Practice development Innovations Hyperbaric oxygen therapy has also References 37.Heinle EC, Dougherty WR, Garner


WL, Reilly DA. The use of 5% mafenide acetate solution in the postgraft


treatment of necrotizing fasciitis. J Burn Care Rehab 2001; 22:35–40.


38.De Geus HRH, Van der Klooster JM. Vacuum-assisted closure in the treatment of large skin defects due to


necrotizing fasciitis. Intensive Care Med 2005; 31:601.


39.Bronchard R, de Vaumas C, Lasocki S, Jabbour K, Geffroy A, Kermarrec N, Montravers P. Vacuum-assisted


closure in the treatment of perineal necrotizing skin and soft tissue


infections. Intensive Care Med 2008; 34: 1345–7.


40.Riseman JA, Zamboni WA, Curtis A, Graham DR, Konrad HR, Ross DS. Hyperbaric oxygen therapy for


necrotizing fasciitis reduces mortality and the need for debridements. Surgery 1990; 108: 847–50.


41.Korhonen K. Hyperbaric oxygen


therapy in acute necrotizing infections with a special reference to the effects on tissue gas tensions.Ann Chir Gynaecol Suppl 2000; 89: 7–36.


42Escobar SJ, Slade JB Jr, Hunt TK,


Cianci P. Adjuvant hyperbaric oxygen therapy (HBO2) for treatment of necrotizing fasciitis reduces mortality


and amputation rate.Undersea Hyperb Med 2005; 32: 437–43.


43Norrby-Teglund A, Muller MP,


Mcgeer A, Gan BS, Guru V, Bohnen J, Thulin P, Low DE. Successful management of severe group A streptococcal soft tissue infections


using an aggressive medical regimen including intravenous polyspecific immunoglobulin together with a


conservative surgical approach. Scand J Infect Dis2005; 37: 166–72.


44Cawley MJ, Briggs M, Haith LR Jr, Reilly KJ, Guilday RE, Braxton GR, Patton ML. Intravenous immunoglobulin as adjunctive


treatment for streptococcal toxic shock syndrome associated with necrotizing fasciitis: case report and review. Pharmacotherapy1999; 19: 1094–8.


45Simmonds M. Necrotising fasciitis and group A streptococcus toxic shock-like syndrome in pregnancy: treatment with plasmapheresis and


immunoglobulin. Int J Obstet Anesth 1999; 8: 125–30.


46Purnell D, Hazlett T, Alexander SL. A new weapon against severe sepsis


related to necrotizing fasciitis.Dimens Crit Care Nurs 2004; 23: 18–23.


Figure 3: The same patient as shown in Figure 2, two months post coverage with split thickness skin grafts.


split-thickness skin grafts[9] [Fig 3]. This can


be performed in the hospital or the patient can be discharged to a rehabilitation centre until their nutrition is sufficient for the wounds to heal. Skin replacement matrices have been


recommended for covering these wounds due to the loss of the full thickness of the tissues from the skin all the way down to the muscle fascia[33, 34]


. However, the authors do not recommend


this management protocol as despite the surgical excision and antibiotic administration, these wounds are never clean, and carry a high risk of infection until the matrix is well vascularised. After adequate control of the infection and when the patient's nutrition has been stabilised the wound can be closed by skin grafts. Daily wound care should be performed,


including daily cleansing, the application of topical agents and the use of appropriate dressings[9]


. Some centres recommend


the use of sterile saline, while others recommend using tap water. A Cochrane study into open wounds compared these two methods and found a reduced rate of wound infection when using tap water, probably due to its greater availability, which means it can be used more often[35, 36] The use of 5% mafenide acetate has been


shown to facilitate early wound closure[37] and the authors use silver sulfadiazine 2% cream once or twice daily to help prepare a reasonably clean wound that is ready for closure. Recent reports have recommended the


use of vacuum-assisted closure, because it reduces the number of dressing changes, meaning less stress for patients and a lighter workload for nurses,[38, 39]


but this technique still needs to be fully examined. 17 Wounds International Vol 2 | Issue 2 | ©W ol 2 | Issue 4 | ©Wounds International 2011


been recommended as an adjunct to treatment[40-42]


. , however, the evidence is still


controversial and hyperbaric oxygen therapy use should not interfere with early and complete surgical excision[9]


Other adjunctive techniques have been


reported and small case series have been performed on the use of immunoglobulin G (IgG), plasmapheresis or activated protein C[43-46]


. However, their role is still to be


assessed in prospective controlled studies, meaning that there has yet to be conclusive evidence[1, 9]


.


PROGNOSIS NSTI carries high mortality rate, which has been reported as approximately 46% in total[1]


between 16–24%[14,16]


, although other reports cite a rate . Yilmazlar et al[19]


have reported that an APACHE II score of 13 or greater and disease dissemination (the involvement of more than one anatomical areas of the human body, for example the upper extremities and the trunk) were found to be independently and associated with the mortality of patients with NSTI.


CONCLUSION In summary, NSTI is a serious infection that can cause death. It requires prompt diagnosis, and early and complete surgical excision in addition to broad spectrum antibiotic coverage and organ support. This requires a team approach involving a


critical care specialist, an infectious disease specialist, a surgeon, nurses, dietitians and rehabilitation specialists in order to achieve a satisfactory outcome.


.


AUTHOR DETAILS Shady Hayek MD is Assistant Professor, Plastic and Reconstructive Surgery, Hand Surgery, Burn Surgery, American University of Beirut-Medical Center, Lebanon; Amir Ibrahim MD is Chief Resident in Plastic and Reconstructive Surgery, American University of Beirut-Medical Center, Lebanon; Bishara Atiyeh, MD is Professor in Clinical Surgery, Plastic and Reconstructive Surgery, American University of Beirut-Medical Center, Lebanon and General Secretary, MBC Executive Editor, Annals of Burns and Fire Disasters.


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