Necrotizing Fasciitis

Jennifer T. Trent, MD, Robert S. Kirsner, MD

Disclosures

Wounds. 2002;14(8) 

In This Article

Treatment

The most effective treatment found to decrease mortality is early diagnosis and prompt surgical debridement.[23] The gold standard of treatment for NF includes intravenous antibiotics with broad-spectrum antibacterial coverage, prompt surgical debridement, and supportive care in an intensive care unit (ICU). ICU care involving hemodynamic support, wound care, and nutritional support is critical.[1,2,6,7,8,9,10,11,12,13,22,25,26,27,28] A combination of broad spectrum antibiotics, such as a penicillin, an aminoglycoside or third generation cephalosporin, and clindamycin or metronidazole, are typically employed to provide broad bacterial coverage. Once the gram stain and culture and sensitivity results are obtained, the antibiotic regimen can be adjusted.

If a diagnosis of NF is made, emergent surgical debridement and/or fasciotomy should be considered.[1,2,6,7,8,9,10,11,12,13,22,25,26,27,28] Debridement beyond the visible margin of infection is necessary. Repeated debridements may be required and should continue until the subcutaneous tissue can no longer be separated from the deep fascia.[2,6,9,11] Fasciotomy may be performed at the time of debridment.[11,32] If infection progresses despite serial debridements and antibiotics, amputation may be life saving.

Supportive care in an ICU is critical to survival. This involves fluid resuscitation, cardiac monitoring, aggressive wound care, and adequate nutritional support.[1,11,23,26] Patients with NF are in a catabolic state and require increased caloric intake to combat infection.[1] Nutritional supplementation can be delivered orally or via nasogastric tube, peg tube, or intravenous hyperalimentation. Nutritional support should begin immediately (within the first 24 hours of hospitalization).[26] Prompt and aggressive nutritional support has been shown to lower complication rates.[1] Baseline and repeated monitoring of albumin, prealbumin, transferrin, blood urea nitrogen, and triglycerides should be performed to ensure the patient is receiving adequate nutrition.

Wound care is also an important concern.[23] Advanced wound dressings have replaced wet-to-dry dressings. These dressings promote granulation tissue formation and speed healing. Advanced wound dressings may lend to healing or prepare the wound bed for grafting. A healthy wound bed increases the chances of split-thickness skin graft take. Vacuum-assisted closure (V.A.C., KCI International Inc., San Antonio, Texas) was recently reported to be effective in a patient whose cardiac status was too precarious to undergo a long surgical reconstruction operation.[33] With the V.A.C., the patient's wound decreased in size, and the V.A.C. was thought to aid in local management of infection and improve granulation tissue.

Biologic debridement with maggots has been used in a number of chronic wounds, as well as osteomyelitis, burns, and traumatic wounds.[34] One report highlighted maggot therapy in a patient with a NF wound of the neck. This patient suffered from severe coronary artery disease and a delicate cardiac status, which prohibited a long surgical debridement procedure. Additionally, the neck has many important structures, and complete surgical debridement is more difficult. In light of these circumstances, the patient underwent a prompt but abbreviated debridement of the necrotic tissue in the neck wound under general anesthesia. Post-operatively, maggots were placed in the wound. After 48 hours, the slough was decreased and the wound had improved clinically without need for further debridement. After two more days, the maggots were removed since new granulation tissue and reepithelialization had begun. The maggots not only cleansed the wound of necrotic tissue but also prevented and controlled infection and odor.

The role of adjunctive hyperbaric oxygen (HBO) in the treatment of NF has been controversial.[1,6,8,9,11,23,27,28,32,35,36] HBO works by increasing the partial pressure of oxygen in tissues. This increases leukocyte function and may increase destruction of anaerobic bacteria, reduce tissue edema, stimulate fibroblast proliferation, increase collagen formation, reduce ischemia, enhance the action of antibiotics, stimulate angiogenesis, and promote granulation tissue.[8,11,28,32] Several series suggest that HBO significantly reduced mortality in NF patients. These cases reported a mortality reduction of 66 to 23 percent, 35 to 16 percent, and 43.5 to 20.7 percent.[11,28,35,37] However, Brown, et al., did not find a decrease in mortality of NF patients treated with HBO (30 vs. 42%).[11,28]

Intravenous immunoglobulins (IVIG) have been shown to be an effective adjunctive treatment for patients with Streptococcal toxic shock syndrome (STSS).[2,38,39] IVIG contains many antibodies, which neutralize the exotoxins/superantigens secreted by the Streptococcus and are involved in the pathogenesis of STSS.[2] By inhibiting the binding of the superantigen to the T-cell receptor, certain cytokines, like TNF and IL-1, which are involved in tissue destruction and organ failure, are inhibited. IVIG has been shown to decrease the hyperproliferation of T cells by binding Streptococcal toxin as well as opsonizing bacteria.[1,28] Since STSS and NF are mediated by the Streptococcal toxins and inflict their tissue destruction via some of the same cytokines, it was postulated that IVIG would be as effective a treatment in NF as it was in STSS. While prospective trials on the use of IVIG for treatment of NF are lacking, there have been sporadic reports on their benefit.[1,2,6,8,28] Kaul, et al., reported a significant increase in survival in the group of patients receiving IVIG, 34 vs. 67 percent.[28]

processing....