Necrotizing Fasciitis: A Review of Management Guidelines in a Large Obstetrics and Gynecology Teaching Hospital

摘要

Necrotizing fasciitis is a severe, life-threatening soft tissue infection that results in rapid and progressivedestruction of the superficial fascia and subcutaneous tissue. Because of its varied clinicalpresentation and bacteriological make-up, it has been labelled with many other names such as acutestreptococcal gangrene, gangrenous erysipelas, necrotizing erysipelas, hospital gangrene, and acutedermal gangrene. Although described by Hippocrates and Galen, it has received increasing attentionin obstetrical and gynecological literature only within the last 20 years. This review includes tworecent cases successfully managed at Parkland Memorial Hospital, Dallas, Texas. The first patientwas a 50 year old, morbidly obese, diabetic woman who presented with a small, painful lesion on thevulva. After failing triple antibiotic therapy with ampicillin, clindamycin, and gentamicin, the diagnosisof necrotizing fasciitis of the vulva was made, and she was taken to the operating room forextensive excision. She was discharged home on hospital day 29. The second patient was a 65 yearold, obese, diabetic woman with risk factors for atherosclerosis who had a wound separation after anabdominal hysterectomy. Two days later a loss of resistance to probing was noted in the subcutaneoustissue. Necrotizing fasciitis was suspected, and she was taken to the operating room for resection.The patient was discharged home on hospital day 27. The mortality rate after diagnosis ofnecrotizing fasciitis has been reported to be 30% to 60%. We review the literature and outline theguidelines used in a large Ob/Gyn teaching hospital to minimize the adverse outcome. Lectures onsoft-tissue infections are included on a regular basis. The high-risk factors of age over 50, diabetes,and atherosclerosis are emphasized. The need for early diagnosis and surgical treatment within 48hours is stressed, and any suspicious lesions or wound complications are reported to experiencedsenior house officers and staff. We use two recent cases to highlight the diagnostic clues andmanagement strategies for this often fatal polymicrobial infection.