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Nekrotisierende Fasziitis

Update 2011

Necrotizing fasciitis

2011 update

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Zusammenfassung

Die nekrotisierende Fasziitis gehört zu den komplizierten Weichgewebeinfektionen mit potentieller Lebensbedrohung. Trotz zunehmendem Erkenntnisgewinn in Bezug auf Ätiologie, Risikofaktoren und Pathophysiologie ist die Letalität mit ca. 20% hoch. Eine relevante Reduktion wird nur bei früher Diagnosestellung und konsequenter Therapie verzeichnet. Klinische Symptome sind in >75% der Patienten der disproportionale Schmerz, Schwellung, Ödem und Spannungsgefühl, Bläschenbildung und Rötung. Notwendig ist eine frühe Unterscheidung in eine nekrotisierende oder eine nichtnekrotisierende Weichgewebeinfektion. Bei unklarer Situation muss die chirurgische Exploration durchgeführt werden. Das pathologische Charakteristikum ist die verflüssigende Nekrose der Faszie, eine Vaskulitis und Thrombosen der lokalen Gefäße, die Ansammlung der verursachenden Mikroorganismen sowie mononukleärer Zellen und polymorphkerniger neutrophiler Granulozyten im Fasziengewebe. Sekundär können die Kutis sowie die Muskulatur befallen sein. In vielen Fällen besteht zwischen der Ausprägung systemischer und lokaler Symptome keine Beziehung. Es werden v. a. zwei Hauptformen unterschieden: die polymikrobielle Mischinfektion Typ I und die invasiver und in der Regel fulminanter verlaufende monomikrobielle Infektion Typ II (meist durch β-hämolysierende Streptokokken der Gruppe A).

Invasive, schwer verlaufende Streptokokkenerkrankungen scheinen in ihrer Häufigkeit zuzunehmen. Die Behandlung muss multimodal erfolgen und interdisziplinär ausgerichtet sein. Ihre Säulen sind das frühzeitige radikale Débridement, die breit angelegte, systemische Antibiotikatherapie und die Intensivtherapie, ggf. kombiniert mit einer Immunglobulin- (bei Strepto- oder Staphylokokkeninfektion) oder hyperbaren Sauerstofftherapie (HBO; bei Clostridienmischinfektion). Für die lokale Wundbehandlung der teilweise ausgedehnten Weichteildefekte bewährte sich die Vakuumversiegelung.

Abstract

Necrotizing fasciitis belongs to a group of complicated soft tissue infections that can be even life threatening. Despite growing knowledge about its etiology, predictors, and the clinical progression, the mortality remains at a high level with 20%. A relevant reduction can be achieved only by an early diagnosis followed by consistent therapy. The clinical findings in about 75% of the cases are pain out of proportion, edema and tenderness, blisters, and erythema. It is elementary to differentiate a necrotizing or a non-necrotizing soft tissue infection early. In uncertain cases it can be necessary to perform a surgical exploration to confirm the diagnosis. The histopathologic characteristics are the fascial necrosis, vasculitis, thrombosis of perforating veins, the presence of the disease-causing bacteria as well as inflammatory cells like macrophages and polymorphonuclear granulocytes. Secondly, both the cutis and the muscle can be affected. In many cases there is a disproportion of the degree of local and systemic symptoms. Depending on the infectious agents there are two main types: type I is a polymicrobial infection and type II is a more invasive, serious, and fulminant monomicrobial infection mostly caused by group A Streptococcus pyogenes.

Invasive, severe forms of streptococcal infections seem to occur more often in recent years. Multimodal and interdisciplinary therapy should be based on radical surgical débridement, systemic antibiotic therapy as well as enhanced intensive care therapy, which is sometimes combined with immunoglobulins (in streptococcal or staphylococcal infections) or hyperbaric oxygen therapy (HBOT, in clostridial infections). For wound care of extensive soft tissue defects vacuum-assisted closure has shown its benefit.

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  1. Klinik für Unfallchirurgie und Orthopädie, Bundeswehrkrankenhaus Ulm, Ulm, Deutschland

    M. Herr, H.-J. Riesner & B. Friemert

  2. Klinische Mikrobiologie und Krankenhaushygiene (KMH), Klinikum der Universität München, München, Deutschland

    B. Grabein

  3. Controlling und Qualitätsmanagement, Bundeswehrkrankenhaus Ulm, Ulm, Deutschland

    H.-G. Palm

  4. Abteilung für Radiologische Diagnostik, Bundeswehrkrankenhaus Ulm, Ulm, Deutschland

    K. Efinger

  5. Chirurgisches Zentrum, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland

    C. Willy Oberfeldarzt

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  2. B. Grabein
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  3. H.-G. Palm
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  4. K. Efinger
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  5. H.-J. Riesner
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  6. B. Friemert
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  7. C. Willy Oberfeldarzt
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Correspondence to C. Willy Oberfeldarzt.

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Herr, M., Grabein, B., Palm, HG. et al. Nekrotisierende Fasziitis. Unfallchirurg 114, 197–216 (2011). https://doi.org/10.1007/s00113-010-1893-6

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  • DOI: https://doi.org/10.1007/s00113-010-1893-6

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