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Open Access Journal [doi: 10.54584/lms.2022.3] Research Article
and Medical Sciences
Assessment of Adult Patients with a Diagnosis of Necrotizing Fasciitis:
A Three-Year Experience
Nekrotizan Fasiit Tanısı Olan Yetişkin Hastaların Değerlendirilmesi:
Üç Yıllık Deneyim
Abdifatah AHMED1 [ ], Nor ABDI YASIN1 [ ], Sadettin ER1 [ ]
1Department of General Surgery, Mogadishu Somalia-Turkey Recep Tayyip Erdoğan Training and Research Hospital,
Mogadishu, Somalia.
Article Info: Received; 07.01.2020. Accepted; 02.02.2020. Published; 02.02.2020.
Correspondence: Sadettin Er; MD, Department of General Surgery, Mogadishu Somalia-Turkey Recep Tayyip Erdoğan
Training and Research Hospital, Mogadishu, Somalia. E-mail: ersadettin74@gmail.com
Cite as: Ahmed A, Abdi Yasin N, Er S. Assessment of Adult Patients with a Diagnosis of Necrotizing Fasciitis: A Three-Year
Experience. Life Med Sci 2022; 1(1): 20-23.
Abstract
The aim of this study is to evaluate experiences about diagnosis, follow-up, and treatment of
necrotizing fasciitis (NF) patients who admitted to our hospital. The records of patients who had a diagnosis
of NF that referred to our hospital between 01.01.2017 and 01.01.2020 were retrospectively analyzed.
Patients' demographic feature, additional disease, number of operations, length of hospital stays, and
responses for treatment was evaluated. All of 20 patients with NF were followed up and treated at our hospital.
We found 15 (75%) of the patients were male and 5 (25%) were female. The mean age of the patients was
53 (min: 28 - max: 80). While nine (45%) of patients had diabetes mellitus. Concerning the site of infection,
13 (65%) patients had abdominal wall - (NF of the anterior, lateral, and posterior regions), the four (20%)
patients of NF involved the chest wall- (NF of the anterior and posterior regions), three (15%) patients’ perianal
region with Fournier’s gangrene (secondary to NF). In 75%of patients received double antibiotic (ceftriaxone
+ metronidazole combination) therapy. Then, the majority of patients were exposed to lots of debridement
and diversion colostomy, ranging from 1 to 6 surgeries (mean being two operations). Negative pressure wound
closure was applied to 17 (85%) of the patients after debridement and three (15%) of the patients were
treated with open dressing. Skin grafting was tackled in our hospital for 13 of these patients while four (31%)
of the patients were treated with surgical flap methods. The length of hospital stay varies from 90 days to one
day. This time was 37 (1-90). Mortality in this study was found to be 30%- one patient dying on the day of
admission after the broad debridement. NF is a malady that is often related with mortality when it is not
treated. In many patients, are immunosuppressed and that's why diagnosis can be delayed. In patients with
early diagnosis, fast and broad debridement for treatment can achieve enough outcomes.
Keywords: Early diagnosis, Necrotizing fasciitis, Early treatment.
Özet
Hastanemize başvuran nekrotizan fasiit (NF)’li hastaların tanı, takip ve tedavisi ile ilgili deneyimlerimizi
değerlendirmekti. 01.01.2017 ve 01.01.2020 tarihleri arasında hastanemize başvuran NF tanısı alan hastaların
kayıtları retrospektif olarak incelendi. Hastaların demografik özellikleri, ek hastalıkları, ameliyat sayıları,
©Copyright . Licenced by Creative Commons Attribution-NonCommercial 4.0 International ( ).
Ahmed A, et al. Life Med Sci 2022; 1(1): 20-23.
21
hastanede kalış süreleri ve tedaviye yanıtları değerlendirildi. Toplam 20 NF hastası takip ve tedavi edildi.
Hastaların 15'i (%75) erkek, beşi (%25) kadın idi. Yaş ortalaması 53 (minimum: 28 - maksimum: 80) idi.
Hastaların 9'unda (%45) diabetes mellitus vardı. Enfeksiyon yeri ile ilgili olarak, 13 (%65) hastada karın duvarı
- (ön, lateral ve arka bölgelerin NF'si), dört (%20) NF hastasında göğüs duvarı- (ön ve arka bölgelerin NF'si)
vardı ), üç (%15) hasta perianal bölge ile birlikte Fournier gangreni (NF'ye sekonder Fournier gangreni)
mevcuttu. Hastaların %75'i ikili antibiyotik (seftriakson + metronidazol kombinasyonu) tedavisi aldı. Tanıdan
sonra çoğunlukla 1 ila 6 ameliyat arasında değişen ortalama debridmanlara ve diversiyon kolostomisi yapıldı.
