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This chapter discusses necrotizing, gangrenous, and purulent bacterial infections of the skin, soft tissue, fascia, and muscle. Broadly speaking, the different entities can be characterized by anatomic depth of infection with necrosis extending to the skin (gangrenous cellulitis), fascia (necrotizing fasciitis), and muscle (pyomyositis). However, it should be noted that there is significant overlap between these entities in terms of presentation, clinical course, and treatment. Given this, some current literature groups these infections (as well as necrotizing fungal infections) into 1 larger, overarching subgroup of necrotizing soft-tissue infections.1 Trends in how the medical community chooses to approach and classify these disease entities may change with time and this broader, all-encompassing nomenclature may become the favored terminology in the future. Given the clinical and management nuances for each of these categories, as well as the fact that the term necrotizing soft-tissue infections has not been broadly accepted, this chapter describes the clinical features intrinsic to each separately here. The reader is encouraged to follow how classification for this group of infections may evolve in the literature in the years to come.



Necrotizing fasciitis is a rare, rapidly progressive infection of the skin and subcutaneous soft tissue that tracks down to and spreads rapidly along the fascial plane. The disease is characterized by progressive necrosis and high mortality rates in the absence of prompt diagnosis and management.

Initial signs and symptoms of necrotizing fasciitis were described by Hippocrates in the fifth century BC.2 In 1871, this group of infections was named “hospital gangrene” by Joseph Jones, a surgeon who served in the Confederate Army and subsequently went on to become the Secretary of the Southern Historical Society where he spent time chronicling disease states he encountered in the war.1,3 In 1918, Pfanner diagnosed a patient with a necrotizing beta-hemolytic streptococcal infection and coined the term necrotizing erysipelas.4 In 1924, a case series of necrotizing infection of the skin and subcutaneous tissue described as “streptococcal gangrene” was reported by Melany.4 The term necrotizing fasciitis was finally introduced by Wilson in 1951 to 1952 to encompass both gas-forming and non–gas-forming necrotizing soft-tissue infections encompassing and spreading along the fascial plane.2,3 Only recently was necrotizing fasciitis thought to represent part of a larger group of necrotizing and gangrenous soft-tissue infections. More recent literature includes necrotizing fasciitis as one of several necrotizing soft-tissue infections, that are grouped together given similarities in behavior, diagnosis, management, and poor prognosis without prompt intervention.1,3


Data surrounding current necrotizing fasciitis epidemiology is limited. A 2013 study by Psoinos and colleagues utilized the Nationwide Inpatient Sample Database to examine necrotizing soft-tissue infection epidemiology as a group within the United States.5 This study found 56,527 admissions for ...

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