今日の臨床サポート

壊死性筋膜炎

著者: 村中清春 諏訪中央病院 総合診療科/リウマチ膠原病内科/感染症科

監修: 上原由紀 聖路加国際病院 臨床検査科/感染症科

著者校正/監修レビュー済:2021/03/24
患者向け説明資料

概要・推奨   

  1. A群溶連菌group A streptococcusGAS)による壊死性筋膜炎の血液培養陽性は60%であり、起因菌同定に有用である。抗菌薬投与前に2セット採取することが望ましい[1](推奨度1、G
  1. 壊死性筋膜炎を疑ったら早期に皮膚切開し、筋膜所見を観察することが強く推奨される。同時に筋膜を約1cm角に切り取り、その一部を病理検査に提出する。筋膜の壊死が認められれば診断となる(推奨度1、G
  1. 滲出液のグラム染色、深部の貯留液や壊死組織の培養を推奨する(推奨度2、G
  1. 画像で壊死性筋膜炎を診断することはできない。しかし、Clostridium属などのガス産生菌の場合は、画像上ガス産生が指摘できれば診断の補助となるため推奨される。しかし、異常所見がなくても壊死性筋膜炎の否定にはならない[1](推奨度2、G)。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
村中清春 : 特に申告事項無し[2021年]
監修:上原由紀 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行い、情報の整理、追加や並び替えを行った。 

病態、疫学、診察

疾患情報  
  1. 壊死性筋膜炎とは、浅層筋膜を細菌感染の主座として急速に壊死が拡大する致死性の軟部組織感染症である。
  1. 視診上の皮疹の程度に比べて激しい痛み、バイタルサインの異常があるときや、疼痛範囲の拡大が速いときは壊死性筋膜炎を疑う。
  1. 壊死性筋膜炎の予後を左右するのは早期診断/早期治療開始である。早期診断のためには試験切開による筋膜の肉眼的・病理学的評価が必要である。
  1. 皮膚病変部位に「握雪感がないこと」や「水疱がないこと」は壊死性筋膜炎の否定にならない。壊死性筋膜炎の診断に典型的所見を求め過ぎてはならない。
問診・診察のポイント  
  1. 視診上、皮疹の程度が軽微に見えても「強く痛がる」「バイタルサインがおかしい」「疼痛範囲の拡大が速い」場合は壊死性筋膜炎を疑う。筋膜壊死が起こった部位では痛覚脱失を認めることもある。

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文献 

著者: Dennis L Stevens, Alan L Bisno, Henry F Chambers, E Patchen Dellinger, Ellie J C Goldstein, Sherwood L Gorbach, Jan V Hirschmann, Sheldon L Kaplan, Jose G Montoya, James C Wade
雑誌名: Clin Infect Dis. 2014 Jul 15;59(2):147-59. doi: 10.1093/cid/ciu296. Epub 2014 Jun 18.
Abstract/Text A panel of national experts was convened by the Infectious Diseases Society of America (IDSA) to update the 2005 guidelines for the treatment of skin and soft tissue infections (SSTIs). The panel's recommendations were developed to be concordant with the recently published IDSA guidelines for the treatment of methicillin-resistant Staphylococcus aureus infections. The focus of this guideline is the diagnosis and appropriate treatment of diverse SSTIs ranging from minor superficial infections to life-threatening infections such as necrotizing fasciitis. In addition, because of an increasing number of immunocompromised hosts worldwide, the guideline addresses the wide array of SSTIs that occur in this population. These guidelines emphasize the importance of clinical skills in promptly diagnosing SSTIs, identifying the pathogen, and administering effective treatments in a timely fashion.

© The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.
PMID 24947530  Clin Infect Dis. 2014 Jul 15;59(2):147-59. doi: 10.1093・・・
著者: J Chelsom, A Halstensen, T Haga, E A Høiby
雑誌名: Lancet. 1994 Oct 22;344(8930):1111-5.
Abstract/Text During November, 1992, to May, 1994, 13 patients were treated at Haukeland University Hospital, Norway, for necrotising fasciitis due to group A beta-haemolytic streptococci. 3 patients died, 1 before admission. Mucoid group A streptococci were isolated from affected tissue (12 patients) and/or blood (5). Strains from 11 patients were serotype M-1 (5 patients), M-3 (2), M-6 (2), M-28 (1), and M-untypable (T-1, opacity factor negative) (1). For the 12 patients admitted alive, the following preoperative events were recorded: 8 had clinical signs of shock with systolic blood pressure of 90 mm Hg or less, 8 had impaired renal function, and 7 had biochemical markers of disseminated intravascular coagulation. At least 6 patients fulfilled the criteria for streptococcal toxic shock syndrome. Preoperative C-reactive protein was substantially raised ( > 200 mg/L) in 10 patients. The 12 patients were given high doses of antibiotics and were operated on with aggressive debridement of necrotic skin and fascia, 7 of them within 24 h of admission. The increasing incidence of necrotising fasciitis in western Norway reflects the resurgence of invasive group A streptococcal infections documented in Scandinavia since 1987. The high case-fatality rate can be reduced by early diagnosis and aggressive surgery combined with adequate antibiotic therapy.