Debridman sonrası 17 (%85) hastaya negatif basınçlı yara kapatma yöntemi uygulandı ve üç (%15) hastaya
açık pansuman uygulandı ve sekonder iyileşmeye bırakıldı. Bu hastaların 13'üne hastanemizde deri greftleme
uygulandı, dördüne (%31) cerrahi flep yöntemi uygulandığı görüldü. Yatış günlerinin sayısı 1 gün ila 90 gün
aralığında değişiyordu. Hastanede ortalama kalış süresi 37 (1-90) gün idi. Bu çalışmada mortalite %30 olarak
bulundu - bir hastada yoğun debridmandan sonra yatışının birinci gününde mortalite gelişti. NF, tedavi
edilmediğinde mortalite ile ilişkili bir hastalıktır. Birçok hastada, bağışıklık sistemi baskılanır ve bu nedenle tanı
gecikebilir. Erken tanı alan hastalarda, tedavi için hızlı ve geniş debridman yeterli sonuçlara ulaştırabilir.
Anahtar Kelimeler: Erken tanı, Nekrotizan fasiit, Erken tedavi.
Introduction
Necrotizing fasciitis (NF) is a rare malady that results in high morbidity and mortality unless treated
in its early term. [1]. But, early period, it is difficult to distinguish from another superficial skin situations
like cellulitis [2]. In the presence of symptoms such as pain, fever and erythema, doctors should have a
high level of suspicion for referral to surgery [3]. NF is a quickly advancing soft tissue infection mainly
involving the superficial fascia and subcutaneous tissue. It is leaded to Streptococcus pyogenes or
synergistic infection of aerobic and facultative anaerobic bacteria. NF has been divided into three types
based on microbiological cultures. Type-I is polymicrobial and generally caused by an aerobic and an
anaerobic organism. Type-II caused by Streptococci only or with staphylococci [4]. Marine vibrio is the
cause of Type-III [5].
Material and Methods
Study Design
Mogadishu, Somalia, Turkey, Recep Tayyip Erdogan Research and Training Hospital after obtaining
the approval of the Ethics Committee, records of the NFA patients were analyzed retrospectively between
01/01/2017 and 01/01/2020. Age, gender, co morbidity, total number of surgeries, length of hospital
stays, fever, place of infection, laboratory results, microbiological cultures and timing. Thereafter, the
number and response to treatment were recorded.
Statistical Analysis
Data “Statistical Package for the Social Sciences (SPSS) for Windows 21.0. Descriptive statistics
minimum for continuous variables and maximum, categorical variables frequency and percentage.
Operation characteristics and risk factors were compared. Statistical p <0.05 was considered significant.
Results
All of 20 patients with NF were followed up and treated at our hospital. We found 15 (75%) of the
patients were male and 5 (25%) were female. The mean age of the patients was 53 (Min: 28 - Max:
80). While nine (45%) of patients had diabetes mellitus. Concerning the site of infection, 13 (65%)
patients had abdominal wall - (NF of the anterior, lateral and posterior regions), the four (20%) patients
of NF involved the chest wall- (NF of the anterior and posterior regions), three (15%) patients’ perianal
region with Fournier’s gangrene (secondary to NF). Fever in 14 cases was observed on admission.
Leukocytosis was observed in 20 cases. The organisms isolated; Staphylococcus aureus 7 cases. Mixed
polymicrobial infection (coccobacillus) and Enterobacteriaceae like Klebsiella spp., Escherichia coli and
Pseudomonas aeruginosa were identified in 11 cases. No growth was seen in bacterial culture of two
Ahmed A, et al. Life Med Sci 2022; 1(1): 20-23.
22
patients. In 75%of patients received double antibiotic (ceftriaxone + metronidazole combination)
therapy. Later they were tailored as per culture and sensitivity reports. Then, the majority of patients
were exposed to lots of debridement and diversion colostomy, ranging from 1 to 6 surgeries (mean being
two operations). Negative pressure wound closure was applied to 17 (85%) of the patients after
debridement and 3 (15%) of the patients were treated with open dressing and secondary surgical closure
methods. Skin grafting was tackled in our hospital for 13 of these patients while four (31%) of the
patients were treated with surgical flap methods. The length of hospital stay varies from 90 days to one
day. This time was 37 (1-90). Mortality in this study was found to be 30%- one patient dying on the day
of admission after the broad debridement. The above-mentioned results are summarized in .
Table 1. Demographic and statistical data of patients with necrotizing fasciitis. Total patients (n=20)
Age
Mean (Min-Max): 53 (28-80)
Gender
Male 15 (75%), Female 5 (25%)
Chest wall (%)
4 (20%)
Co-morbidities
Diabetic 9 (45%)
Sign
Fever 14 (70%)
Culture (%)
S. aureus 7 (35%), polymicrobial 11 (55%), No growth 2 (10%)
Length of hospital stay
Mean; 37 day (1-90 day)
Discussion
This situation was defined in a number of reports in the end 1800s, and it was Dr. B. Wilson who
first called the situation NF in 1952 liver function problems eats contaminated seafood or a wound is
contaminated with sea water containing Vibrio vulnificus [6]. Mucormycosis is an uncommon reason for
NF reported in a caesarean wound in young female patients. Fungal periorbital NF reported in an
immunocompetent adult NF has been reported following laparoscopic appendicectomy, cholecystectomy
and following medical termination of pregnancy [7]. A rare case of NF of the thigh because of the extent
of sigmoid colon cancer was reported. In one study, thirty-three patients were examined in the three-
year period. Predisposing factors included intravenous drug misuse (30%), diabetes (21%), and obesity
(18%).
