On 24/8, Doctor Nguyen Xuan Lam from the Infectious Disease Resuscitation Department of the 108 Military Central Hospital, reported treating two patients with necrotizing fasciitis that led to multiple organ failure.

The patients presented with pain and tightness in both calves, accompanied by redness, swelling, bruising, blisters, and rapidly spreading damage up their thighs. This progressed to multiple organ damage, including respiratory and circulatory failure, liver and kidney damage, and bone marrow suppression. Despite intensive treatment, both patients rapidly deteriorated, succumbing to severe septic shock and irreversible multiple organ failure within 2 to 3 days.

Necrotizing fasciitis (NF) is a severe, rapidly progressing soft tissue infection with a high mortality rate. It is characterized by the rapid spread of necrotizing infection in the subcutaneous tissue and fascia, potentially reaching muscles and deeper organs, causing septic shock and multiple organ failure (respiratory, liver, kidney, neurological failure, blood clotting disorders, and acid-base imbalance).

NF can be caused by various bacteria, typically classified into three groups based on their pathogenic characteristics: Type I, the most common, is caused by gram-negative bacteria (e.coli, klebsiella, vibrio vulnificus, aeromonas hydrophila) and gram-positive bacteria (staphylococcus). Type II is caused by streptococcus pyogenes (group A beta-hemolytic streptococcus). Type III is caused by anaerobic bacteria (bacteroides, clostridium).

Necrotizing fasciitis begins when bacteria enter soft tissue through open wounds, surgical sites, injections, or burns. The infection then quickly spreads along the fascia, often extending beyond the initial injury. The bacteria release tissue-degrading enzymes, destroying connective tissue structure and facilitating deeper penetration.

Some bacteria release toxins like streptococcal pyrogenic exotoxins, triggering a massive release of inflammatory factors. This leads to shock, blood vessel necrosis, plasma leakage, and reduced local blood flow. Additionally, some bacteria secrete alpha-toxin, causing cell membrane lysis, embolism, and subcutaneous gas formation.

The elderly, individuals with diabetes, those with weakened immune systems, and those with alcohol addiction are more prone to an uncontrolled, strong systemic inflammatory response. This, combined with toxins from both the bacteria and necrotic tissue, leads to irreversible multiple organ failure. Consequently, the bacteria spread rapidly, making the disease difficult to control.

Treatment of a patient with necrotizing fasciitis at the Infectious Disease Resuscitation Department, 108 Military Central Hospital. Photo: Hospital provided

Treatment of a patient with necrotizing fasciitis at the Infectious Disease Resuscitation Department, 108 Military Central Hospital. Photo: Hospital provided

Warning signs and treatment

Onset: Severe pain disproportionate to the visible injury is a hallmark symptom and may be the first sign. The pain intensifies rapidly and spreads along the fascial planes.

Progression stage: Swelling, redness, and tightness in the affected area, unresponsive to common antibiotics. The skin color darkens, bruises appear, blisters (bullae) form, and eventually, necrosis sets in. Fever may be absent initially but develops as the infection spreads, accompanied by systemic infection.

Systemic signs: Extensive necrosis, damage to adjacent organs (muscles, skin, blood vessels), and multiple organ failure if not treated promptly.

Patients exhibiting these signs should seek immediate hospital treatment.

NF is a surgical emergency requiring a multi-modal approach for patient survival:

Early and complete surgical debridement of necrotic tissue is crucial for survival. The thoroughness of the initial debridement heavily relies on the surgeon's expertise. The wound should be reassessed after 24-48 hours to evaluate progression and additional debridement may be necessary.

Broad-spectrum intravenous antibiotics based on the suspected pathogen: Empirical treatment should be initiated with broad-spectrum antibiotics targeting potential bacteria, combined with antibiotics that inhibit bacterial toxins. Once the pathogen is identified, antibiotic therapy should be adjusted accordingly based on antibiotic susceptibility testing.

Intensive care support: Fluid resuscitation, acid-base balance correction, vasopressors to raise blood pressure, mechanical ventilation for respiratory support, blood sugar control, and continuous renal replacement therapy for multi-organ failure.

The mortality rate for NF is 20-40%, potentially reaching 70% with delayed diagnosis or surgical intervention. Poor prognostic factors include advanced age, multi-organ failure upon admission, widespread infection or gas in the tissues, and delayed surgery beyond 24 hours.

Le Nga