Necrotizing Fasciitis: A Comparative Analysis of 56 Cases: RESULTS

4 Dec
2009

Over the four-year period, a total of 56 patients were treated, out of which 32 (57.1%) were children <15 years, while the remaining 24 (42.9%) were adults aged >15 years. There were 31 males and 25 females, giving the male-to-female ratio of 1.2:1; the corresponding sex ratios for children and adults were 1.7:1 and 1:1.2, respectively. The ages ranged from six days to 70 years (mean 19.9 years). Figure 1 shows the age/sex distribution of all the patients. The common presenting features in both age groups were pain (100%), fever (children 78.1%, adults 37.5%o), tissue necrosis with undermining and surrounding cellulitis/edema (100%) and jaundice (children 20.8%, adults 9.4%).

Figure 1. Age-sex distribution of all patients

Figure 1. Age/sex distribution of all patients

Table 1. Anatomical distribution of lesions

Region    Children %

Adults

%

Total

%

n=32

n=24

n=56

Head/neck

9

28.1

9

16.1

Trunk

16

50.0

3

12.5

19

33.9

Upper limb

7

21.9

4

16.7

11

19.6

Lower limb

4

12.5

13

54.2

17

30.4

Perineum

2

6.3

2

20.8

4

7.1

Buttocks

5

8.3

5

8.9

Table 2. Cultural characteristics of isolated organisms

Bacteria    Children

%

Adult

%

Total

%

n=32

n=24

n=56

S. aureus

23

71.9

11

45.8

34

60.7

Streptococcus 19 Pyogenes

59.4

7

29.2

26

46.2

E. coli

15

46.9

6

25.0

21

37.5

P. aeruginosa

12

37.5

17

70.8

29

51.8

Klebsiella species

8

25.0

10

41.7

28

50.0

Nil growth

1

3.1

4

16.7

5

8.9

Figure 2. A 50-year-old woman

Figure 2. A 50-year-old woman with necrotizing fasciitis of the gluteal region following radiotherapy for cervical

One or more precipitating factors were identified in 30 (53.6%) patients (18 children, 12 adults), including trauma in 12 (21.4%), injection in seven (12.5%) and pustules/boils in 15 (26.8%) patients. One child had NF following colostomy for high anorectal anomaly, while a woman had it from radiotherapy for cancer of the cervix (Figure 2). In the remaining 26 (46.4%) patients, no precipitating factor could be identified. The premorbid conditions included malnutrition in 13 children. In adults, there were three patients, three with lymphedema of the lower limbs and two with HIV. The duration of symptoms ranged from 3-37 days (children 3-19 days, adults 5-37 days), with a mean of 9.9 days (children 6.4 days, adults 13.3 days). The total body surface area (BSA) involved ranged from 1-16% (children 2-16%, adults 1-7%), with a mean of 4.3% (children 5.9%, adults 2.7%). While the trunk was the most commonly involved anatomical region of the body (50.0%) in children (Figure 3), it was the lower limb in adults (54.2%). Table 1 shows the anatomical regions of the body affected in both children and adults. The infection was polymicrobial in 62.5% of patients (children 65.6%, adults 58.3%). The commonest offending organisms were staphylococcus aureus and pseudomonas in children and adults, respectively (Table 2). In five (8.9%) patients, no organism was isolated.

Table 3. Number of major debridements undertaken

Number of

Children

%

Adults

%

Total

%
Debridements

n=32

n=24

n=56

Nil

2

8.3

CM

3.6

1

23,

71.9

10

41.7

33

58.9

2

7

21.9

7

29.2

14

25.0

3

2

6.3

4

6.7

6

10.7

4

1

4.2

1

1.8

In both children and adults, >35% of patients had multiple wound debridements (Table 3). The most common mode of wound resurfacing was healing by secondary intention in children (46.9%) and STSG in adults (37.5%), as seen in Table 4. Transfusion of whole blood was undertaken in 22 (39.3%) patients: 9/32 children (28.1%) and 13/24 adults (54.2%). The blood volume transfused ranged from 40-3,500 mis (children 40-1,050 mis, adults 1,000-3,500 mis), with a mean of 892.5 mis (children 355 mis; adults 1,430 mis). Septicemia was the commonest complication, as it was observed in 57.1% of patients (Table 5). The duration of hospital stay ranged from 3-126 days (children 14-96 days, adults 3-126 days), with a mean of 36 days (children 27.6 days, adults 44.3 days). Follow-up ranged from two weeks to 2.5 years (children: three weeks to six months, adults: two weeks to 2.5 years), with a mean of 5.4 months (children 52.4 days, adults 9.1 months). Overall mortality was 12.5% (seven patients), comprising three children (9.4%) and four adults (16.7%), resulting mainly from septicemia (five), tetanus (one) and cardiovascular complications of anemia (one). levitra plus

Figure 3. Necrotizing fasciitis

Figure 3. Necrotizing fasciitis of the anterior trunk in a 19-day-old boy after two major debridements

Table 4. Modes of wound resurfacing

Wound Resurfacing

Children n=32%

Adults n=24

%

Total n=54

%

Healing by second intention

15

46.9

6

25.0

21

37.5

Direct suturing

2

6.3

4

16.7

6

10.7

Split-thickness skin grafting

7

21.9

9

37.5

16

28.6

Local flap reconstruction

4

12.5

4

7.1

SAMA/died                                  4          12.5                5SAMA/died: signed against medical advice or died before wound resurfacing

20.8

9

16.1

Table 5. Complications

Complication

Children

%

Adults

%

Total

%

n=32

n=24

n=56

Septicemia2371.99

37.5

32

57.1

Anemia928.113

58.2

22

39.3

Joint stiffness

3

12.5

3

5.4

Measles1

3.1

1

1.8

Tetanus

1

4.2

1

1.8

Chronic osteomyelitis

1

4.2

1

1.8

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