We present twenty cases of NF managed in our hospital in Somalia 3 years. 13 (65%) patients
had abdominal wall - (NF of the anterior, lateral and posterior regions), The 4 (20%) patients of NF
involved the chest wall- (NF of the anterior and posterior regions), 3 (15%) patients’ perianal region
with Fournier’s gangrene (Fournier gangrene secondary to necrotizing fasciitis). The atypical NF is
increasing worldwide and there is no recent data available in our country, we tried in this study to elude
the atypical NF and some of its risk factors among the adult patients attending to our hospital. The
atypical necrotizing fasciitis has risk factors; in this research we found that the most common risk factor
was diabetic. Our study we can conclude that males are more prone to develop.
NF is an uncommon but potentially mortal malady. It is a surgical emergency with a high morbidity
and mortality rate. This situation is more widespread in men, diabetes mellitus being the most
widespread comorbid malady. The NF more common in extremities. We report here typical cases of
necrotizing infections of the trunk, this type of NF is a rare but life-threatening infection with high a
mortality rate [8]. NF is many times severe, rapidly advancing, and related with sepsis and multi-organ
failure. Despite progress in care, mortality from NF remains high, approximately between 20% and 30%
[9]. Mortality rate, in present study was observed to be 30%- one patient dying on the day of acceptance
after the broad debridement. The limitation of this study was retrospective and limited number of
patients included in the study. As a result, in patients with NF, we think that early diagnosis and drainage
are crucial for reducing the spread of the disease.
Ahmed A, et al. Life Med Sci 2022; 1(1): 20-23.
23
Declaration of interest: The authors declare no conflict of interest and alone is responsible for the content
and writing of the paper.
Financial Disclosure: The authors declared that this study received no financial support.
This article previously published as: “Somalia Turkey Journal of Medical Science 2020; 1(1): 6-8.” Currently, Somalia Turkey
Journal of Medical Science was merged with Life and Medical Sciences.
References
1. Sarkut P, Işık Ö, Öztürk E, Gülcü B, Ercan İ, Yılmazlar T.
Gender does not affect the prognosis of Fournier's
gangrene: a case-matched study. Ulus Travma Acil Cerrahi
Derg 2016; 22(6): 541-4. [ ] [ ]
2. Sehmi S, Osaghae S. Type II diabetes mellitus: new
presentation manifesting as Fournier's gangrene. JRSM
Short Rep 2011; 2(6): 51. [ ] [ ]
3. Heijkoop B, Parker N, Spernat D. Fournier's gangrene:
not as lethal as previously thought? A case series. ANZ J
Surg 2019; 89(4): 350-2. [ ] [ ]
4. Erichsen Andersson A, Egerod I, Knudsen VE, Fagerdahl
AM. Signs, symptoms and diagnosis of necrotizing fasciitis
experienced by survivors and family: a qualitative Nordic
multi-center study. BMC Infect Dis 2018; 18(1): 429.
[ ] [ ]
5. Khalid M, Junejo S, Mir F. Invasive Community Acquired
Methicillin-Resistant Staphylococcal Aureus (CA-MRSA)
Infections in Children. J Coll Physicians Surg Pak 2018;
28(9): S174-7. [ ] [ ]
6. Fernando SM, Tran A, Cheng W, Rochwerg B,
Kyeremanteng K, Seely AJE, et al. Necrotizing Soft Tissue
Infection: Diagnostic Accuracy of Physical Examination,
Imaging, and LRINEC Score: A Systematic Review and
Meta-Analysis. Ann Surg 2019; 269(1): 58-65. [ ]
[ ]
7. Fais P, Viero A, Viel G, Giordano R, Raniero D,
Kusstatscher S, et al. Necrotizing fasciitis: case series and
review of the literature on clinical and medico-legal
diagnostic challenges. Int J Legal Med 2018; 132(5): 1357-
66. [ ] [ ]
8. Yaşar NF, Uylaş MU, Badak B, Bilge U, Öner S, İhtiyar E,
Çağa T, Paşaoğlu E. Can we predict mortality in patients
with necrotizing fasciitis using conventional scoring
systems? Ulus Travma Acil Cerrahi Derg 2017; 23(5): 383-
8. [ ] [ ]
9. Naseer U, Steinbakk M, Blystad H, Caugant DA.
Epidemiology of invasive group A streptococcal infections in
Norway 2010-2014: a retrospective cohort study. Eur J Clin
Microbiol Infect Dis 2016; 35(10): 1639-48. [ ]
[ ]
