Necrotizing Fasciitis: A Six-Year Experience

Edin Tunovic, BSc MED,* Justin Gawaziuk, MSc,* Tom Bzura, BSc MED,*
John Embil, MD,* Ali Esmail, MD,* Sarvesh Logsetty, MD*

Necrotizing fasciitis (NF) is a life-threatening infectious disease whose incidence has been
on the rise. Commonly a consequence of group A beta-hemolytic Streptococcus infection, it
results in high levels of morbidity and mortality. Diagnosis is difficult and treatment in-
volves emergent surgical intervention and antibiotic therapy. The aim of this study is to ex-
amine the incidence of NF in Manitoba with the goal of observing whether there is a geo-
graphic variation in incidence and outcomes based on Regional Health Authorities (RHAs).
This is a 6-year retrospective chart review of all NF patients who presented to the Health
Sciences Center from 2004 to 2009. A total of 130 patients satisfied the inclusion criteria.
The mean age was 47 16 years. The most common comorbidities were diabetes (33.8%)
and hypertension (33.1%). The overall mortality was 13.1% with advanced age being an in-
dependent risk factor (P < .05). Lower extremity was the most common location of infec-
tion (44.6%) and the most common causative organism was group A beta-hemolytic Strepto-
coccus (63.9%). The type of infection (mono- vs. polymicrobial) was not found to affect
length of stay, amputation rate, or mortality. There was no statistical difference in rate of
amputations, length of stay, or mortality based on RHA. Incidence within the province,
however, varied significantly based on RHA and ethnicity (P < .05). We determined that
regardless of origin before admission, all our patients have equivalent prognosis. Burn-
twood RHA was found to have substantially higher incidence than the rest of the province,
and higher incidence was established among the Aboriginal population. (J Burn Care Res
2012;33:93100)

Necrotizing fasciitis (NF), commonly known as may vary as this does not take into account other
flesh-eating disease, causes significant tissue dam- infective organisms. In Canada, as of 2001, there
age, can lead to amputation, and is potentially life were 90 to 200 estimated cases of NF per year which
threatening. The disease was originally described in was fatal in about 20 to 30% of cases.1
France in 1783.1 Throughout the 19th and 20th cen- Due to the magnitude of the consequences of the
turies, it was commonly chronicled in military hospi- disease, it is considered a mandatorily reportable dis-
tals with occasional outbreaks noted in the general ease under the Public Health Act in Manitoba.1 Re-
public.1 While a number of bacteria may cause NF, cently the Chief Medical Examiner of Manitoba
the most common organism is group A beta-hemolytic stated that there seems to be an increasing incidence
Streptococcus (GABS). Canadian studies report an an- of NF in this province.3 Manitoba has a population
nual incidence of GABS infection of 1.5 cases per base of approximately 1.15 million but has recently
100,000 individuals, wherein 6% of these infections reported more than 20 cases a year, almost one third
progress to NF.2 Actual numbers of NF infections of the total reported for Canada despite having less
than 4% of the population.4 The incidence is dispro-
portionately high within the context of the relatively
From the *University of Manitoba, Sections of General and
Plastic Surgery, Department of Surgery, and Section of small population of Manitoba compared with the rest
Infectious Diseases, Department of Medicine, Winnipeg, of Canada. This trend is disturbing considering the
Manitoba, Canada. seriousness of the disease process and its impact on
Presented at the 43rd annual meeting of the American Burn
Association, Chicago, Illinois, March 29 to April 1, 2011. health care resources.
Address correspondence to Sarvesh Logsetty, MD, Department of The rationale for our project is centered on the
Surgery and Childrens Health, University of Manitoba, GC observation of the increased incidence of NF in Man-
401A-820 Sherbrook Street, Winnipeg, MB R3A 1R9.
Copyright 2012 by the American Burn Association. itoba and motivated by the fact that this is a serious
1559-047X/2012 disease that carries substantial morbidity and mortal-
DOI: 10.1097/BCR.0b013e318239d571 ity. In recent studies, mortality rates have been re-

