Treatment of Necrotizing Fasciitis Caused by Staphylococcus epidermidis Harold R.
Mancusi-Ungaro, Jr,
MD
\s=b\ Postoperative necrotizing fasciitis with septicemia caused by Staphylococcus epidermidis was documented by cultures of the blood and wound biopsy specimen. Therapy consisted of surgical debridement, topical application of mafenide acetate dressings, and parenteral administration of cefazolin sodium. The combination effectively reversed the progression of infec-
methicillin sodium. The wound exúdate included S epidermidis with identical sensitivities. A rectus muscle biopsy yielded S epidermidis at greater than 10' organisms per gram of tissue, plus a swarming Proteus that progressively spread in vitro to thwart sensitivity testing of the S epidermidis.
COMMENT
tion and necrosis.
(Arch Surg 113:288, 1978)
infection with Staphylococcus epidermidis resulted in necrotizing fasciitis with septicemia. A successful method of treatment is demonstrated.
Wound
REPORT OF A CASE A previously healthy 19-year-old man sustained a head injury in automobile accident. On hospitalization, he received a course of dexamethasone and cephalothin sodium therapy. On the 15th hospital day, he underwent plication of a bleeding duodenal ulcer with vagotomy, hemigastrectomy, and Billroth II gastrojejunostomy, all approached through a midline incision. A feeding gastrostomy tube was brought out through a separate stab wound. On the fifth postoperative day, the abdominal wound exuded foul, purulent material. The wound was debrided and povidoneiodine dressings were prescribed. The next day, the patient's temperature spiked to 39.4 C, and intravenous cephalothin therapy an
was
reinstituted.
the eighth postoperative day, a necrotizing infection had consumed the anterior rectus sheath. Antibiotic therapy was changed empirically to oxacillin sodium and gentamicin sulfate. Over the next 24 hours, progressive necrosis exposed the posterior rectus sheath and dissected along it to encompass the gastrostomy. Dressings with mafenide acetate cream then replaced the povidone-iodine, in the expectation that the antibiotic could halt infection deep to the necrosis. When culture reports became available, systemic antibiotic therapy was changed to cefazolin sodium, 1.0 gm intravenously every six hours. Within 24 hours after applying mafenide, but less than 12 hours after changing to cefazolin, the extension of the necrosis ceased. The patient's condition continued to improve. Blood samples in four of four culture bottles yielded S epider¬ midis sensitive to cephalothin and gentamicin, but resistant to
By
Accepted
for publication June 15, 1977. From the Department of Surgery, Yale-New Haven Hospital, New Haven, Conn. Dr Mancusi-Ungaro is presently with the Henry Ford
Hospital, Detroit. Reprint requests to Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202 (Dr Mancusi-Ungaro).
The unique characteristic of this case lies in the firm documentation of S epidermidis as an etiologic agent in necrotizing fasciitis with septicemia. Although not the only organism isolated, S epidermidis can be termed a causative organism, because it was isolated by biopsy in a quantity greater than 107' bacteria per gram of tissue.1 Moreover, only S epidermidis grew in cultures taken from the blood. Because patterns of antibiotic sensitivity were identical, we made the assumption that the same organism contributed to both the wound infection and the septi¬ cemia. Resolution of the process followed the topical adminis¬ tration of mafenide. Though the role of cefazolin cannot be completely discounted, the intravenous route may not have been as effective as topical application of a chemothera¬ peutic agent. It was reasoned that the intrinsic necrotizing process destroyed the blood supply to the wound. Mafenide, in contrast, is absorbed and lowers bacterial counts within necrotic wounds.7 Topical mafenide dressings appeared to reverse the course of postoperative necrotizing fasciitis with septi¬ cemia caused in part by S epidermidis. Treatment also included surgical debridement and specific systemic anti¬ biotic therapy with cefazolin.
Supported 5733.
