Necrotizing Soft-Tissue Infections

151 Necrotizing soft-tissue infections have been recognized for centuries. Hippocrates vividly described the disease in the 5th century BC, as follows: ÒThe erysipelas would quickly spread in all directions. Flesh, sinews, and bones fell away in great quantities.Ó Necrotizing soft-tissue infections were subsequently designated as Òstreptococcal gangrene,Ó Òphagedena,Ó and Òphagedena gangrenosum.Ó The first report of necrotizing fasciitis in the United States was made in 1871 by Joseph Jones,1 a Confederate Army surgeon, who called it Òhospital gangreneÓ and described it thus: ÒI have seen the skin in the affected spot melt away in twenty-four hours into a grayish and greenish slough.Ó By the early 1900s, hospital gangrene was believed to be a disease of the past. However, sporadic outbreaks were still reported. In 1924, Meleney2 described an outbreak of Òhemolytic streptococcal gangreneÓ in a Peking hospital. In this report, he emphasized the critical role of early surgical debridement. The term Ònecrotizing fasciitis,Ó as it is commonly designated today, first appeared in a report by Wilson3 in 1952 and perhaps best describes the key aspect of the infectious process. Sporadic outbreaks continue to be reported and have piqued the interest of the popular press. When a cluster of cases were reported in Gloucestershire, England, in 1994, the British tabloids termed this ÒnewÓ disease Ògalloping gangreneÓ and referred to the cause as a Òkiller bugÓ and Òflesh-eating bacteria.Ó These sensationalistic descriptions, and the fact that this disease can strike healthy young individuals and cause devastating morbidity and mortality in a matter of hours, have led to widespread concern about necrotizing fasciitis in the general public. While there is no consensus among infectious disease and epidemiology experts, there are a few reports documenting an increasing incidence of necrotizing fasciitis. For example, in Sweden, the incidence of group A streptococcal bacteremia increased from 1.8 per 100,000 in 1987 to 2.4 per 100,000 in 1989.4 However, other authors believe that the numerical increase is due to heightened awareness and better reporting, rather than reflecting a true increase in incidence. While there has been no active surveillance of group A streptococcal