May 31 is Necrotizing Fasciitis (NF) Awareness Day when we share information on the treatment and prevention of the most common flesh-eating disease in the world today.

NF is a bac­te­r­i­al infec­tion that can cause the death of skin, mus­cle and tis­sue, and organ fail­ure if left uncon­trolled. Treat­ment often involves surgery, antibi­otics, and sup­port­ive care to pre­vent fur­ther infec­tion and dam­age. Life-sav­ing limb ampu­ta­tion is often required.

It’s been around a long time

Hip­pocrates, the father of med­i­cine, first described NF more than 2000 years ago, report­ing peo­ple devel­op­ing skin infec­tions that caused bones, flesh and sinew to ‘fall off from the body’ result­ing in many deaths.

Sur­geons in the Amer­i­can Civ­il War called it ‘hos­pi­tal gangrene’.

Today, NF is still affect­ing peo­ple includ­ing 2001 Nobel Prize-win­ning Physi­cist Pro­fes­sor Eric Cor­nell, who lost an arm and shoul­der to the dis­ease. The Unit­ed States Cen­tre for Dis­ease Con­trol says up to 1 in 5 peo­ple who devel­op NF will die.

How do you get NF?

It’s most­ly caused by bac­te­ria enter­ing the body through a break in the skin from cuts and scrapes, burns, bites, sur­gi­cal wounds and punc­tures includ­ing from IV drug use.

The most com­mon bac­te­ria involved in NF is A Strep­to­coc­cus, also known as Group A strep or GAS. It lives on our skin and in our throats with­out caus­ing harm, but in open wounds it can fes­ter, releas­ing tox­ins that cause sep­tic shock, mak­ing blood pres­sure drop, which can cause body tis­sue to die.

While NF infec­tions are incred­i­bly rare in healthy peo­ple, cas­es are on the rise in the Unit­ed King­dom, the Unit­ed States and Europe. NSW Health Pathology’s Insti­tute for Clin­i­cal Pathol­o­gy and Med­ical Research (ICPMR) advis­es there is evi­dence of increas­ing GAS cas­es in NSW and Vic­to­ria as well.

How do you avoid NF?

Those who devel­op it tend to have oth­er health prob­lems that low­er their immu­ni­ty such as can­cer, dia­betes and kid­ney disease.

There are no vac­cines to pre­vent GAS infec­tion but you can do sim­ple things to pro­tect your­self such as:

• Wash your hands and use hand sani­tis­er to kill bac­te­ria and pre­vent transmission
• Clean cuts and wounds with water and soap and ban­dage open wounds until healed
• See a doc­tor for more seri­ous wounds and punctures
• If you have open wounds, avoid rivers, lakes and swim­ming pools where bac­te­ria live
• Treat fun­gal infec­tions, because fun­gi may also cause NF

How we’re helping

NF is typ­i­cal­ly diag­nosed through a com­bi­na­tion of clin­i­cal eval­u­a­tion, CT scans and MRI, and lab­o­ra­to­ry testing.

Our lab­o­ra­to­ries per­form rapid cul­ture and sen­si­tiv­i­ty test­ing to iden­ti­fy which bac­te­ria is at work and advise treat­ing doc­tors which antibi­otics to use to kill them. We test blood and wound cul­tures as well as tis­sue biop­sies. Oth­er tests per­formed to sup­port NF diag­no­sis are com­plete blood counts, C‑reactive pro­tein to gauge inflam­ma­tion and coag­u­la­tion pro­files for very ill patients.

That’s not all we do

Our work also extends to pub­lic health pro­tec­tion and research.

We use whole genome sequenc­ing to study and under­stand NF-caus­ing bac­te­ria. It can show how they work, if they are relat­ed and how they can be treat­ed. It’s like look­ing at a unique blue­print of the bac­te­ria that helps us learn more about them.

Giv­en increas­ing rates of antimi­cro­bial resis­tance there is an urgent need for the devel­op­ment of new antimi­cro­bials and con­tin­u­al review of antibi­ot­ic treat­ment guide­lines to ensure they remain effec­tive. Our NSWHP-ICPMR Micro­bi­ol­o­gy Depart­ment tests nov­el antibi­otics against a range of bac­te­ria includ­ing drug com­bi­na­tions and shares data nationally.

NF is not the only flesh-eat­ing dis­ease we manage

The world-class exper­tise of our clin­i­cal and sci­en­tif­ic staff means we’re often the first port of call for inves­ti­ga­tion of oth­er high­ly uncom­mon flesh-eat­ing diseases.

These include those caused by M. ulcer­ans (buruli ulcer, some­times called ‘Bairns­dale ulcer’, because it was first detect­ed in that region of Vic­to­ria almost 100 years ago) and M. lep­rae (lep­rosy). Oth­ers are oth­er trau­mat­ic mucormy­co­sis and oth­er inva­sive fun­gal infec­tions, and cuta­neous nocardiosis.

Thank­ful­ly, our experts have knowl­edge and expe­ri­ence to recog­nise, diag­nose and treat these infections.

MEET A CLINICAL MICROBIOLOGIST

Dr Ker­ri Basile, what is your role?

I work as a clin­i­cal micro­bi­ol­o­gist and infec­tious dis­eases physi­cian at NSWHP-ICPMR. 

What are your qualifications?

I under­took a med­ical degree (MBBS) and then com­plet­ed spe­cial­ist train­ing in Micro­bi­ol­o­gy (FRCPA) and Infec­tious Dis­eases (FRACP) and am cur­rent­ly under­tak­ing a PhD. 

Why do you like it?

I enjoy my work as it is var­ied, with con­stant oppor­tu­ni­ties to learn and be chal­lenged. Work­ing in the lab­o­ra­to­ry is extreme­ly reward­ing as advances in diag­nos­tics such as whole genome sequenc­ing have the poten­tial to improve the health of indi­vid­ual patients as well as the wider com­mu­ni­ty. Whole genome sequenc­ing is being increas­ing­ly utilised to mon­i­tor pathogens of pub­lic health sig­nif­i­cance (such as SARS-CoV­‑2 dur­ing the COVID-19 pandemic). 

How do you keep safe while han­dling these microbes?

Safe­ty is a top pri­or­i­ty in the lab­o­ra­to­ry. We deal with thou­sands of sam­ples each day, and many unknowns, so until we know the iden­ti­ty of the bug we per­form all our cul­ture work up in a Bio­log­i­cal Safe­ty Cabinet.

For high­ly infec­tious pathogens we may work in a lab with cus­tom air­flow and pres­sure prop­er­ties as a fur­ther precaution.

We wear per­son­al pro­tec­tive equip­ment includ­ing gowns, gloves, gog­gles and/or face masks. Hand wash­ing is essen­tial. We’re immu­nised against many vac­cine-pre­ventable infections.

Has your expe­ri­ence with these bugs changed your habits?

Yes, I’m very care­ful with wounds. But this doesn’t stop me enjoy­ing trav­el and the outdoors. 

Make sure you get the tetanus boost­er before you set out and be aware of injuries 

Resources, ref­er­ences and fur­ther reading

• https://www.cdc.gov/groupastrep/diseases-public/necrotizing-fasciitis.html
• https://www.thelancet.com/journals/laninf/article/PIIS1473-3099%2814%2970922–3/fulltext
• https://www.healthdirect.gov.au/buruli-ulcer
• Eric Allen https://www.nature.com/articles/434945a
• https://www.msn.com/en-us/health/condition/necrotizing-fasciitis
• https://time.com/4984752/flesh-eating-bacteria-necrotizing-fasciitis/

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