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      The clinical presentation and early outcomes of necrotizing fasciitis in a Ugandan Tertiary Hospital- a prospective study

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          Abstract

          Background

          Necrotizing fasciitis is an infectious process characterized by rapidly progressing necrosis of superficial fascia and subcutaneous tissue with subsequent necrosis of overlying skin.

          Necrotizing fasciitis is a rare but fatal infection. The worldwide incidence is at 0.4 per 100,000. Mortality is up to 80% with no intervention, and 30-50% with intervention. Delay in intervention is associated with poor outcome. The risk factors for necrotizing fasciitis are diabetes mellitus, HIV, malignancy, illicit drug use, malnutrition among others.

          The aim of this study was to describe the clinical presentation and early outcomes of necrotizing fasciitis amongst Ugandan patients.

          Methods

          A prospective descriptive case series study conducted at Mulago National Referral and Teaching hospital from 5 th January to 30 th April 2011. Patients with necrotizing fasciitis were consecutively recruited after clinical evaluation, laboratory and microbiological tests were performed. Aggressive debridement was done and broad-spectrum antibiotics administered. Patients were followed up on surgical wards. Ethical approval was obtained.

          Results

          Thirty five patients were recruited over a 4 months period. More males were affected with, M: F 3:1. The 20-40 years age group was most affected. Attainment of healthy granulation tissue took 19 days on average. Mortality rate was 14% (5/35). Limbs were the most affected body parts 20/35 (57%), the scrotum and perineum (23%). Among infants the scalp was the most affected. Co-morbidities included HIV 8/35 (17%), and DM (5%) among others. The commonest organisms were gram negative. Split skin grafting was necessary in 74% (26/35) of patients.

          Conclusion

          There were a high number of patients with necrotizing fasciitis; it was associated with low mortality but high morbidity (long hospital stay). There was a high preponderance to males and limbs were the more affected body parts.

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          Most cited references11

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          Necrotizing fasciitis: current concepts and review of the literature.

          Babak Sarani, Michelle Strong, José Pascual … (2009)
          Article 0 comments Cited 137 times – based on 0 reviews     Review now
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            Molecular basis of group A streptococcal virulence.

            A L Bisno, M O Brito, C M Collins (2003)
            The group A streptococcus (GAS) (Streptococcus pyogenes) is among the most common and versatile of human pathogens. It is responsible for a wide spectrum of human diseases, ranging from trivial to lethal. The advent of modern techniques of molecular biology has taught much about the organism's virulence, and the genomes of several GAS types have now been deciphered. Surface structures of GAS including a family of M proteins, the hyaluronic acid capsule, and fibronectin-binding proteins, allow the organism to adhere to, colonise, and invade human skin and mucus membranes under varying environmental conditions. M protein binds to complement control factors and other host proteins to prevent activation of the alternate complement pathway and thus evade phagocytosis and killing by polymorphonuclear leucocytes. Extracellular toxins, including superantigenic streptococcal pyrogenic exotoxins, contribute to tissue invasion and initiate the cytokine storm felt responsible for illnesses such as necrotising fasciitis and the highly lethal streptococcal toxic shock syndrome. Progress has been made in understanding the molecular epidemiology of acute rheumatic fever but less is understood about its basic pathogenesis. The improved understanding of GAS genetic regulation, structure, and function has opened exciting possibilities for developing safe and effective GAS vaccines. Studies directed towards achieving this long-sought goal are being aggressively pursued.
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              Aggressive surgical management of necrotizing fasciitis serves to decrease mortality: a retrospective study.

              B D Bilton, G B Zibari, R W McMillan … (1998)
              Necrotizing fasciitis is an aggressive soft-tissue infection that in the past has carried a significant mortality rate. One of the most important determinants of outcome is recognition of the disease process. This is followed by aggressive resuscitation measures and radical debridement at the initial operation to control the infectious spread at the outset. The objective of this study is to help reveal the benefits of aggressive early surgical debridement in the treatment of necrotizing fasciitis. A retrospective review of the medical records of 68 patients between the years 1980 and 1996 with the diagnosis of necrotizing fasciitis was performed. The patients were assigned to two groups, Group A (21; 31%), who had delay in therapy or inadequate preliminary therapy and Group B (47; 69%), who underwent aggressive surgical debridement from the outset. Concomitant disease processes were noted. The medical records of 68 patients were studied. Age ranged from 13 to 67 (mean, 52) years of age. There were 38 (56%) females, 21 (64%) of the patients were African-American, 24 (73%) of the patients had concomitant disease processes, 29 (42%) of the patients had a history of tobacco use, 11 (16%) of the patients had a history of alcohol consumption, and 11 (16%) of the patients were obese. Mortality in Group A was 8 of 21 patients (38%). Mortality in Group B was 2 of 47 patients (4.2%). The difference in mortality was found to be statistically significant (P = 0.0007). Early recognition and expeditious initial wide excision and debridement along with appropriate antibiotic coverage and support of systemic effects of necrotizing fasciitis serve to decrease morbidity and mortality. We believe the above is an absolute necessity followed by frequent washing and minor debridement of the wound until granulating tissue is observed. This can then be followed by procedures to close/cover the surgical defect (i.e., split-thickness skin grafts or various coverage flaps).
              Article 0 comments Cited 50 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                John Magala
                Patson Makobore
                Timothy Makumbi
                Sam Kaggwa
                Edris Kalanzi
                Moses Galukande
                Journal
                Journal ID (nlm-ta): BMC Res Notes
                Journal ID (iso-abbrev): BMC Res Notes
                Title: BMC Research Notes
                Publisher: BioMed Central
                ISSN (Electronic): 1756-0500
                Publication date Collection: 2014
                Publication date (Electronic): 28 July 2014
                Volume: 7
                Page: 476
                Affiliations
                [1 ]Department of Surgery, Mulago National Referral Hospital, Kampala, Uganda
                [2 ]Department of Surgery, Makerere University College of Health Sciences, Kampala, Uganda
                Article
                Publisher ID: 1756-0500-7-476
                DOI: 10.1186/1756-0500-7-476
                PMC ID: 4119938
                PubMed ID: 25069415
                SO-VID: 3d128b0a-b9cf-46a1-9402-579b1eca993b
                Copyright © Copyright © 2014 Magala et al.; licensee BioMed Central Ltd.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Date received : 16 October 2013
                Date accepted : 21 July 2014
                Categories
                Subject: Research Article

                ScienceOpen disciplines: Medicine
                Keywords: necrotizing fasciitis,clinical presentation and early outcome
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: necrotizing fasciitis, clinical presentation and early outcome

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