title: Multifocal necrotising fasciitis: an overlooked entity?
abstract: OBJECTIVE
  The aim of the study is to report a case of multi-focal necrotising fasciitis, review research on this subject to identify common aetiological factors and highlight suggestions to improve management.
  
  
  BACKGROUND
  Necrotising fasciitis is a severe, life-threatening soft tissue infection that typically arises from a single area, usually secondary to a minor penetrating injury. Multi-focal necrotising fasciitis, where there is more than one non-contiguous area of necrosis, is much less commonly reported. There are no guidelines specific to the management of multi-focal necrotising fasciitis, and its under-reporting may lead to missed management opportunities.
  
  
  METHODS
  A systematic literature review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol.
  
  
  METHODS
  A search of MEDLINE, OLD MEDLINE and the Cochrane Collaboration was performed from 1966 to March 2011 using 16 search terms.
  
  
  METHODS
  All articles were screened for genuine non-contiguous multi-focal necrotising fasciitis. Of the papers that met this criterion, data on patient demographics, likely inciting injury, presentation time-line, microbial agents, sites affected, objective assessment scores, treatment and outcome were extracted.
  
  
  RESULTS
  A total of 31 studies met our inclusion criteria and 33 individual cases of multi-focal necrotising fasciitis were included in the quantitative analysis. About half (52%) of cases were type II necrotising fasciitis; 42% of cases had identifiable inciting injuries; 21% of cases developed multi-focal lesions non-synchronously, of which 86% were type II. Nearly all (94%) of cases had incomplete objective assessment scores. One case identified inflammatory imaging findings prior to clinical necrosis.
  
  
  CONCLUSIONS
  Multifocality in necrotising fasciitis is likely to be associated with type II disease. We postulate that validated objective tools will aid necrotising fasciitis management pathways that will identify high-risk groups for multifocality and advise early pre-emptive imaging. We recommend the adoption of regional multi-focal necrotising fasciitis registers.
authors.affiliation: Mountbatten Department of Plastic and Reconstructive Surgery, Queen Alexandra Hospital, Curie Road, Cosham, Portsmouth PO6 3LY, UK. ussamah.elkhani@doctors.org.uk
authors.forename: Ussamah
authors.initials: U
authors.lastname: El-Khani
authors.forename: Jean
authors.initials: J
authors.lastname: Nehme
authors.forename: Ammar
authors.initials: A
authors.lastname: Darwish
authors.forename: Benjamin
authors.initials: B
authors.lastname: Jamnadas-Khoda
authors.forename: Godwin
authors.initials: G
authors.lastname: Scerri
authors.forename: Simon
authors.initials: S
authors.lastname: Heppell
authors.forename: Nicholas
authors.initials: N
authors.lastname: Bennett
mesh_terms: D003646:Debridement; D019115:Fasciitis, Necrotizing / Q000209:etiology* / Q000628:therapy*; D006801:Humans