practice
Neonatal necrotising fasciitis managed conservatively: An experience from a tertiary centre Objective: Conventional therapy for neonatal necrotising fasciitis (NF) involves resuscitation and aggressive surgical debridement of necrotic tissue. This approach adds surgical stress in septicaemic neonates with low reserves. The present study reports a more conservative approach to the management of neonatal NF. l Method: A prospective study was conducted between July 2010 and June 2013 and included 11 cases of neonatal NF. Demographic characteristics of patients were noted. No debridement was performed. Dressings were applied after cleaning with normal saline every 24 hours. The necrotic slough was allowed to separate spontaneously. A record was made of type and duration of supportive modalities and complications. The primary outcome was recorded as final recovery, need of surgical intervention or need of grafting. l Results: Out of 11 neonates, 6 were males and 5 were females. Age ranged from 13 to 24 days (mean age 18.45±3.24 days), and weight varied from 1.8 to 2.6 kg (mean weight 2.12±0.24kg) at presentation. Duration of illness before admission to hospital ranged from 3 to 9 days (mean 4.84±2.13 days). The most common site of the initial involvement was the neck and upper thoracic region (n=4), scalp (n=3), lower back (n=2), face (n=1) and extremities (n=1). In all cases, the wound was cleaned with normal saline, dressed, necrotic slough was allowed to separate spontaneously and granulation tissue was allowed to develop; this took approximately 14 to 28 days (mean 20.45±5.78 days). l Conclusion: As opposed to the conventional approach of aggressive debridement in neonatal NF, these cases can be managed conservatively without increase in morbidity or mortality. This approach also minimises the surgical risk and requirement of blood transfusion. Antifungal drugs have a definitive role in management of these immunologically deficient babies. l Declaration of interest: There were no external sources of funding for this study. The authors have no conflicts of interests to declare. l
N
ecrotising fasciitis (NF) is rare in neonates, and is associated with high morbidity and mortality.1 In neonates, most cases of NF are attributable to secondary infections.2,3 There is lack of literature regarding the exact pathogenesis and management guidelines of neonatal NF, owing to the rarity of the condition. Conventionally, NF is managed by resuscitation and aggressive surgical debridement of necrotic tissue; this approach adds surgical stress in a state of physiological compromise.1 The neonatal period is a phase of physiological transition, where the stress of surgical debridement can add insult to injury. The present study reports a more conservative approach to the management of neonatal NF, which gave good results with minimal morbidity or mortality.
Method A prospective study was conducted between July 2010 and June 2013 after approval from an institutional ethical committee. A total of 11 cases of neonatal NF were included in the study. The diagnosis
270
of NF was made by clinical and microbiological testing, and demographic characteristics of patients were noted. A record was made of the site of involvement, extent and depth of spread, culture and sensitivity from the wound. Pre-existing conditions, initiating factors, length of time to access medical care, symptoms and physical findings were also recorded. An initial investigation was performed to evaluate complete blood count, random blood sugar, serum electrolytes, urea, creatinine and C-reactive protein levels. After resuscitation, patients received Amoxicillin-clavulunate (100mg/kg/day in three divided doses), Amikacin (15mg/kg/per dose, single dose per day) and metronidazole (7.5mg/kg/dose, three doses per day). Antibiotics were later changed according to culture and sensitivity. Oral paracetamol (10mg/kg/dose 6 hourly) was used as an analgesic and antipyretic. Fluconazole (6mg/kg/day) was added in neonates with evidence of fungal infection on culture or persistent fever even after seven days of antimicrobials. Granulocyte-macrophage colony stimulating factor (GM-CSF) was given (10µg/kg subcutaneous for 3 days) to two neonates present-
© 2014 MA Healthcare
V. Pandey, MBBS, MS, MCh, Senior Resident; A.N. Gangopadhyay,1 MBBS, MS, MCh, Professor; D.K. Gupta,1 MBBS, MS, MCh, Professor; S.P. Sharma,1 MBBS, MS, MCh, Professor; V. Kumar,1 MBBS, MS, MCh, Associate Professor; P.Tiwari,2 BDS, MDS, Oral and Maxillofacial Surgeon; 1 Department of Paediatric Surgery, Institute of Medical Sciences, Banaras Hindu University,Varanasi, India; 2 Samayan Hospital, Varanasi, India. Email: drtiwaripraeeti@ gmail.com
ltd
necrotising fasciitis; neonates; debridement; antifungal therapy 1
J O U R N A L O F WO U N D C A R E V O L 2 3 , N O 5 , M AY 2 0 1 4
ournal of Wound Care. Downloaded from magonlinelibrary.com by 130.179.016.201 on September 3, 2015. For personal use only. No other uses without permission. . All rights reserved
practice ing with leucopoenia. No debridement was performed. The wound was dressed after cleaning with normal saline every 24 hours. The necrotic slough was allowed to separate spontaneously. The sloughed tissue was sent for culture. Dressing was continued at increasing intervals until the wound began to contract. A record was made of type and duration of supportive modalities such as blood product transfusion and mechanical ventilation and complications.