93
 Journal of Burn Care & Research
94 Tunovic et al January/February 2012

ported to range from 4 to 33%.511 To examine this ties can result in significant long-term sequelae. Re-
trend, we performed a 6-year (2004 2009) retro- cent evidence by Light et al15 demonstrates that pa-
spective chart review of all NF patients admitted to tients who survive an episode of NF, despite being
the Health Sciences Center (HSC) in Winnipeg, treated appropriately for it, are at a risk of premature
Manitoba, Canada. This is one of only two centers death when compared with age- and gender-matched
with plastic surgery coverage in the province and re- controls. Given the burden of illness, it is important
ceives the majority of NF patients for the province. that we gain insight into the Manitoba experience
The disease is grouped into two etiological types with NF so that we can understand our patient pop-
based on the causative organisms. Type I is a polymi- ulation and take the appropriate steps to minimize the
crobial infection and can involve Gram-positive, impact of the disease on our patient population as
Gram-negative, and aerobic as well as anaerobic or- well as health care system.
ganisms in addition to fungi in rare cases. Type II is a
monomicrobial infection typically by group A Strep- Literature Review
tococcus either with or without the association of The literature review was conducted using searches
Staphylococcus aureus.12,13 The invasive process is on PubMed/Medline. Terms used were NF, NF
aided by the production of various exotoxins and en- literature review(s), NF chart review studies, NF and
dotoxins, which accelerate the infection by significantly diabetes, NF comorbidities, NF treatment, and NF in
contributing to progressive tissue necrosis.12,13 Throm- Canada. Searches were initially conducted for general
bosis of local vessels, ischemia, liquefaction necrosis, and reviews on the subject. Case studies were excluded
an exaggerated immune response are the hallmarks of from the review.
NF.5,1214 This process can extend from the superficial Several recent large-scale studies were used as spe-
plane to the deep fascial planes.14 The infection can cific reference material for information regarding co-
spread as fast as 2.5 cm (1 inch) per hour leading to morbidities, morbidity, and mortality, as well as other
further necrosis, sepsis, toxic shock, and eventual death patient outcomes. Eight representative studies were
if it is not controlled.12,13 examined with publication years ranging from 2003
Antibiotic therapy has an important role to play in to 20106 8,10 12,15,16 (Table 1). The number of pa-
the treatment of NF. A challenge to selecting the tients ranged from 12 to 345. The majority of studies
correct antibiotic is the growing number of resistant had less than 10 patients a year. As such the studies
bacteria in the community. The current standard of were not consistent in reporting factors of interest. A
care is to use broad-spectrum antibiotics early and to study may report microbiology, surgical intervention,
narrow the antibiotic choice once the bacterial sensi- or on outcomes, but no study reported on all factors.
tivities are known. One theoretical problem with early Comorbidities and risk factors seen with NF are
antibiotic treatment in NF is that it may mask the varied, but there has been some consensus in recent
underlying condition thus delaying diagnosis.9 large group studies. Diabetes mellitus (DM) is the
The approach to treatment of patients with NF is most commonly associated comorbidity in the NF
emergent surgical debridement and appropriate anti- patient population. Additional conditions often re-
biotics. Studies have shown that a delay in surgical ported include immunocompromised status, varicella
treatment is associated with increased mortality rates. zoster in children, peripheral vascular disease, alco-
Golger et al demonstrated that patients who under- holism, congestive heart failure, chronic obstructive
went surgery within 24 hours had a better outcome pulmonary disease, end-stage renal disease, tubercu-
when compared with the patients who were operated losis, and malignancy.511,18 It is clear that DM is
on at 36 hours (27 percent versus 55 percent mor- becoming the most commonly associated comorbid-
tality rate), and many authors have recommended ity around the world.5,6,9
early, often wide, surgical debridement as an initial A New Zealand study, by Tiu et al, was unique
treatment in all patients with NF.57 Multiple surgical because it examined the referral population based on
debridements/interventions are often required for ethnicity, finding that Maori and Pacific Islanders
preventing disease progression and effective treat- accounted for 64% of total admissions despite making
ment of the infectious process. Surgery often requires up only 31% of the referral population. This partic-
amputation of portions and even entire limbs.5,8,9 ular ethnic group is found to be of lower socioeco-
Given the large transport distances involved with pa- nomic status and to have a high incidence of DM,
tient care in Manitoba, we hypothesized that there is which was found to be an independent risk factor for
a potential difference in outcomes based on health mortality in their study.7
care region and distance to tertiary surgical care. All NF cases in the Manitoba are typically trans-
The disease burden and accompanying comorbidi- ferred to one of two hospitals with the majority of
Journal of Burn Care & Research
Volume 33, Number 1 Tunovic et al 95

