Multifocal necrotising fasciitis: an overlooked entity?

Objective: The aim of the study is to report a case of multi-focal necrotising fasciitis, review research on this subject to identify common aetiological factors and highlight suggestions to improve management.

Context: Necrotising fasciitis is a severe, life-threatening soft tissue infection that typically arises from a single area, usually secondary to a minor penetrating injury. Multi-focal necrotising fasciitis, where there is more than one non-contiguous area of necrosis, is much less commonly reported. There are no guidelines specific to the management of multi-focal necrotising fasciitis, and its under-reporting may lead to missed management opportunities.

Design: A systematic literature review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol.

Data sources: A search of MEDLINE, OLD MEDLINE and the Cochrane Collaboration was performed from 1966 to March 2011 using 16 search terms.

Data extraction: All articles were screened for genuine non-contiguous multi-focal necrotising fasciitis. Of the papers that met this criterion, data on patient demographics, likely inciting injury, presentation time-line, microbial agents, sites affected, objective assessment scores, treatment and outcome were extracted.

Data synthesis: A total of 31 studies met our inclusion criteria and 33 individual cases of multi-focal necrotising fasciitis were included in the quantitative analysis. About half (52%) of cases were type II necrotising fasciitis; 42% of cases had identifiable inciting injuries; 21% of cases developed multi-focal lesions non-synchronously, of which 86% were type II. Nearly all (94%) of cases had incomplete objective assessment scores. One case identified inflammatory imaging findings prior to clinical necrosis.

Conclusions: Multifocality in necrotising fasciitis is likely to be associated with type II disease. We postulate that validated objective tools will aid necrotising fasciitis management pathways that will identify high-risk groups for multifocality and advise early pre-emptive imaging. We recommend the adoption of regional multi-focal necrotising fasciitis registers.