6. Krieg:Umbruchvorlage 12.01.2009 9:39 Uhr Seite 33 January 28, 2009 EUROPEAN JOURNAL OF MEDICAL RESEARCH 33 Fig. 3. Definitive reconstructions after successful treatment of necrotizing fasciitis. An initial necrosectomy with debridement of necrotic tissue and fascia was performed in all patients until healthy, vascularized margins were reached (Fig. 2 C). Twenty-one patients (80.8 %) underwent at least one revision because of progressing necrotic and in- flammatory tissue (range 1 to 8), of which the first was necessary in two patients (10 %) on the subse- quent day. Three patients with involvement of the per- ineum received a colostomy. The mean delay from on- set of symptoms to operation was 3.6 days ± 3.3 (range 0 to 14 days). Because of progressive infection after initial debridement an amputation below the knee was necessary in one patient for definitive treatment. A mean number of 3.7 ± 2.1 (range 1 to 10) opera- tions were performed until complete resolution of the infection and reconstruction. Definitive reconstruc- tion procedures included mesh graft coverage in twelve patients (46.2 %) or secondary wound closure in eight patients (30.8 %). No reconstruction was per- formed in five patients (19.2 %) due to a fatal out- come (Fig. 3). Bacteriological culture results of tissue specimen or smears obtained at the first debridement identified in nine patients (34.6 %) a single organism and in thir- teen patients (50 %) multiple organisms. In four pa- tients (15.4 %) no organism could be isolated. Thus in fourteen patients (53.8 %) a type I polymicrobial necrotizing fasciitis according to the classification by Giuliano et al. was present. As summarized in Table 3, isolates in these patients included non-group-A strep- tococci, staphylococci, enterobacteriaceae such as escherichia coli, klebsiella species, pseudomonas species and anaerobes. Eight infections (30.8 %) were type II infections according to the classification by Giuliano et al. [4] and were caused by group-A b haemolysing streptococci alone or in combination Table 3. Microbiological isolates among patients (n = 26) with necrotizing fasciitis. Organism Group-A Streptococcus Non-Group-A Streptococcus Enterococcus Escherichia coli Proteus Klebsiella Staphylococcus Anaerobes Unknown/no growth Number [%] 8 (30.8 %) 2 (7.7 %) 4 (16 %) 6 (23 %) 1 (3.8 %) 1 (3.8 %) 5 (19.2 %) 8 (30.8 %) 3 (11.5 %) Fig. 4. Relationship between number of surgical revisions and existence of anerobic bacterial strains ( p = 0.005; Mann- Whitney-test). with staphylococci. Patients with positive anaerobic bacteriological cultures underwent significantly ( p = 0.005) more surgical procedures (median 3; quartile range 25%-75%: 1.25-5.5; interquartile range: 4.25) than patients without anaerobic involvement (median 1; quartile range 25%-75%: 0-1; interquartile range: 1) (Fig. 4). The mean length of stay was 48.1 ± 25.5 days (range 2 to 113). 19 patients (73.1 %) were admitted to our intensive care unit with a mean ICU stay of 20.1 ± 19.9 days (range 1 to 61 days). Out of this group twelve patients (63.2 %) required a mean of 20.3 ± 16 respirator days (range 1 to 61 days). Patients with se- vere systemic infection (ASA IV - V) had to be venti- lated for a significantly ( p = 0.003) longer period (me- dian 16.5; quartile range 25%-75%: 3.25-26.75; in- terquartile range: 23.5) than patients without any clini- cal signs of severe systemic inflammation (ASA II and III) (median 0: quartile range 25%-75%: 0-0; in- terquartile range: 0) (Fig. 5 A). Additionally ASA IV and V patients suffering from necrotizing fasciitis re-