Table 1. Major studies used for literature review

Author(s) Golger et al Light et al Wong et al Tiu et al Rieger et al Khanna et al Redman et al Ryssel et al

Journal Plast Reconstr J Burn Care Res J Bone Joint ANZ J Surg Ann Plastic Surg Int J Low Extrem South Med J Arch Orthop
Surg (2010) Surg Am (2005) (2007) Wounds (2003) Trauma
(2007) (2003) (2009) Surg
(2010)
Demographics
No. patients 99 345 (226 used for 89 48 16 (13 NF and 3 118 12 34
retrospective necrotizing
chart review) myositis)
Mortality (%) 20 25 21.3 29 25.4 (NF) 15 33 4
Male/female (%) 54/46 57/43 59.6/40.4 56/44 66/44 66.1/42.9 33.3/66.7 52.9/47.1
Avg. age 44.6 23.9 49 (avg.) 56 (avg.) 51 (median: 47.1 (avg.) 45 16 (mean: 58 (mean: 56.7 10.6
(avg.) 1980) 1295) 2690) (avg.)
Comorbidities (%)
Diabetes 30 56 70.8 39.6 24 39 16.7 56
Immunocompromised 17 0.85 8.3
Renal failure 4 12 4.2 1.7 33.3 16
Malignancy 5 5 2.2 3.4
CV disease 6 38 6.2 25 68*
IV drug use 3 31.3
Ethanol abuse 24 16.7
Smoking 33
Location of infection
Upper extremities 27 10.1 62 7.7 0 25 100
Lower extremities 28 69.7 69.2 100 75
Genitalia/perineum 21 0 1518 0 0 0 N/A
Trunk 18 20.2 20 15.4 0 0 0
Head and neck 5 0 5 7.7 0 0 N/A
Microbiology
Type I (%) 54 53.9 31 31.3 12.2 98 47
Type II (%) 46 46.1 69 62.5 87.8 2 53
Surgery
No. procedures Avg. 2.7 4 (median: 5.2 (avg.: 2.3 (mean: 15) 3.4 (mean: 3.3 (avg)
debridements 113) 215) 010)
Days in hospital 40.6 31 (median: 46.6 (avg.: 34.3 21 (avg.: 1 64 5.5
1300) 2133) (mean: 648) 94)
Amputations (%) 22.5 10.42 0 20.3 0 23.5

* HTN (40) and coronary disorders (28).

Only for NF patients in study.
CV, cardiovascular; HTN, hypertension; NF, necrotizing fasciitis.

cases being treated at the Health Sciences Centre. project proposal was approved by the Faculty Eth-
This 6-year retrospective study aims to examine the ics Committee for the use of human subjects in
increasing incidence of NF and achieve a further un- research and the Health Research Ethics Board at
derstanding into the causative factors and details of University of Manitoba.
this phenomenon. It is unique because it is the first to After Health Research Ethics Board approval, pa-
examine this phenomenon in Manitoba while analyz- tients were identified by Health Information Services
ing geographic variation in NF characteristics. Al- at Health Sciences Centre with a search based on
though our study is focused on Manitoba, we believe ICD-10-CA codes as well as patient discharges as
that there is a significant potential for universal appli- noted on HSC patient ward admission logs. The
cation of our results for patient treatment, manage- ICD-10-CA codes used to find patients were NF
ment, and education. (M72.6), Fourniers Gangrene (male/female:
N49.3/N76.8), and myositis (M60). For each indi-
vidual patient (2004 2009), the chart was reviewed
METHODS and confirmed as a true NF case based on macro-
Our study is a 6-year retrospective chart review scopic surgical confirmation at the time of surgical
ranging from 2004 to 2009 inclusive. We have in- debridement. To ensure that no cases were missed,
cluded all cases of NF admitted to the Health Sci- we also included those patients with sepsis and sus-
ences Center in Winnipeg, Manitoba, Canada. The pected NF who succumbed before surgical confir-
 Journal of Burn Care & Research
96 Tunovic et al January/February 2012