in part
by
Veterans Administration medical research grant
Nonproprietary Names and Trademarks of Drugs Cefazolin sodium—A ncefl
Kefzol. Cephalothin soaivaa—Keflin. Gentamicin sulfate—Garamycin. Methicillin sodium—Celbenin, Staphcillin. References MC, Krizek TJ, Heggers JP: Biology of surgical infection. Curr Probi Surg, March 1973, pp 1-62. 2. Mendelson JA, Lindsey D: Sulfamylon\s=r\(mafenide) and penicillin as expedient treatment of experimental massive open wounds with C perfringens infection. J Trauma 2:239-261, 1962. 1. Robson
Downloaded From: http://archsurg.jamanetwork.com/ by a Western University User on 06/09/2015
Mancusi-Ungaro, Jr,
MD
\s=b\ Postoperative necrotizing fasciitis with septicemia caused by Staphylococcus epidermidis was documented by cultures of the blood and wound biopsy specimen. Therapy consisted of surgical debridement, topical application of mafenide acetate dressings, and parenteral administration of cefazolin sodium. The combination effectively reversed the progression of infec-
methicillin sodium. The wound exúdate included S epidermidis with identical sensitivities. A rectus muscle biopsy yielded S epidermidis at greater than 10' organisms per gram of tissue, plus a swarming Proteus that progressively spread in vitro to thwart sensitivity testing of the S epidermidis.
COMMENT
tion and necrosis.
(Arch Surg 113:288, 1978)
infection with Staphylococcus epidermidis resulted in necrotizing fasciitis with septicemia. A successful method of treatment is demonstrated.
Wound
REPORT OF A CASE A previously healthy 19-year-old man sustained a head injury in automobile accident. On hospitalization, he received a course of dexamethasone and cephalothin sodium therapy. On the 15th hospital day, he underwent plication of a bleeding duodenal ulcer with vagotomy, hemigastrectomy, and Billroth II gastrojejunostomy, all approached through a midline incision. A feeding gastrostomy tube was brought out through a separate stab wound. On the fifth postoperative day, the abdominal wound exuded foul, purulent material. The wound was debrided and povidoneiodine dressings were prescribed. The next day, the patient's temperature spiked to 39.4 C, and intravenous cephalothin therapy an
was
reinstituted.
the eighth postoperative day, a necrotizing infection had consumed the anterior rectus sheath. Antibiotic therapy was changed empirically to oxacillin sodium and gentamicin sulfate. Over the next 24 hours, progressive necrosis exposed the posterior rectus sheath and dissected along it to encompass the gastrostomy. Dressings with mafenide acetate cream then replaced the povidone-iodine, in the expectation that the antibiotic could halt infection deep to the necrosis. When culture reports became available, systemic antibiotic therapy was changed to cefazolin sodium, 1.0 gm intravenously every six hours. Within 24 hours after applying mafenide, but less than 12 hours after changing to cefazolin, the extension of the necrosis ceased. The patient's condition continued to improve. Blood samples in four of four culture bottles yielded S epider¬ midis sensitive to cephalothin and gentamicin, but resistant to
By
Accepted
for publication June 15, 1977. From the Department of Surgery, Yale-New Haven Hospital, New Haven, Conn. Dr Mancusi-Ungaro is presently with the Henry Ford
Hospital, Detroit. Reprint requests to Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202 (Dr Mancusi-Ungaro).
The unique characteristic of this case lies in the firm documentation of S epidermidis as an etiologic agent in necrotizing fasciitis with septicemia. Although not the only organism isolated, S epidermidis can be termed a causative organism, because it was isolated by biopsy in a quantity greater than 107' bacteria per gram of tissue.1 Moreover, only S epidermidis grew in cultures taken from the blood. Because patterns of antibiotic sensitivity were identical, we made the assumption that the same organism contributed to both the wound infection and the septi¬ cemia. Resolution of the process followed the topical adminis¬ tration of mafenide. Though the role of cefazolin cannot be completely discounted, the intravenous route may not have been as effective as topical application of a chemothera¬ peutic agent. It was reasoned that the intrinsic necrotizing process destroyed the blood supply to the wound. Mafenide, in contrast, is absorbed and lowers bacterial counts within necrotic wounds.7 Topical mafenide dressings appeared to reverse the course of postoperative necrotizing fasciitis with septi¬ cemia caused in part by S epidermidis. Treatment also included surgical debridement and specific systemic anti¬ biotic therapy with cefazolin.
Supported 5733.
in part
by
Veterans Administration medical research grant
Nonproprietary Names and Trademarks of Drugs Cefazolin sodium—A ncefl
Kefzol. Cephalothin soaivaa—Keflin. Gentamicin sulfate—Garamycin. Methicillin sodium—Celbenin, Staphcillin. References MC, Krizek TJ, Heggers JP: Biology of surgical infection. Curr Probi Surg, March 1973, pp 1-62. 2. Mendelson JA, Lindsey D: Sulfamylon\s=r\(mafenide) and penicillin as expedient treatment of experimental massive open wounds with C perfringens infection. J Trauma 2:239-261, 1962. 1. Robson
Downloaded From: http://archsurg.jamanetwork.com/ by a Western University User on 06/09/2015