PMID 7934492  Lancet. 1994 Oct 22;344(8930):1111-5.
著者: Chin-Ho Wong, Haw-Chong Chang, Shanker Pasupathy, Lay-Wai Khin, Jee-Lim Tan, Cheng-Ooi Low
雑誌名: J Bone Joint Surg Am. 2003 Aug;85-A(8):1454-60.
Abstract/Text BACKGROUND: Necrotizing fasciitis is a life-threatening soft-tissue infection primarily involving the superficial fascia. The present report describes the clinical presentation and microbiological characteristics of this condition as well as the determinants of mortality associated with this uncommon surgical emergency.
METHODS: The medical records of eighty-nine consecutive patients who had been admitted to our institution for necrotizing fasciitis from January 1997 to August 2002 were reviewed retrospectively.
RESULTS: The paucity of cutaneous findings early in the course of the disease makes the diagnosis difficult, and only thirteen of the eighty-nine patients had a diagnosis of necrotizing fasciitis at the time of admission. Preadmission treatment with antibiotics modified the initial clinical picture and often masked the severity of the underlying infection. Polymicrobial synergistic infection was the most common cause (forty-eight patients; 53.9%), with streptococci and enterobacteriaceae being the most common isolates. Group-A streptococcus was the most common cause of monomicrobial necrotizing fasciitis. The most common associated comorbidity was diabetes mellitus (sixty-three patients; 70.8%). Advanced age, two or more associated comorbidities, and a delay in surgery of more than twenty-four hours adversely affected the outcome. Multivariate analysis showed that only a delay in surgery of more than twenty-four hours was correlated with increased mortality (p < 0.05; relative risk = 9.4).
CONCLUSIONS: Early operative débridement was demonstrated to reduce mortality among patients with this condition. A high index of suspicion is important in view of the paucity of specific cutaneous findings early in the course of the disease.

PMID 12925624  J Bone Joint Surg Am. 2003 Aug;85-A(8):1454-60.
著者: Dennis L Stevens, Alan L Bisno, Henry F Chambers, E Dale Everett, Patchen Dellinger, Ellie J C Goldstein, Sherwood L Gorbach, Jan V Hirschmann, Edward L Kaplan, Jose G Montoya, James C Wade, Infectious Diseases Society of America
雑誌名: Clin Infect Dis. 2005 Nov 15;41(10):1373-406. doi: 10.1086/497143. Epub 2005 Oct 14.
Abstract/Text
PMID 16231249  Clin Infect Dis. 2005 Nov 15;41(10):1373-406. doi: 10.1・・・
著者: Chin-Ho Wong, Lay-Wai Khin, Kien-Seng Heng, Kok-Chai Tan, Cheng-Ooi Low
雑誌名: Crit Care Med. 2004 Jul;32(7):1535-41.
Abstract/Text OBJECTIVE: Early operative debridement is a major determinant of outcome in necrotizing fasciitis. However, early recognition is difficult clinically. We aimed to develop a novel diagnostic scoring system for distinguishing necrotizing fasciitis from other soft tissue infections based on laboratory tests routinely performed for the evaluation of severe soft tissue infections: the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score.
DESIGN: Retrospective observational study of patients divided into a developmental cohort (n = 314) and validation cohort (n = 140)
SETTING: Two teaching tertiary care hospitals.
PATIENTS: One hundred forty-five patients with necrotizing fasciitis and 309 patients with severe cellulitis or abscesses admitted to the participating hospitals.
INTERVENTIONS: None.
MEASUREMENTS AND MAIN RESULTS: The developmental cohort consisted of 89 consecutive patients admitted for necrotizing fasciitis. Control patients (n = 225) were randomly selected from patients admitted with severe cellulitis or abscesses during the same period. Hematologic and biochemical results done on admission were converted into categorical variables for analysis. Univariate and multivariate logistic regression was used to select significant predictors. Total white cell count, hemoglobin, sodium, glucose, serum creatinine, and C-reactive protein were selected. The LRINEC score was constructed by converting into integer the regression coefficients of independently predictive factors in the multiple logistic regression model for diagnosing necrotizing fasciitis. The cutoff value for the LRINEC score was 6 points with a positive predictive value of 92.0% and negative predictive value of 96.0%. Model performance was very good (Hosmer-Lemeshow statistic, p =.910); area under the receiver operating characteristic curve was 0.980 and 0.976 in the developmental and validation cohorts, respectively.
CONCLUSIONS: The LRINEC score is a robust score capable of detecting even clinically early cases of necrotizing fasciitis. The variables used are routinely measured to assess severe soft tissue infections. Patients with a LRINEC score of > or = 6 should be carefully evaluated for the presence of necrotizing fasciitis.

