Management of Necrotizing Fasciitis: Single centre experience. Retrospective analytical study
Authors: Soliman Mosaad , Soliman Reem , Mowafy Khalid , Khafagy Tamer , Elsaadany Nashaat , Elmetwally Ahmed 
Published: May 2020

Abstract
Background: Necrotizing fasciitis (NF) is a rare soft tissue infection, that is rapid and subtle. Inflammation and necrosis begin at the fascia, then spread to the subcutaneous fat and the muscles, with subsequent necrosis of the overlying skin. Predominantly affecting patients suffering from immune compromise, diabetes mellitus, or vascular insufficiency that prompt early diagnosis and urgent surgery.Methods: A retrospective analytical study conducted at diabetic foot surgery unit, vascular and endovascular surgery department, Mansoura university hospital, including all patients diagnosed with NF, from January 2019 to December 2019. All patient's records were analyzed to determine preexisting illnesses, admitting symptoms including the length of time to access medical care, physical admission findings, laboratory results, site of origin of the initial infection, extent and depth of spread, and microbiology of the wound cultures. The procedure of surgical management described as an aggressive debulking of infected tissue. All necrotic skin, subcutaneous tissue, fascia, and nonviable muscle were removed and sent for microbiologic and histologic examination. Viable dermis and soft tissue were saved to aid following the closure, even after undermining to remove all necrotic fascia.Study design: Retrospective analytic studyResults:A total of 850 patients with diabetic foot were admitted wherein NF diagnosed in 107 patients (12.6 %). All four types were recorded in different ratios; Type I (n=22, 20.6 %), Type II (n=48, 38.3 %), Type III (n=30, 28 %) and Type IV (n=14, 13.1 %). Age ranged between 9-85 years with mean 48.60 years; gender distribution was 55 female (51.4%) and 52 males (48.6%). Diabetes mellitus (49.5%) was the most common identifiable risk factor while immunosuppression, trauma and postoperative complications, fish-bone sting, drug abuse and malignancy represented 11.2 %, 10.3%, 9.3%, 8.4% and 4.7% respectively. In seven cases (6.5%), no apparent cause was discovered. 73 cases (68.2%) presented with late manifestations such as blisters, purple or blue skin patches (n= 30, 28%) crepitus ((n= 17, 15.9%), necrosis ((n= 20, 18.7 %) and multi-organ failure (n=6, 5.6 %). On the other hand; early manifestations in the form of pain out of proportion clinical signs, erythema and tenderness was reported in 31.8 % (n= 34). The anatomical sites of NF involved; extremities, trunk and perineum in 80 (74.8%), 15 (14%), and 12 patients (11.2%) respectively. The total leucocytic count was elevated in nearly all cases ranging from 14 to 40, and C-reactive protein (CRP) ranged from 38 to 300. Extensive surgical debridement was done in 87 (81.3 %) cases, amputations in 17 (15.9 %) cases of whom 14 cases were presented with late manifestations and disarticulations were done in 3 (2.8 %) cases. Mortality documented in 34.6 % (37 cases) and was intimately related to the time of intervention, where immediate intervention resulted to a lower mortality rate 13.1% (n=14) than the early intervention 21.5 % (n=23). Patients with late symptoms and signs had higher mortality (n=27, 25.2%) than cases with early presentation (n= 10, 9.4%) twenty-one patients (50 %) had undergone MRI imaging that was required and led to delay in the surgical exploration.Conclusion: Necrotizing fasciitis is no longer rare but a severe disease that might cause mortality, very early (within 4 hours) surgical management is recommended, especially in cases with late symptoms and signs. Female gender is a significant predictor of mortality. Surgical exposure should be prompt without delay for the results of Magnetic resonant imaging (MRI) once NF is suspected. Trial Registration: IRB Mansoura university committee approval number R.19.09.605.R1, retrospectively registered 21 September 2019.