mation. Laboratory and microbiology data were

collected from the HSC computer records. Surgical
information was collected as per explanation in the
surgical notes with flaps, grafts, and amputations
being the most pertinent information collected.
Amputations were considered to be any bony de-
bridement with the exception of the digits where
amputation was considered to be removal of pha-
lange(s) or more. Obesity was defined as a BMI
greater than 35 kg/m2.
Regional health authority was assigned based on the
patients residence postal code. Patient information was
entered into a database created using FileMaker Pro 11
software (Apple, Cupertino, CA), and statistical analysis
was completed using SPSS version 19 software (IBM,
Chicago, IL). Descriptive statistics were obtained for all Figure 1. Age distribution of patients with necrotizing
variables. Students t-test or Wilcoxon rank-sum test fasciitis.
were used for continuous variables, and 2 or Fishers
exact tests were used to compare proportions between
the various groups. Regression analysis was performed affected, the mean is 6.3 6.2% (range: 0.15
to determine determinants of death, amputation, and 35.0%). Mean white blood cell count was 16.7 9.4.
length of stay. A P value .05 was accepted as statisti- The most common comorbidities identified in the
cally significant. patient population were DM (33.8%), hypertension
(HTN) (33.1%), smoking (24.6%), obesity (13.1%),
and substance (drugs or ethanol) abuse (23.1%).
RESULTS Obesity was identified as a body mass index (BMI)
greater than 35 kg/m2.
A total of 130 patients were identified (Table 2). Of Lower extremity was the most common location of
these patients, 75 were male and 55 were female. The infection (44.6% of cases) followed by upper extrem-
mean age was 47.0 15.9 years (range: 0.8 79.3 ity (23.1%), genitalia (20.8%), trunk (13.1%), and
years) and follow a normal distribution (Figure 1). head/neck (7.7%).
During this period, we identified that only two chil- Microbiological data (Table 3) could only be ac-
dren were admitted to our provincial childrens hos- quired for 114 of 130 patients. Data for 16 patients
pital with NF. Patients had an average TBSA of 723 were omitted due to lack of electronic records. For
745 cm2 (range: 53925 cm2). Expressed as % TBSA 8.5% (N 11), there was no organism isolated de-
spite cultures being obtained. Analysis showed that
43.1% of all patients were diagnosed with a type II
Table 2. General patient characteristics (N 130)

Age (yr) 47.0 15.9 Table 3. Microbiological data

Sex (n)
Type of Infection No. Patients % of all Patients
Male 75
Female 55 Type I 5 3.8
Body area involved (%) (N 108) TII: Strep 39 30.0
Head and neck 7.7 TII: non-GABS Strep 6 4.6
Upper extremity 23.1 TII: Non-Strep 11 8.5
Trunk 13.1 Missing 16 12.3
Genitalia 20.8 No growth 11 8.5
Lower extremity 44.6 Unknown 42* 32.3
TBSA (cm2) 723.4 745.3 Total 130 100
Length of stay 33.3 38.7
No. procedures 2.4 1.2 Type I is polymicrobial infection. Type II is monomicrobial and is
WBC (N 97) 16.7 9.2 subdivided into Streptococcal (GABS, Group C, or Strep. spp.) and
non-Streptococcal categories.
Data are shown as mean SD. * Patients whose cultures grew contaminants but no pathogens.
WBC, white blood cell. GABS, group A beta-hemolytic Streptococcus.
Journal of Burn Care & Research
Volume 33, Number 1 Tunovic et al 97

Table 4. Microbiological data based on presence or

absence of Streptococcal spp. infection

Type of Infection No. Patients % of all Infections

Type I 5 8.2
TII: Strep 39 63.9
TII: non-GABS Strep 6 9.8
TII: Non-Strep 11 18.9
Total 61 100

GABS, group A beta-hemolytic Streptococcus.