PMID 15241098  Crit Care Med. 2004 Jul;32(7):1535-41.
著者: Shannon M Fernando, Alexandre Tran, Wei Cheng, Bram Rochwerg, Kwadwo Kyeremanteng, Andrew J E Seely, Kenji Inaba, Jeffrey J Perry
雑誌名: Ann Surg. 2019 Jan;269(1):58-65. doi: 10.1097/SLA.0000000000002774.
Abstract/Text OBJECTIVE: We sought to summarize accuracy of physical examination, imaging, and Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score in diagnosis of necrotizing soft tissue infection (NSTI) in adults with a soft tissue infection clinically concerning for NSTI.
SUMMARY OF BACKGROUND DATA: NSTI is a life-threatening diagnosis. Delay to diagnosis and surgical management is associated with increased mortality.
METHODS: We searched 6 databases from inception through November 2017. We included English-language studies reporting diagnostic accuracy of testing or LRINEC Score. Outcome was NSTI confirmed by surgery or histopathology. Two reviewers screened all citations and extracted data independently. Summary measures were obtained from the Hierarchical Summary Receiver Operating Characteristic model.
RESULTS: From 2,290 citations, we included 23 studies (n = 5982). Of physical examination signs, pooled sensitivity and specificity for fever was 46.0% and 77.0% respectively, for hemorrhagic bullae 25.2% and 95.8%, and for hypotension 21.0% and 97.7%. Computed tomography (CT) had sensitivity of 88.5% and specificity of 93.3%, while plain radiography had sensitivity of 48.9% and specificity of 94.0%. Finally, LRINEC ≥ 6 had sensitivity of 68.2% and specificity of 84.8%, while LRINEC ≥ 8 had sensitivity of 40.8% and specificity of 94.9%.
CONCLUSIONS: Absence of any 1 physical examination feature (eg, fever or hypotension) is not sufficient to rule-out NSTI. CT is superior to plain radiography. LRINEC had poor sensitivity, and should not be used to rule-out NSTI. Given the poor sensitivity of these tests, a high clinical suspicion warrants early surgical consultation for definitive diagnosis and management.

PMID 29672405  Ann Surg. 2019 Jan;269(1):58-65. doi: 10.1097/SLA.00000・・・
著者: Nikos Zacharias, George C Velmahos, Ahmed Salama, Hasan B Alam, Marc de Moya, David R King, Robert A Novelline
雑誌名: Arch Surg. 2010 May;145(5):452-5. doi: 10.1001/archsurg.2010.50.
Abstract/Text HYPOTHESIS: In contrast to previous beliefs, we hypothesize that computed tomography (CT) scanning is sensitive and specific for the diagnosis of necrotizing soft tissue infections (NSTIs).
DESIGN: Retrospective and prospective case series.
SETTING: Academic medical center.
PATIENTS: Patients who were clinically suspected of having NSTIs from January 1, 2003, through April 30, 2009, and who underwent imaging with a 16- or 64-section helical CT scanner were studied. The CT result was considered positive if inflamed and necrotic tissue with or without gas or fluid collections across tissue planes was found. The disease (NSTI) was considered present if surgical exploration revealed elements of infection and necrosis of the soft tissues and pathological analysis confirmed the findings. The disease was considered absent if surgical exploration and pathological analysis failed to identify any of these findings or the patient was successfully treated without surgical exploration.
MAIN OUTCOME MEASURES: Sensitivity and specificity of CT for diagnosing NSTI.
RESULTS: Of 67 patients with study inclusion criteria, 58 underwent surgical exploration, and NSTI was confirmed in 25 (43%). The remaining 42 patients had either nonnecrotizing infections during surgical exploration (n = 33) or were treated nonoperatively with successful resolution of the symptoms (n = 9). The sensitivity of CT to identify NSTI was 100%, specificity was 81%, positive predictive value was 76%, and negative predictive value was 100%. No differences were found in demographics, white blood cell count on admission, symptoms, or site of infection between those with a false- or true-positive CT result.
CONCLUSIONS: A negative CT result reliably excludes the diagnosis of NSTI. A positive CT result correctly identifies the disease with a high likelihood.

