Practice development The diagnosis and management of necrotising fasciitis


resonance imaging (MRI) have all been evaluated for their usefulness in diagnosing NSTI. X-ray can only show subcutaneous gas, which proves the presence of gas- producing bacteria such as E. coli or Clostridium species[1,20]


. This means that


X-ray is highly specific, but with low sensitivity, as it can miss many of the NSTIs caused by non-gas-producing bacteria. CT scans have the advantage of being


able to diagnose deep abscesses or other indicators of NSTI[20-22]


. The major limitation


of CT scans, however, is that they indicate the presence of NSTI by comparing the thickness of the fascial layer of an involved area with a non-involved area, rather than with an area exhibiting non-necrotising infection. Therefore, they do not distinguish between different infections[20–22]


. Another


disadvantage to using CT scans is that patients with suspected NSTI are often in shock and thus the use of intravenous contrast is contraindicated to avoid kidney damage[20]


. Ultrasound imaging has the same


limitations as CT scans because it only compares the fascial layer[23]


. MRI scans do show oedema in the tissues


but have a major limitation in that any contrast enhancement only highlights the edges of a necrotic area, not the necrosis itself[20]


.


proceeds [Fig 2]. This strategy has been very helpful in confirming clinical suspicion after frozen section or other imaging studies while reducing any delays to surgery.


MANAGEMENT Like any other surgical infection, the management of NSTI relies on three main


principles: n Source control n Correct antimicrobial administration n Organ support[1]


. NSTI is a perfect example and


demonstrates the importance of immediate source control[26]


excision of all infected tissues, mortality increases and may approach 100%[1, 27–29] Skin bridges and flaps should be


.


avoided because they can be the source for expanding pockets of fasciitis and micro-abscesses[9]


. Frequent monitoring


and assessment of these patients postoperatively is mandatory as they may require another visit to the operating room for further debridement[9, 30]


. Concomitant with early and complete . In addition, MRI tends to overestimate


necrosis because it cannot distinguish surrounding non-infectious oedema[20] General consensus in the literature is that


if performing imaging studies for NSTI is going to delay treatment then they should not be performed due to the need for early surgery in these patients[1, 20]


.


PATHOLOGICAL EXAMINATION Two studies looked at the outcome of frozen section pathological examination on a biopsy that included fascia and muscle layers[24, 25]


. They reported a decreased


mortality rate compared with historical controls, however, this might be due to the clinical suspicion that led to the early ordering of the frozen section biopsy rather than to the biopsy itself[1]


. In the authors’ experience, if there is


any doubt about the diagnosis, they will perform a small incision down to the fascial layer. If there is pus or necrosis then this confirms the diagnosis and fascial excision


surgical excision is the administration of broad spectrum antibiotics to cover the wide range of possible infection-causing organisms[1]


. Antimicrobials should


include penicillin (for the Gram-positive bacteria), clindamycin (to inhibit the secretion of Streptococcal exotoxin), and a fluoroquinolone or an aminoglycoside (for the Gram-negative bacteria)[1, 9, 26, 31] With the increasing incidence of


.


community-acquired MRSA and its involvement in mono or polymicrobial NSTI, the addition of vancomycin to the antimicrobial regimen is recommended until cultures show the absence of MRSA[1, 8, 32] The antimicrobial regimen should


.


continue until organ system failure stops and the wound status improves. It should also be adjusted according to the final culture results[1]


. Organ support, whether respiratory,


circulatory or any other system, should be continued until the system improves[1]


. .


Nutritional and fluid support should not be neglected, particularly for patients with large open wounds[9]


Wound coverage should be carried out


within a few weeks of improvement and is usually performed by applying


www.woundsinternational.com 16 . Without complete surgical References


28.Bilton BD, Zibari GB, McMillan RW, Aultman DF, Dunn G, McDonald JC. Aggressive surgical management of necrotizing fasciitis serves to decrease mortality: a retrospective study. Am Surg 1998; 64: 397–400; discussion 400–1.


29.Brandt MM, Corpron CA, Wahl WL. Necrotizing soft tissue infections: a surgical disease. Am Surg 2000; 66: 967–70.


30.Endorf FW, Klein MB, Mack C, Jurkovich GJ, Rivara FP. Necrotizing soft- tissue infections: differences in patients at burn centers and non-burn centers. J Burn Care Res 2008; 29: 933–8.


31.Stevens DL, Bryant AE, Hackett SP. Antibiotic effects on bacterial viability, toxin production, and host response. Clin Infect Dis 1995; 20: S154–7.


32.Wang R, Braughton KR, Kretschmer D, Bach TH, Queck SY, Li M, Kennedy AD, Klebanoff SJ, Peschel A, DeLeo FR, Otto M. Identification of novel cytolytic peptides as key virulence determinants for community-associated MRSA.Nat Med 2007; 13: 1510–4.


33.Akhtar S, Hasham S, Abela C, Phipps AR. The use of Integra in necrotizing fasciitis. Burns2006; 32: 251–4.


34.Muangman P, Engrav LH, Heimbach DM, Harunari N, Honari S, Gibran NS, Klein MB. Complex wound management utilizing an artificial dermal matrix. Ann Plast Surg 2006; 57: 199–202.


35.Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database of Systematic Reviews 2008; 1(art. no. CD003861). Available at: http://www. mrw.interscience.wiley.com/cochrane/ clsysrev/articles/CD003861/pdf_fs.html.


36.Hayek S, El Khatib A, Atiyeh B. Burn wound cleansing — A myth or a scientific practice.Ann Burns Fire Disasters 2010; 23: 19–24.


Practice development


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