Diagnosis and Treatment of Pediatric Necrotizing Fasciitis: A Systematic Review of the Literature

Abstract

Pediatric necrotizing fasciitis (NF) is a rare but severe, life-threatening infection. Early diagnosis is crucial to reduce morbidity and mortality, but initial symptoms are nonspecific. Little sound data exists on factors aiding clinicians to recognize NF in children. With a systematic literature review, we aimed to better characterize pediatric NF. We focused on triggers, symptoms, and laboratory and microbiological findings and differences between pediatric adult patients. A literature research was conducted according to the guidance of the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses." Articles published between January 2010 and October 2015 were included. Data extraction was performed as an iterative process. A total of 32 articles describing 53 pediatric patients with NF were included in the analysis. Overall mortality was 15.4%. Frequency peaks were found for neonates and children aged between 1 and 2 years. These two age groups were predominantly affected on the torso. Another frequency peak was found in patients aged around 10 years of age. These patients were predominantly affected on the extremities and face. In general, early symptoms were found to be fever, erythema, localized selling, and tenderness or pain. "Pain out of proportion" was not mentioned as a typical symptom. Fever and leukocytosis were more common in teenage patients. Monomicrobial necrotizing (type 2) fasciitis was much more common than polymicrobial (type 1) fasciitis. Next to Streptococci and Staphylococci, Pseudomonas aeruginosa was often isolated. Early aggressive surgical treatment was the treatment of choice. Pediatric NF has distinguishing features that differ from adult NF. Knowledge of these details should increase early diagnosis and improve treatment.

Pediatric Necrotizing Fasciitis: Restitutio Ad Integrum after Early Diagnosis and Aggressive Surgical Treatment

“…“Pain out of proportion” to physical findings is often described as a typical sign in adult NF; a recent literature review did not verify this as a common symptom in pediatric NF 2. In accordance, our patient showed unspecific symptoms.…”

“…Type 2 infections are caused by a single organism infection 1. For the pediatric patient cohort, type 2 infections seem to be more frequent 2. Knowing the possible pathogens, patients should receive broad-spectrum IV antibiotics to cover streptococci, staphylococci, gram negative rods, and anaerobes 8.…”

“…Subsequent systemic inflammation is common; morbidity and mortality are high. The estimated prevalence in children is 0.08 per 100,000 children per year,1 and mortality is found to be ∼15% 2. Early diagnosis is as essential for pediatric NF as for adult cases since it enables early therapy which significantly improves survival and outcome.…”

Alcohol use disorder increases the risk of necrotizing fasciitis

“…[ 6 , 8 – 13 ] However, some review articles have not reported AUD as a risk factor. [ 19 – 24 ] The concrete relationship between NF and AUD remains debatable. In our study, we found a strong positive association between AUD and NF.…”

“…This finding of an evidently high risk is inconsistent with those of previous studies. [ 6 , 8 – 13 , 19 – 24 ] The most likely etiology is alcohol-related immunosuppression. Previous studies have proven that alcohol consumption, particularly chronic heavy drinking, affects all components of the immune system.…”