Flesh-eating bacteria – Nicky Steadman – Senior Product Manager Eschmann

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  Posted by: Dental Design      18th January 2020

While rare, necrotising fasciitis is a very dangerous, potentially disfiguring and life-threatening disease that affects around 500 people a year in the UK.[i] Luridly referred to as flesh-eating bacteria, the disease progresses rapidly, making early detection vitally important. Elderly patients and those with comorbid conditions such as diabetes are at greater risk, however, anyone can potentially develop the disease. Dental infection is the most frequent cause of necrotising fasciitis of the head and neck (which carries a higher rate of mortality than other locations), so while very uncommon it should be a threat dentists are alert to.[ii], [iii], [iv] The initial point of infection is most often dento-facial (particularly around the second and third molars), but the infection can take hold anywhere in the body.[v] Group A Streptococcus (S. pyogenes), the same bacteria responsible for strep throat, is the most frequent cause of necrotising fasciitis (NF), though other bacteria can cause the illness too and the infection can be – and often is – polymicrobial.i

Progression and symptoms

The invasive bacteria penetrates into the soft tissue, before spreading through the deep fascia. The infection can spread to the venous and lymphatic systems, resulting in edema. The flesh-eating moniker is misleading, with cells being effectively choked to death rather than consumed by the bacteria directly. As the bacteria multiplies and spreads, thrombosis occurs in the blood vessels of the dermal papilla, interrupting the blood supply to the patient’s skin and subcutaneous fat, rapidly resulting in gangrene and cell death. If the fascia is breached the infection can spread to muscle tissue, causing myositis. Gas pockets can form beneath the skin due to bacteria like Clostridium, giving rise to characteristic gas gangrene. The bacteria involved produce toxic by-products, which lead to toxic shock-like symptoms. Ultimately, this can progress to septic shock and multi-organ failure.[vi] Even following detection and surgery, 20-40% of patients do not survive the disease.[vii]

While thankfully very rare, a high index of suspicion is recommended for NF due to its potential severity and aggressive progression.i In its early stages NF does not present specific distinguishing clinical features, which can make it hard to detect until it has progressed and done more damage to the patient. NF should therefore not be completely discounted until it can be clinically ruled out. Due to the initially mundane presentation of the disease, dentists can find themselves the first care provider to encounter a case. This was true just a few months ago in South Africa, leading to tabloid headlines such as, “Woman goes to dentist with toothache turns out to be flesh-eating bug”. In that particular case, the patient went to her dentist with toothache and was initially prescribed antibiotics, which failed to arrest the infection. A few days later the patient’s pain had intensified, she found it difficult to breath and what had initially been a small black dot rapidly blossomed into a palm-sized stinking dark blotch on her neck. The patient then went to a different dentist who recognised the condition and referred her to doctors for emergency surgical treatment.[viii], [ix], [x]

Early symptoms of NF to watch for include: intense pain that seems disproportionate to external signs of infection, a small but painful cut or scratch, fever and flu-like symptoms.[xi]

Within three to four days, symptoms can escalate to include: swelling of the affected area, a rash, diarrhoea and vomiting, and large dark blotches that will fill with fluid to become blisters.xi

Within four to five days symptoms become critical, resulting in: a dramatic fall in blood pressure, toxic shock and unconsciousness.xi

Prevention

Necrotising fasciitis is a serious threat to a patient’s life, with the potential to cause cardiovascular, respiratory and renal failure.ii Treating NF requires intensive care, surgical debridement (often multiple times) and sometimes amputation, which necessitates reconstructive surgery.[xii] It can leave the patient with life-long scarring, disability and psychological trauma. Even with prompt treatment the disease is frequently fatal.

NF does not generally spread from person to person, however, the bacteria that can provoke the condition are readily transferable. Punctures and breaks in the skin or gums can allow harmful bacteria to aggressively colonise soft tissue. Because NF can result from seemingly trivial injuries, even among otherwise healthy people, achieving total prevention is impossible. However, reducing opportunities for infection to occur is both possible and a responsibility. There are cases in the literature tracing NF to dental abscesses and cysts, caused by caries, impacted teeth and other relatively routine origins such as herpes.[xiii], [xiv], [xv] Origins can also be iatrogenic, accidental punctures and improperly sterilised surgical tools can potentially drive bacteria deep into tissue, placing the patient in danger of an array of infectious diseases, including necrotising fasciitis.[xvi]

Of course, the best defence against these bacteria is to ensure that all instruments in your dental practice are decontaminated using the appropriate technology. The Little Sister range of autoclaves from Eschmann are particularly excellent, as not only are they all built to the highest decontamination and compliance standards, but the wide choice of models available means that there is always an autoclave that will suit you.

