Current Insights On The Multidisciplinary Treatment 
Of Necrotizing Fasciitis


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Author(s): 
David M. Davidson, DPM

In Conclusion

Necrotizing fasciitis requires a multidisciplinary approach to treatment. In this case, internal medicine, infectious disease, radiology and podiatric surgery staff provided rapid diagnosis and early surgical intervention. Improved technology, such as installation therapy together with NPWT, allowed this patient to recover and return to normal life.

   Dr. Davidson is in private practice with Podiatry Affiliates, PC, in New York State. He is a Diplomate of the American Board of Podiatric Surgery, a Diplomate of the American Board of Podiatric Medicine, and a Fellow of the American Academy of Podiatric Sports Medicine.

References

1. Roje Z, Roje Z, Matić D. Necrotizing fasciitis: literature of contemporary strategies for diagnosing and management with three case reports: torso, abdominal wall, upper and lower limbs. World J Emer Surg. 2011;6(1):46.

2. Davis K. Will simultaneous irrigation become a trend for NPWT? Today’s Wound Clinic. 2014;8(3):10-12.

3. Kim PJ, Attinger CE, Steinberg JS, et al. The impact of negative pressure wound therapy with installation compared to standard NPWT: a retrospective, historical, cohort, controlled study. Plast Reconstr Surg. 2014;133(3):709–716.

4. Kologlu MB, Yildiz RV, Alper B, Yagmurly A, Ciftci E, Gockora IH, Emiroglu M, Dindur H. Necrotizing fasciitis in children: Diagnostic and therapeutic aspects. J Pediat Surg. 2007;42(11):1892-1897.

5. Anaya A, Dellinger EP. Necrotizing soft tissue infections: diagnoses and management. Clin Infect Dis. 2007;44(5):705-710.

6. Varos D, Pissiotis C, Georgantas D, Katsaragakis S, Antoniou S, Papadimitriou J. Role of early and extensive surgery in the treatment of severe necrotizing soft tissue infection. Br J Surg. 1993;80(9):1190-11.

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John Crew, MDsays: July 15, 2014 at 3:40 pm

Dear Dr. Davidson,

Congratulations on this important study! It confirms our earlier results (Crew JR, Varilla A, Rocas III TA, Abdul Rani S, Debabov D. 2013. Treatment of acute necrotizing fasciitis using negative pressure wound therapy (NPWT) and adjunctive NeutroPhase® irrigation under the foam. Wounds. 25: 272-277). We feel that these results represent a new paradigm for therapy of necrotizing fasciitis (NF). The new important element is NPWT with HOCl irrigation after incisions are made and surgical suctioning of the necrotic toxic material is removed. Below are some specific comments.

Your comment: Necrotizing soft tissue infections are rare but potentially fatal. They are generally divided into three categories based upon anatomical involvement: crepitant cellulitis, necrotizing fasciitis and myonecrosis

My answer: It is important to realize that NF or flesh eating bacteria are just reflections of a disease process which should be labeled Toxic Inflammatory Cellulitis. The accurate description of pathogenesis is “Frozen in phase II of wound healing” or “cytokine storm”, even though bacteria and bacterial toxins start the process. Finally, I think the three phases you describe, cellulitis, NF and myonecrosis, are just that, phases of Toxic Inflammatory Cellulitis.

Your comment: Typically, these infections are polymicrobial.
My answer: Type I NF is classified as a polymicrobial infection whereas type II is classified as a monomicrobial infection. Historically, Group A Streptococcus (GAS) made up most cases of type II infections. However, since as early as 2001, another serious form of monomicrobial NF has been observed with increasing frequency (Lee TC,Carrick MM, Scott BG, Hodges JC, Pham HQ. Incidence and clinical characteristics of methicillin-resistant Staphylococcus aureus necrotizing fasciitis in a large urban hospital. Am J Surg. 2007;194(6):809-813.)

Your comment: Two days after surgery, I removed the packing and we started negative pressure wound therapy (NPWT) with instillation using Dakin’s solution. Instillation therapy delivers and removes topical solutions to an infected wound at controlled times and also provides standard negative pressure

My answer: As pure 0.01% hypochlorous acid in saline pH 4 (NeutroPhase®) has been shown to both rapidly kill bacteria and neutralize bacterial toxins in vitro, clinical administration of NeutroPhase® with NPWT was recently explored in a case of NF (Crew et al.,2013). This patient was dying with a totally sterile arm. This is how we discovered that NeutroPhase inactivates toxins. Dakin’s solution contains sodium hypochlorite along with hypochlorous acid (HOCl) which is the active species. Starting the instill VAC immediately rather than waiting for 2 days later would be probably more beneficial.

John Crew, MD, FACS
Medical Director of AWCW Seton Hospital Daly City Ca.
jcrewmd@att.net

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