PMID 20479343  Arch Surg. 2010 May;145(5):452-5. doi: 10.1001/archsurg・・・
著者: J Majeski, E Majeski
雑誌名: South Med J. 1997 Nov;90(11):1065-8.
Abstract/Text BACKGROUND: Necrotizing fasciitis is a soft tissue gangrenous infection that is optimally treated by early diagnosis, radical surgical debridement of all involved necrotic tissue, broad spectrum antibiotics, and aggressive nutritional support. The early clinical diagnosis of an area of necrotizing fasciitis is difficult and frequently unreliable. We are reporting a series of cases in which an early, accurate diagnosis of necrotizing fasciitis was established by a frozen section tissue biopsy obtained at the bedside.
METHODS: Over a 15-year period, a consecutive series of 43 patients had a bedside biopsy under local anesthesia with immediate frozen section evaluation. All patients were seen in the hospital or emergency room for treatment of an inflammatory process.
RESULTS: These 43 patients had bedside biopsy and frozen section evaluation of an inflammatory process. Twelve patients were found to have necrotizing fasciitis. These patients were treated with immediate surgical debridement of all gross necrotic tissue, broad spectrum antibiotics, and adequate nutritional support. All of them survived. No cases of infectious gangrene occurred in the group of patients whose biopsy did not reveal necrotizing fasciitis.
CONCLUSION: Frozen section tissue biopsy is a useful adjunct in establishing an early, accurate diagnosis of infectious gangrene.

PMID 9386043  South Med J. 1997 Nov;90(11):1065-8.
著者: L A Sudarsky, J C Laschinger, G F Coppa, F C Spencer
雑誌名: Ann Surg. 1987 Nov;206(5):661-5.
Abstract/Text Necrotizing fasciitis has been associated with significant morbidity and mortality. Thirty-three patients were studied over a 3-year period. Predisposing factors included intravenous drug abuse (30%), diabetes (21%), and obesity (18%). Severe pain (94%) and abnormal temperature (88%) were present, whereas laboratory data and x-ray were nonspecific. Gram-positive organisms were most frequently recovered (B-hemolytic streptococcus 45%). Treatment consisted of antibiotics, surgical debridement, re-exploration 24 hours before surgery, nutritional support, and early soft tissue coverage as needed. Mean duration from admission to operation was 43 hours. The average number of operative debridements was three and the average length of hospitalization was 47 days. Patients operated on less than 12 hours from admission or greater than 48 hours had shorter hospital stays (36 and 38 days). The critical time period was 12-48 hours after admission; all deaths and amputations were in this group and the average hospital stay was 62 days (p less than 0.05). The number of operations did not correlate to hospital stay. Despite antibiotics and aggressive debridement, significant morbidity exists if operation is delayed more than 12 hours. Methods of early detection such as local bedside diagnostic incision and fascial inspection may be needed in high risk patients to further reduce the morbidity and mortality.

PMID 3314752  Ann Surg. 1987 Nov;206(5):661-5.
著者: Daniel A Anaya, E Patchen Dellinger
雑誌名: Clin Infect Dis. 2007 Mar 1;44(5):705-10. doi: 10.1086/511638. Epub 2007 Jan 22.
Abstract/Text Necrotizing soft-tissue infections (NSTIs) are highly lethal. They are frequent enough that general and specialty physicians will likely have to be involved with the management of at least 1 patient with NSTI during their practice, but they are infrequent enough that familiarity with the disease will seldom be achieved. Establishing the diagnosis of NSTI can be the main challenge in treating patients with NSTI, and knowledge of all available tools is key for early and accurate diagnosis. The laboratory risk indicator for necrotizing fasciitis score can be helpful for distinguishing between cases of cellulitis, which should respond to medical management alone, and NSTI, which requires operative debridement in addition to antimicrobial therapy. Imaging studies are less helpful. The mainstay of treatment is early and complete surgical debridement, combined with antimicrobial therapy, close monitoring, and physiologic support. Novel therapeutic strategies, including hyperbaric oxygen and intravenous immunoglobulin, have been described, but their effect is controversial. Identification of patients at high risk of mortality is essential for selection of patients that may benefit from future novel treatments and for development and comparison of future trials.