infection. In patients with a discernable infection, the

most common causative organism was Streptococcus
in 91.8% (Table 4). This is in contrast to an article by Figure 2. Annual incidence of necrotizing fasciitis at
Anaya et al., in which the most common species iso- Health Sciences Center.
lated was Staphylococcus aureus.17 The type of infec-
tion was found not to affect length of stay, amputa-
tion rate, or mortality. We found that 7.8% of our twood showed the highest incidence per capita in the
total patients were methicillin-resistant Staphylococcus Aboriginal population and also the highest incidence
aureus positive on admission swabs. per capita in the non-Aboriginal population.
The average patient received 2.4 1.2 (range:
0 7) procedures. A total of six patients (4.6%) re-
DISCUSSION
ceived amputations as a definitive treatment. It was
found that amputation rate did not depend on re- We identified a total 130 NF patients over 6 years,
gional health authority (RHA), age, gender, ethnic- making our study one of the largest NF patient pop-
ity, body part affected, source of admission (internal ulations examined at a single center in such short
vs. external admission), number of comorbidities, or time. Our patient demographics and comorbidities
number of procedures. were similar to other studies. The mean age of 47.0
The overall mortality rate was 13.1% (17/130 pa- 15.9 years was in the middle of the distribution when
tients). The only factor significantly associated with compared with other studies (Table 1).
rate of mortality was advanced patient age (P .05). The two most common comorbidities identified
Examination of geographic origin revealed that were DM (33.8%) and HTN (33.1%). Other major
there was no statistical difference in rate of amputa- comorbidities identified were smoking, obesity, sub-
tions, length of stay, and mortality based on RHA. stance abuse, and renal disease. Of those, DM, HTN,
Patients identified were all from RHAs with the ex- malignancy, and renal disease were consistently noted
ception of Churchill and Brandon. There were a total in the charts. Recording of the other comorbidities
of 17 patients who were from outside of Manitoba. varied and hence they may be underrepresented. We
Annual incidence increased from 12 cases in 2004 believe that obesity, in particular, was significantly
to a high of 32 cases in 2007 and 2008. It has then underrepresented, as recorded information regarding
decreased to 16 cases/year in 2009 (Figure 2). Inci- patient weight and height was highly variable from
dence within the province (Table 5) was highest in chart to chart. This made BMI calculations difficult to
the Burntwood RHA (Figure 3), with an incidence of obtain for a large number of patients. We were able to
9.68 per 100,000 individuals which is 5.2 times the obtain it only for 18 patients.
provincial average. As found in other studies, the most common site of
Information on ethnicity (Table 6) shows a higher infection was the extremities (67.7%), with the lower
incidence of NF in Manitoba in the Aboriginal pop- extremities being the most common at 44.6%.
ulation with an incidence of 29.8 per 100,000 indi- We had bacteriologic information in 72 patients. As
viduals compared with an incidence of 8 per 100,000 expected, the most common bacterial species was Strep-
individuals in the province. The difference between tococcus with GABS representing 73.7% of all infections
First Nations patients and non-First Nations patients (Table 4). We still recommend initial broad-spectrum
varied across the province. Winnipeg and Central antibiotics, not specifically targeted at Streptococcus, as
RHA showed a higher incidence of NF in the Aborig- there is a significant proportion of infections with other
inal population than the general population. Burn- bacteria, and the risk of not treating these infections is
 Journal of Burn Care & Research
98 Tunovic et al January/February 2012

Table 5. Rates of comorbidities in Manitoba health care regions for patients with NF

Health Region or Province of Origin DM HTN Smoking Obesity Substance Abuse Renal Disease

Assiniboine 1 1
Burntwood 9 13 5 5 5 4
Central 3 1 2 1 2
Interlake 3 2 1 2 1 1
Nor-Man 1 1 1 2 1
North Eastman 2 3 4 1 1
Parkland
South Eastman
Winnipeg 19 18 16 5 17 1
Nunavut 1
Ontario 7 4 2 2
Total Manitoba 37 38 30 15 28 7
% Total patients affected 33.8 33.1 24.6 13.1 23.1 6.2

NF, necrotizing fasciitis; DM, diabetes mellitus; HTN, hypertension.

devastating. Hence, the current protocol of starting some interesting results. With regard to prognosis,
with broad-spectrum antibiotics and narrowing once we found that there was no statistical difference in
the organism is isolated is still appropriate. Although rate of amputations, length of stay, and mortality
7.8% of our patients were swab positive for methicillin- based on RHA. This means that regardless of distance
resistant Staphylococcus on admission, in only three of travelled before admission at our institution, all our
these cases was methicillin-resistant Staphylococcus au- patients have equivalent prognosis once they are
reus deemed to be a causative organism as evidenced by transferred to our facility. There were, however, sig-
positive wound culture or absence of other pathological nificant differences noted when it comes to regional-
bacteria in the wound. ity of NF incidence.
We found that amputation rate showed no associ- Analysis revealed that 65.4% of our population
ation based on health region, age, gender, ethnicity, were from only two RHAs. 47.7% of our patient
body part affected, number of comorbidities, or num- population was from Winnipeg and 17.7% was from
ber of procedures. This indicates that rate of ampu- the Burntwood RHA. This result is startling con-
tation may be not be related to individual character- sidering that Burntwood has 4% of the total pro-
istics or distance to tertiary care. vincial population.19 Normalizing for population
Mortality rates of NF patients treated at the HSC we found that the highest incidence was in Burn-
were 13.1% (17/130 patients). This is lower than twood at 6.3 times the annual incidence of the rest
most NF populations studied, the majority of which of the province (Figure 3).
(6/8; Table 1) had a mortality rate 20%. Searching for explanations for this high localized
Examining whether there is geographic variation to incidence, we reviewed comorbidities and presence
NF incidence and outcomes in Manitoba, we found of risk factors between the regions. A recent study
revealed that Burntwood RHA has the highest
prevalence of DM in Manitoba.20 Considering the
relationship between NF and DM as a comorbidity,
this could be a link between Burntwood and a high
incidence of NF.

