Early diagnosis and management of Necrotizing Fasciitis

Abstract

Introduction: The term Necrotising Fasciitis (NF) refers to ‘severe inflammation of the muscle sheath that leads to necrosis of the subcutaneous tissue and adjacent fascia’. Incidence of NF varies from 0.24 – 0.4 per 100 000 adults with high morbidity and mortality Early clinical suspicion, repeated aggressive wound debridement and broad spectrum antibiotics with interdisciplinary management improve the survival rate and reduce morbidity. However, early NF can be difficult to distinguish from non-necrotising soft tissue infections in the absence of severe sepsis, multi organ failure or pain. Based on the evolving cutaneous features, Wang Y et al described three stages of NF. Based on various microbial flora involved, Morgan classified NF into types I–IV. Wong et al first described the laboratory risk indicator (LRINEC) for scoring the severity of NF. We are presenting a retrospective observation study of 112 cases of Necrotizing Fasciitis to analyse the methods for early diagnosis and management. Materials and methods: All the case sheets of the patients diagnosed and treated as necrotizing fasciitis from 03-06-2014 to 12-08-2015 were retrieved from medical records department of our Medical College Hospital. From the case sheets, the patients’ demographic, clinical, investigation management and morbidity & mortality data were collected, tabulated and analysed to find out the best possible methods for early diagnosis and management of NF. Results: The data collected in of our study are comparable with and similar to those of previous authors. Conclusion: Clinical findings to suspect / diagnose NF are neither specific nor sensitive especially in early stages. LRINEC scoring is a sensitive diagnostic tool but it is less specific. Imaging modalities are not useful in early cases. Gas in soft tissue X-ray is seen in 40% of cases only. Negative wound culture and biopsy do not rule out NF. Bedside finger test is more specific. Extensive literature review does not show any study to suggest definitive methods for early diagnosis and management of NF. To create proper level of evidence larger prospective study is needed with set protocols for early diagnosis and specific indications for emergency operative intervention, delayed operative intervention and conservative management.