Necrotizing Fasciitis
Necrotizing fasciitis (NF) of the female vulva and perineum is a life-threatening soft tissue infection. Risk factors include diabetes mellitus, obesity, immunosuppression, intravenous drug and alcohol abuse, trauma, and postoperative surgical wound compl
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Sara Wood
47.1 Introduction Necrotizing fasciitis (NF) of the female vulva and perineum is a life-threatening soft tissue infection that necessitates immediate multidisciplinary coordinated care to limit morbidity and mortality. The contiguous nature of the vulvar fascia and associated adipose tissue facilitates rapid spread of NF and leads to widespread destruction of tissue and systemic infection. Perineal NF carries a twofold increase in mortality compared to NF originating in the limbs with reported mortality rates ranging from 14% to 48% [1–6]. Delays in diagnosis and debridement likely represent two of the greatest factors responsible for even higher rates of mortality, underscoring the prompt multidisciplinary efforts needed for treatment [2, 7].
47.2 Risk Factors Risk factors for necrotizing fasciitis include diabetes mellitus, obesity, immunosuppression, intravenous drug and alcohol abuse, trauma, and iatrogenic causes from postoperative surgical wounds [7–10]. These severe infections have also S. Wood (*) Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Mercy Hospital St. Louis, St. Louis, MO, USA
been reported after routine obstetric and gynecologic procedures, such as vaginal and cesarean delivery, episiotomy, marsupialization of Bartholin’s gland, mid-urethral sling, and hysterectomy [7, 11–15]. Providers caring for women with wound infections in the postpartum setting should be particularly astute to the possibility and risk of group A streptococcus (GAS) and its associated severe systemic illness [7, 16].
47.3 Pathophysiology and Microbiology The pathophysiology of NF is complex. Microbial invasion commonly begins through superficial skin trauma or perforation of the lower gastrointestinal tract or urogenital organs [8]. As bacteria spread along the fascia, virulence factors (i.e., endo- or exotoxins, surface proteins, and superantigens) are produced allowing for evasion of host immune factors and cause activation of host inflammatory and coagulation cascades [17–19]. Ultimately, tissue edema and impaired capillary blood flow lead to tissue necrosis, subsequent shock, and multi-organ system failure with possible death [18–20]. Although NF is most commonly polymicrobial, single-pathogen NF also occurs, particularly in the obstetric setting [8]. Polymicrobial infections include gram-positive cocci (Staphylococcus aureus and Streptococcus),
© Springer International Publishing AG, part of Springer Nature 2019 J. Bornstein (ed.), Vulvar Disease, https://doi.org/10.1007/978-3-319-61621-6_47
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gram-negative rods (Klebsiella, Escherichia coli, and Bacteroides), anaerobes, and less frequently gram-positive rods (Clostridia species) [8, 10, 21–23]. Monomicrobial NF infections caused by group A streptococcus (GAS) are unique due to the potential for associated toxic shock syndrome and the ability of GAS to survive within macrophages, thereby evading antibiotic treatment [8, 17].
47.4 Clinical Presentation Multiple studies h
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