Table 6. Incidence of NF in Manitoba according

to ethnicity

Aboriginal Unknown

Total cases 30 83
Population (2006) 100,640 1,032,875
Incidence/100,000 29.8 8.0
Figure 3. Incidence of per 100,000 individuals in Mani-
toba Regional Health Authorities. NF, necrotizing fasciitis.
Journal of Burn Care & Research
Volume 33, Number 1 Tunovic et al 99

A second interesting finding was the differences in ment at local hospitals and did not require grafting.
incidence of NF with regard to ethnicity. We found Also, we do not have information on patients who
that the incidence of NF in the province is higher passed away at other centers. In addition, while the
among our Aboriginal population when compared Health Sciences Centre is the primary referral hospital
with the general population (Table 6). Aboriginals for NF for the province of Manitoba, there is a second
comprise 7% of the general Manitoba population regional center. St. Boniface Hospital is estimated to
(Government of Manitoba data), in contrast aborig- receive between 5 and 10 additional cases of NF a
inals comprise 36.1% of the NF population, which is year, predominantly from within the city of Winni-
more than five times higher than the Aboriginal pop- peg. Incorporation of the St. Boniface Hospital data
ulation in the province, which is 7% of the total (MB and obtaining the medical examiners data for deaths
health stats). When normalized per capita, we saw a throughout the province remain our priority to as-
significantly higher incidence (29.8) among the Ab- semble a more complete database.
original population than the general population (8.0
per 100,000 individuals). Future Goals
A contributing factor could be the higher incidence Examining the differences in comorbidities within in-
of DM among aboriginals compared with the rest of dividual RHAs for possible insight into predisposing
the population. Aboriginal males have been previ- factors remains to be determined. In addition, we are
ously reported to have three times the DM incidence discussing this subject matter with First Nations
compared with males in the general population while groups and RHAs at increased risk, especially Burn-
Aboriginal females have four times the incidence of twood, for ways to improve detection and provide
DM as females in the general population.19 earlier treatment is a major focus moving forward. In
In terms of incidence based on ethnicity per RHA, we addition, future studies will identify whether socio-
found that Burntwood had similar incidence in terms of economic, demographic, or medical comorbidities
Aboriginal and non-Aboriginal individuals, while Cen- explain the increased risk in the Aboriginal popula-
tral RHA and Winnipeg have substantially higher inci- tion. As a consequence of this study, we have ap-
dence among the Aboriginal populations. This maybe proached both the Regional Health Authority and
related to the higher prevalence of DM in Burntwood the provincial Aboriginal health care leaders to de-
RHA. There were no differences in outcomes (rate of velop more information on local factors that may ex-
amputations, length of stay, and mortality) based on plain the increased incidence in these groups. In ad-
ethnicity, as mentioned earlier, but the difference in in- dition, we have embarked on an education campaign
cidence warrants further examination. in the Regional Health Authorities at risk to help
primary care givers understand the risks of NF.
Limitations
An important point to note is that Aboriginal inci-
dence of NF may vary from what we reported. For the REFERENCES
purposes of this study, ethnicity was identified by self- 1. Necrotizing fasciitis/Myositis (flesh-eating disease) infor-
reporting in the medical records. It was found that mation sheet. Public Health Agency of Canada, 2008. Avail-
able at http://www.phac-aspc.gc.ca/publicat/info/necro-eng.
this is underreported in hospital charts, and as such a php. Accessed December 2, 2011.
proportion of the group coded as non-Aboriginal 2. Davies HD, McGeer A, Schwartz B, et al. Invasive group A
may in fact be of First Nations origin leading to an streptococcal infections in Ontario, Canada. Ontario Group
A Streptococcal Study Group. N Engl J Med 1996;335:
underestimate of the true incidence of NF in the Ab- 54754.
original population. 3. Skerritt J. Cases of flesh-eating disease take leap in province.
Our ability to comment on the effects associated Winnipeg, Manitoba, Canada: Winnipeg Free Press; 2008.
4. Census: population and dwelling counts. Statistics Canada, 2007.
with specific organisms is limited in that microbiolog- Available at http://www12.statcan.ca/census-recensement/
ical data were not available for a significant number of 2006/rt-td/pd-pl-eng.cfm. Accessed December 2, 2011.
patients. For 16 patients, we were not able to access 5. Wong CH, Chang HC, Pasupathy S, Khin LW, Tan JL, Low
CO. Necrotizing fasciitis: clinical presentation, microbiology,
the laboratory results while others had inconclusive and determinants of mortality. J Bone Joint Surg Am 2003;
culture results despite being cultured. This may be 85:1454 60.
due to aggressive and early antibiotic therapy before 6. Golger A, Ching S, Goldsmith CH, Pennie RA, Bain JR.
Mortality in patients with necrotizing fasciitis. Plast Reconstr
culture or improper culturing techniques. Surg 2007;119:18037.
Although all plastic surgery in the province is done 7. Tiu A, Martin R, Vanniasingham P, MacCormick AD, Hill
at one of two centers, primary debridement may be AG. Necrotizing fasciitis: analysis of 48 cases in South Auck-
land, New Zealand. ANZ J Surg 2005;75:32 4.
undertaken at referring hospitals before transfer. We 8. Rieger UM, Gugger CY, Farhadi J, et al. Prognostic factors in
may have missed patients who underwent debride- necrotizing fasciitis and myositis: analysis of 16 consecutive
 Journal of Burn Care & Research
100 Tunovic et al January/February 2012