The chances of encountering a genuine case of necrotising fasciitis are thankfully slim. However, speedy and effective resolution of bacterial infections, in conjunction with thorough disinfection and sterilisation protocols, and vigilance will help protect your patients from this disease and others.

 

 

For more information on the highly effective and affordable range of decontamination equipment and products from Eschmann, please visit www.eschmann.co.uk or call 01903 01903 875787

 

References

[i] Glass G., Sheil F., Ruston J., Butler P. Necrotising soft tissue infection in a UK metropolitan population.  Annals of The Royal College of Surgeons of England.  2015; 97(1): 46-51. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4473899/ September 12, 2019.

[ii] Maria A., Rajnikanth K. Cervical necrotizing fasciitis caused by dental infection: a review and case report. National Journal of Maxillofacial Surgery. 2010; 1(2): 135-138. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3304199/ September 12, 2019.

[iii] Wang J., Lim H. Necrotizing fasciitis: eight-year experience and literature review. Brazilian Journal of Infectious Diseases. 2014; 18(2): 137-143. http://dx.doi.org/10.1016/j.bjid.2013.08.003 September 18, 2019.

[iv] Lin W., Yeh T., Lu C., Huang H., Chiu W. A catastrophic cervical necrotizing fasciitis after tooth extraction. Internal and Emergency Medicine. 2016; 11(8): 1135-1136. https://link.springer.com/article/10.1007/s11739-015-1379-1 September 18, 2019.

[v] Arruda J., Figueiredo E., Álvares P., Silva Lu., Silva Le., Caubi A., Silveira M., Sobral A. Cervical necrotizing fasciitis caused by dental extraction. Case Resports in Dentistry. Hindawi. 2016; 2016: 1674153.  https://www.hindawi.com/journals/crid/2016/1674153/September 12, 2019.

[vi] Puvanendran R., Huey J., Pasupathy S. Necrotizing fasciitis. Canadian Family Physician. 2009; 55(10): 981-987. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2762295/ September 18. 2019.

[vii] Sultan H., Boyle A., Sheppard N. Necrotising fasciitis. BMJ. 2012; 345: e4274. https://www.bmj.com/content/345/bmj.e4274.fullSeptember 12, 2019.

[viii] Cocksedge C. Woman goes to dentist with toothache turns out to be flesh-eating bug. Unilad. 2019. https://www.unilad.co.uk/news/woman-goes-to-dentist-with-toothache-turns-out-to-be-flesh-eating-bug/ September 18, 2019.

[ix] Gant J. Woman goes to the dentist with toothache in South Africa – only to discover it is actually a flesh-eating bug and has to have part of her jaw and neck cut off. Daily Mail. 2019. https://www.dailymail.co.uk/news/article-7205109/South-Africa-woman-goes-dentist-toothache-actually-flesh-eating-bug.html September 18, 2019.

[x] Coetzee C. Gauteng mother nearly loses her life to flesh-eating bacteria: ‘I was being eaten alive’. News24. 2019. https://www.news24.com/SouthAfrica/News/gauteng-mother-nearly-loses-her-life-to-flesh-eating-bacteria-i-was-being-eaten-alive-20190731 September 18, 2019.

[xi] GOV.UK. Necrotising fasciitis (NF). GOV.UK. 2019. https://www.gov.uk/guidance/necrotising-fasciitis-nf September 12, 2019.

[xii] Hakkarainen T., Kopari N., Pham T., Evans H. Necrotizing soft tissue infections: review and current concepts in treatment, systems of care, and outcomes. Current Problems In Surgery. 2014; 51(8): 344-362. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4199388/September 18, 2019.

[xiii] Traoré A., Traoré A., Dembélé B., Togo A., Diakité I., Kanté L., Konaté M., Karembé B., Bah A., Sidibé Y., Koné T., Diango D., Diallo G. Necrotizing bacterial necrotizing dermatitis with necrotizing fasciitis anterior cervico-thoracic complicating a tooth abscess: clinical case. Clinics In Surgery. 2017; 2: 1523. http://www.clinicsinsurgery.com/full-text/cis-v2-id1523.php September 18, 2019.

[xiv] Oliveira E., Coelho R., Pinto M., Sette-Dias A., Moreira A., Aguiar E., Souza L. A neglected lower impacted premolar leading to cervical necrotizing faciitis. Journal of Dental Health Oral Disorders & Therapy. 2018; 9(6): 517-520. https://doi.org/10.15406/jdhodt.2018.09.00440 September 18, 2019.

[xv] Gore M. Odontogenic necrotizing fasciitis: a systematic review of the literature.  BMC Ear, Nose and Throat Disorders. 2018; 18: 14. https://doi.org/10.1186/s12901-018-0059-y September 18, 2019.

[xvi] Lee G., Bishop P. Microbiology and infection control for health professionals (5th ed). Pearson Higher Education AU. 2012: 408.

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