Necrotising Fasciitis

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It is a rapidly progressive inflammatory infection of the fascia with progressive destruction of the skin and subcutaneous tissue (also known as ‘flesh-eating’ disease).

It is a life threatening condition and if not properly managed may be fatal. It must be managed as an emergency. It is commoner in the immune-compromised state e.g. diabetes, HIV, malignancies.  

Cause

  • Mixed bacterial infections 
    • Strept. spp
    • Staph. spp 
    • Clostridium perfringens 
    • Bacteroides

Symptoms

  • Pain 
  • Fever
  • Swelling 
  • Discharge 

Signs

  • Fever 
  • Swelling 
  • Discharge which may be serosanguinous or purulent
  • Skin colour change

Investigations

  • FBC, ESR
  • CRP
  • Blood culture
  • Random blood sugar
  • HIV screening
  • Gram stain and culture of discharge
  • X-ray 
  • BUE and Creatinine 

TreatmentTreatment Objectives

  • Resuscitate (Save life first) 
  • Eradicate infection
  • Treat underlying cause

Non-pharmacological treatment

  • Surgery
  • Debridement
  • Grafting and or flap cover

Pharmacological treatment 

For eradication of infection

1st Line Treatment

Evidence Rating: [B]

  • Clindamycin, IV,

Adults

600 mg 8 hourly for 4 weeks or until clinical improvement

Children

3-6 mg/kg 6 hourly for 2-4 weeks 

And 

  • Amoxicillin + Clavulanic Acid, IV,

Adults

1.2 g 8 hourly for 4 weeks or until clinical improvement

Children

12-18 years; 600 mg-1.2 g 8 hourly for 4 weeks or until clinical improvement

3 months-12 years; 30 mg/kg 8 hourly, for 4 weeks or until clinical improvement

7 days-3 months; 30 mg/kg 8 hourly for 4 weeks or until clinical improvement

Preterm and < 7 days; 30 mg/kg 12 hourly for 4 weeks or until clinical improvement

2nd Line Treatment:

Evidence Rating: [B]

  • Vancomycin, IV, 

Adults

1 g 12 hourly by slow infusion over 1 hour (max. 2 g daily)

Children

1 month-12 years; 10 mg/kg per day in divided doses 6-12 hourly (max. 1 g daily)

Vancomycin Dosing Modifications: 

Renal impairment: 15 mg/kg initially; further doses are based on renal function, serum drug level, and institutional protocol; dosing intervals range from every 24 to 96 hours, depending on severity of impairment.

General dosing recommendation: 2 g/day IV divided 6-12 hourly; may be increased on basis of body weight or to achieve higher trough values; increased toxicity at dosage > 4 g/day

Peak values 18-26 mg/L; trough values 5-10 mg/L; however, Infectious Diseases Society of America and other guidelines urge troughs 15-20 mg/L

 

Referral Criteria

  • Refer all patients to the plastic, general or orthopaedic surgeons as  soon as the patient has been resuscitated.