These 182 patients grew an average of 4.4 types of microbes from original wound cultures, although a single pathogen was responsible in 28 patients. Eighty five patients had combined aerobic and anaerobic growth, the most common organisms being, Bacteroides find more species, aerobic streptococci, staphylococci, enterococci, Escherihia coli, and other gram-negative rods. Clostridial growth was common but did

not affect mortality unless associated with pure clostridial myonecrosis. Mortality was affected by the presence of bacteriemia, delayed or inadequate surgery, and degree of MODS on admission. Monomicrobial cases are usually caused by Group A Streptococcus pyogenes and Staphylococcus aureus. They occur in otherwise healthy, young, immunocompetent patients and are most usually located on the

extremities. In the study by Anderson et al. [22] more that 71% of cases had a polymicrobial source of infection. A polymicrobial infection is often diagnosed in immunocompromised patients and usually occurs in the perineum and trunk area [23]. Toxic shock syndrome is the most often accompanying syndrome of Streptococcal sepsis [24]. Clinical findings The most representative clinical picture present with abscesses, infected traumatic see more and surgical wounds, intravenous drug abuse, pressure sores burns, perforated viscera (particular colon, rectum, and anus), recently performed liposuction, infected vascular prostheses and grafts, and invasive cancer [18, 19]. Early clinical suspicion and surgery are the keys to improving survival, and patients with necrotizing infections need an integrated multidisciplinary approach Phosphoribosylglycinamide formyltransferase to management. It is adjusting with the infecting organism(s), the site of infection, and the effects from any toxins produced, and incorporate various clinical and laboratory parameters In everyday clinical practice a universal clinical guideline that should be used in the diagnosis and treatment of all types of NSTI/NF does not exist (Table 2, 4, 5). Table 5 Treatment options classified by type of infection and clinical picture Type of NSTI Depth of involvement Usual pathogens Predisposing factors Time of incubation

and rate of progression The main clinical signs Treatment options Polymicrobial NF-type I fascia and muscle obligate and facultative anaerobes different type of wounds long (48-96 h) Hour to days foul- smelling drainage ICU stay critical care therapy surgery antibiotics ev. HBO Monomicrobial NF-type II (Steptococcal gangrene) skin, fascia and muscle Streptococci -groups A, C, G, and B; (B is more common) excoriation or cut wound short (6-48 h) A few hour distinct margins ICU stay critical care therapy surgery antibiotics ev. HBO Gas gangrene (Clostridial myonecrosis) muscle C. perfirngens (C. perfirngens more common) and C. novyi tidy wounds short (6-48 h) A few hour extreme system toxicity ICU stay critical care therapy surgery antibiotics HBO     C.