Results Out of 11 neonates, 6 were males and 5 were females. Their age ranged from 13 to 24 days (mean age 18.45±3.24 days), and weight varied from 1.8 to 2.6 kg (mean weight 2.12±0.24 kg) at presentation. Duration of illness before admission to hospital ranged from 3 to 9 days (mean 4.84±2.13 days). The most common site of the initial involvement was the neck and upper thoracic region (n=4), scalp (n=3), lower back (n=2), face (n=1) and extremities (n=1). Nine babies had no obvious precipitating factors, and a lesion was preceded by local discolouration of skin. Two patients developed NF following admission in intensive care units for neonatal septicaemia. One patient developed pressure sores in the occipital region initially. Another patient developed slough of the scalp following extravasations of fluid from an intravenous line in the scalp. Both these neonates required mechanical ventilation and later died due to severe sepsis. Clinical and laboratory features of the patients are illustrated in Table 1. Fever, irritability and eschar were uniformly present at time of admission. In all the patients, C-reactive protein levels were elevated on average by 12mg/dl. Eight cases had marked leucocytosis (mean 20600/µl) with predom-
Table 1. Clinical and laboratory parameters of neonates with NF at presentation Parameter
No. of patients
Site of involvement Neck and upper thoracic region Scalp Lower back Face Extremity
4 3 2 1 1
Fever (>38°C) and irritability Eschar
11 11
White blood count Leucocytosis (>1800/ml) Leucopenia (
Neonatal necrotising fasciitis managed conservatively: An experience from a tertiary centre Objective: Conventional therapy for neonatal necrotising fasciitis (NF) involves resuscitation and aggressive surgical debridement of necrotic tissue. This approach adds surgical stress in septicaemic neonates with low reserves. The present study reports a more conservative approach to the management of neonatal NF. l Method: A prospective study was conducted between July 2010 and June 2013 and included 11 cases of neonatal NF. Demographic characteristics of patients were noted. No debridement was performed. Dressings were applied after cleaning with normal saline every 24 hours. The necrotic slough was allowed to separate spontaneously. A record was made of type and duration of supportive modalities and complications. The primary outcome was recorded as final recovery, need of surgical intervention or need of grafting. l Results: Out of 11 neonates, 6 were males and 5 were females. Age ranged from 13 to 24 days (mean age 18.45±3.24 days), and weight varied from 1.8 to 2.6 kg (mean weight 2.12±0.24kg) at presentation. Duration of illness before admission to hospital ranged from 3 to 9 days (mean 4.84±2.13 days). The most common site of the initial involvement was the neck and upper thoracic region (n=4), scalp (n=3), lower back (n=2), face (n=1) and extremities (n=1). In all cases, the wound was cleaned with normal saline, dressed, necrotic slough was allowed to separate spontaneously and granulation tissue was allowed to develop; this took approximately 14 to 28 days (mean 20.45±5.78 days). l Conclusion: As opposed to the conventional approach of aggressive debridement in neonatal NF, these cases can be managed conservatively without increase in morbidity or mortality. This approach also minimises the surgical risk and requirement of blood transfusion. Antifungal drugs have a definitive role in management of these immunologically deficient babies. l Declaration of interest: There were no external sources of funding for this study. The authors have no conflicts of interests to declare. l
N
ecrotising fasciitis (NF) is rare in neonates, and is associated with high morbidity and mortality.1 In neonates, most cases of NF are attributable to secondary infections.2,3 There is lack of literature regarding the exact pathogenesis and management guidelines of neonatal NF, owing to the rarity of the condition. Conventionally, NF is managed by resuscitation and aggressive surgical debridement of necrotic tissue; this approach adds surgical stress in a state of physiological compromise.1 The neonatal period is a phase of physiological transition, where the stress of surgical debridement can add insult to injury. The present study reports a more conservative approach to the management of neonatal NF, which gave good results with minimal morbidity or mortality.
