXTREMITIES

The term ''necrotizing soft tissue infections'' describes a group of limb and life-threatening infections. Depending on the tissue level, microbiology and clinical course the necrotizing soft-tissue infections are classified in primary located infections to the subcutaneous level and fascia - like hemolytic streptococcus gangrene, necrotizing fasciitis, gram-negative synergistic necrotizing cellulitis, clostridium-cellulitis, anaerobic non-clostridium-cellulitis and in primary located infections to the muscle - like clostridium myonecrosis and streptococcal myositis. Between 1989 and 1992, 17 patients with necrotizing soft-tissue infections were treated at the Department of Surgery, University Hospital of Zurich. These infections originated from small traumatic injuries or operative wounds (''neglected wounds''). 11 patients suffered from debilitating diseases like diabetes mellitus, drug or alcohol abuse or were compromised by tumors. The average age was 42 years (21-84 years). Following bacteria were found: Staphylococcus aureus, hemolytic Streptococcus, Enterococcus, E. coli, Streptococcus milleri. 2 patients had a mixed infection with more than 3 different bacteria, 6 patients with 2, and 9 patients had a monoinfection. In 14 patients the infection was on the subcutaneous and fascia level, 3 patients showed a myositis or myonecrosis. No patient died, amputation of the limb was necessary in 4 cases. The average hospitalisation was 41 days (13-137 days) whereas 10 patients required between 4 and 53 days intensive care (average 18.3 days). Necrotizing soft-tissue infections are severe illnesses which are underestimated in the primary phase due to atypical or minor primary signs, The infections can be caused by a. variety of bacteria and are spreading rapidly. The surgical therapy has to be aggressive with extensive debridement of the affected areas supported by intensive care. Delayed surgical therapy, wrong therapeutical concepts and incomplete debridement with compromises may cause fatal consequences. Repeated debridement as well as amputation of the affected limb is justified to guarantee the patient's survival.