cases at a single institution in Switzerland. Ann Plast Surg 15. Light TD, Choi KC, Thomsen TA, et al. Long-term out-
2007;58:52330. comes of patients with necrotizing fasciitis. J Burn Care Res
9. Khanna AK, Tiwary SK, Kumar P, Khanna R, Khanna A. A 2010;31:939.
case series describing 118 patients with lower limb necrotiz- 16. Wong CH, Yam AK, Tan AB, Song C. Approach to debride-
ing fasciitis. Int J Low Extrem Wounds 2009;8:112 6. ment in necrotizing fasciitis. Am J Surg 2008;196:
10. Redman DP, Friedman B, Law E, Still JM. Experience with e19 24.
necrotizing fasciitis at a burn care center. South Med J 2003; 17. Anaya DA, Bulger EM, Kwon YS, Kao LS, Evans H, Nathens
96:868 70. AB. Predicting death in necrotizing soft tissue infections: a
11. Ryssel H, Germann G, Kloeters O, Radu CA, Reichenberger clinical score. Surg Infect (Larchmt) 2009;10:51722.
M, Gazyakan E. Necrotizing fasciitis of the extremities: 34
18. Oncul O, Erenoglu C, Top C, et al. Necrotizing fasciitis: a
cases at a single centre over the past 5 years. Arch Orthop
life-threatening clinical disorder in uncontrolled type 2 dia-
Trauma Surg 2010;130:151522.
12. McGee EJ. Necrotizing fasciitis: review of pathophysiology, betic patients. Diabetes Res Clin Pract 2008;80:218 23.
diagnosis, and treatment. Crit Care Nurs Q 2005;28:80 4. 19. Manitoba health and healthy living annual statistics
13. Sarani B, Strong M, Pascual J, Schwab CW. Necrotizing 2008 2009. Manitoba: Manitoba Health; 2010. Available at
fasciitis: current concepts and review of the literature. J Am http://www.gov.mb.ca/health/annstats/as0809.pdf.
Coll Surg 2009;208:279 88. 20. Diabetes in Manitoba 1989 to 2006: report of Diabetes Sur-
14. Kihiczak GG, Schwartz RA, Kapila R. Necrotizing fasciitis: a veillance. Manitoba: Manitoba Health; 2009. Available at
deadly infection. J Eur Acad Dermatol Venereol 2006;20: http://www.gov.mb.ca/health/chronicdisease/diabetes/
3659. docs/diabetes100.pdf.