Method A prospective study was conducted between July 2010 and June 2013 after approval from an institutional ethical committee. A total of 11 cases of neonatal NF were included in the study. The diagnosis
270
of NF was made by clinical and microbiological testing, and demographic characteristics of patients were noted. A record was made of the site of involvement, extent and depth of spread, culture and sensitivity from the wound. Pre-existing conditions, initiating factors, length of time to access medical care, symptoms and physical findings were also recorded. An initial investigation was performed to evaluate complete blood count, random blood sugar, serum electrolytes, urea, creatinine and C-reactive protein levels. After resuscitation, patients received Amoxicillin-clavulunate (100mg/kg/day in three divided doses), Amikacin (15mg/kg/per dose, single dose per day) and metronidazole (7.5mg/kg/dose, three doses per day). Antibiotics were later changed according to culture and sensitivity. Oral paracetamol (10mg/kg/dose 6 hourly) was used as an analgesic and antipyretic. Fluconazole (6mg/kg/day) was added in neonates with evidence of fungal infection on culture or persistent fever even after seven days of antimicrobials. Granulocyte-macrophage colony stimulating factor (GM-CSF) was given (10µg/kg subcutaneous for 3 days) to two neonates present-
© 2014 MA Healthcare
V. Pandey, MBBS, MS, MCh, Senior Resident; A.N. Gangopadhyay,1 MBBS, MS, MCh, Professor; D.K. Gupta,1 MBBS, MS, MCh, Professor; S.P. Sharma,1 MBBS, MS, MCh, Professor; V. Kumar,1 MBBS, MS, MCh, Associate Professor; P.Tiwari,2 BDS, MDS, Oral and Maxillofacial Surgeon; 1 Department of Paediatric Surgery, Institute of Medical Sciences, Banaras Hindu University,Varanasi, India; 2 Samayan Hospital, Varanasi, India. Email: drtiwaripraeeti@ gmail.com
ltd
necrotising fasciitis; neonates; debridement; antifungal therapy 1
J O U R N A L O F WO U N D C A R E V O L 2 3 , N O 5 , M AY 2 0 1 4
ournal of Wound Care. Downloaded from magonlinelibrary.com by 130.179.016.201 on September 3, 2015. For personal use only. No other uses without permission. . All rights reserved
practice ing with leucopoenia. No debridement was performed. The wound was dressed after cleaning with normal saline every 24 hours. The necrotic slough was allowed to separate spontaneously. The sloughed tissue was sent for culture. Dressing was continued at increasing intervals until the wound began to contract. A record was made of type and duration of supportive modalities such as blood product transfusion and mechanical ventilation and complications.
Results Out of 11 neonates, 6 were males and 5 were females. Their age ranged from 13 to 24 days (mean age 18.45±3.24 days), and weight varied from 1.8 to 2.6 kg (mean weight 2.12±0.24 kg) at presentation. Duration of illness before admission to hospital ranged from 3 to 9 days (mean 4.84±2.13 days). The most common site of the initial involvement was the neck and upper thoracic region (n=4), scalp (n=3), lower back (n=2), face (n=1) and extremities (n=1). Nine babies had no obvious precipitating factors, and a lesion was preceded by local discolouration of skin. Two patients developed NF following admission in intensive care units for neonatal septicaemia. One patient developed pressure sores in the occipital region initially. Another patient developed slough of the scalp following extravasations of fluid from an intravenous line in the scalp. Both these neonates required mechanical ventilation and later died due to severe sepsis. Clinical and laboratory features of the patients are illustrated in Table 1. Fever, irritability and eschar were uniformly present at time of admission. In all the patients, C-reactive protein levels were elevated on average by 12mg/dl. Eight cases had marked leucocytosis (mean 20600/µl) with predom-
Table 1. Clinical and laboratory parameters of neonates with NF at presentation Parameter
No. of patients
Site of involvement Neck and upper thoracic region Scalp Lower back Face Extremity
4 3 2 1 1
Fever (>38°C) and irritability Eschar
11 11
White blood count Leucocytosis (>1800/ml) Leucopenia (