PMID 17278065  Clin Infect Dis. 2007 Mar 1;44(5):705-10. doi: 10.1086/・・・
著者: Dennis L Stevens, Alan L Bisno, Henry F Chambers, E Patchen Dellinger, Ellie J C Goldstein, Sherwood L Gorbach, Jan V Hirschmann, Sheldon L Kaplan, Jose G Montoya, James C Wade, Infectious Diseases Society of America
雑誌名: Clin Infect Dis. 2014 Jul 15;59(2):e10-52. doi: 10.1093/cid/ciu444.
Abstract/Text A panel of national experts was convened by the Infectious Diseases Society of America (IDSA) to update the 2005 guidelines for the treatment of skin and soft tissue infections (SSTIs). The panel's recommendations were developed to be concordant with the recently published IDSA guidelines for the treatment of methicillin-resistant Staphylococcus aureus infections. The focus of this guideline is the diagnosis and appropriate treatment of diverse SSTIs ranging from minor superficial infections to life-threatening infections such as necrotizing fasciitis. In addition, because of an increasing number of immunocompromised hosts worldwide, the guideline addresses the wide array of SSTIs that occur in this population. These guidelines emphasize the importance of clinical skills in promptly diagnosing SSTIs, identifying the pathogen, and administering effective treatments in a timely fashion.

© The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.
PMID 24973422  Clin Infect Dis. 2014 Jul 15;59(2):e10-52. doi: 10.1093・・・
著者: D L Stevens
雑誌名: Emerg Infect Dis. 1995 Jul-Sep;1(3):69-78. doi: 10.3201/eid0103.950301.
Abstract/Text Since the 1980s there has been a marked increase in the recognition and reporting of highly invasive group A streptococcal infections with or without necrotizing fasciitis associated with shock and organ failure. Such dramatic cases have been defined as streptococcal toxic-shock syndrome. Strains of group A streptococci isolated from patients with invasive disease have been predominantly M types 1 and 3 that produce pyrogenic exotoxin A or B or both. In this paper, the clinical and demographic features of streptococcal bacteremia, myositis, and necrotizing fasciitis are presented and compared to those of streptococcal toxic-shock syndrome. Current concepts in the pathogenesis of invasive streptococcal infection are also presented, with emphasis on the interaction between group A Streptococcus virulence factors and host defense mechanisms. Finally, new concepts in the treatment of streptococcal toxic-shock syndrome are discussed.

PMID 8903167  Emerg Infect Dis. 1995 Jul-Sep;1(3):69-78. doi: 10.3201・・・
著者: Dennis L Stevens, Amy E Bryant
雑誌名: N Engl J Med. 2017 Dec 7;377(23):2253-2265. doi: 10.1056/NEJMra1600673.
Abstract/Text
PMID 29211672  N Engl J Med. 2017 Dec 7;377(23):2253-2265. doi: 10.105・・・
著者: Jane D Siegel, Emily Rhinehart, Marguerite Jackson, Linda Chiarello, Health Care Infection Control Practices Advisory Committee
雑誌名: Am J Infect Control. 2007 Dec;35(10 Suppl 2):S65-164. doi: 10.1016/j.ajic.2007.10.007.
Abstract/Text
PMID 18068815  Am J Infect Control. 2007 Dec;35(10 Suppl 2):S65-164. d・・・
著者: Prevention of Invasive Group A Streptococcal Infections Workshop Participants
雑誌名: Clin Infect Dis. 2002 Oct 15;35(8):950-9. doi: 10.1086/342692. Epub 2002 Sep 26.
Abstract/Text The Centers for Disease Control and Prevention hosted a workshop to formulate recommendations for the control of invasive group A streptococcal (GAS) disease among household contacts of persons with invasive GAS infections and for responding to postpartum and postsurgical invasive GAS infections. Experts reviewed data on the risk of subsequent invasive GAS infection among household contacts of case patients, the effectiveness of chemoprophylactic regimens for eradicating GAS carriage, and the epidemiology of postpartum and postsurgical GAS infection clusters. For household contacts of index patients, routine screening for and chemoprophylaxis against GAS are not recommended. Providers and public health officials may choose to offer chemoprophylaxis to household contacts who are at an increased risk of sporadic disease or mortality due to GAS. One nosocomial postpartum or postsurgical invasive GAS infection should prompt enhanced surveillance and isolate storage, whereas > or =2 cases caused by the same strain should prompt an epidemiological investigation that includes the culture of specimens from epidemiologically linked health care workers.

PMID 12355382  Clin Infect Dis. 2002 Oct 15;35(8):950-9. doi: 10.1086/・・・

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