The clinical patterns and early outcomes of Necrotizing Fasciitis in patients at Mulago Hospital

Abstract

Background Necrotizing fasciitis is a rare and yet potentially fatal infection affecting all age groups. The worldwide incidence is not known; some literature places it at 0.4 per 100,000 and is reported to be increasing probably with the increase in the population at risk10. Necrotizing fasciitis is an infectious process characterized by rapidly progressing necrosis of superficial fascia and subcutaneous tissue with subsequent necrosis of overlying skin affecting any part of the body. Morbidity and mortality is high when intervention is delayed. Mortality is up to 80% with no intervention, and 30-50% with intervention. Delay in intervention is associated with poor outcome. The risk factors for development of the disease have been identified and they include diabetes mellitus, HIV, malignancy, illicit drug use, malnutrition among others. These are on the rise with lifestyle changes and population growth in Uganda as elsewhere. No study so far has been done in Mulago Hospital.

Study objectives: The aim of this study was to describe the clinical patterns and early outcomes of NF amongst Ugandan patients.

Methods: This was a prospective descriptive case series study conducted at Mulago National Referral and Teaching hospital for four months from January 2011 to April 2011. Thirty-five patients any age with necrotizing fasciitis were consecutively recruited by the principal investigator after clinical evaluation, laboratory, microbiological tests.to confirm the diagnosis. Aggressive debridement was done and broad-spectrum antibiotics instituted. Patients were followed up on surgical wards until healthy granulation tissue had formed and assessed for the need for wound coverage. Death due to necrotizing fasciitis was also noted as death arising from complications of the disease. Data collected was analysed and a summary of these results was done using STATA and Epiinfo statistical programmes.

Results Males with necrotizing fasciitis were seen more than females in a ratio of 2.9:1. All age groups were affected but mainly young adults and middle aged. Duration to attainment of healthy granulation tissue was on average 19 days. Most patients with necrotizing fasciitis had a good outcome, 85.71% survived and 14.29% died. The commonest involved body parts were the limbs(57.14%) among adults, others being the scrotum and perineum(22.87%), trunk(11.4%), and head and neck 8.6%. Among infants the scalp was the most affected body part. Comorbidities were found in some patients like HIV(17.14%), DM(5.71%) among others. There were mostly gram negative organisms found(E.coli, Klebsiellla pneumonia, Proteus mirabilis) as the causative agents, gram positive organisms included Staphylococcus aureus, corynebacterium species, and a monomicrobial picture was found commonly. Resistance to some commonly available antibiotics was found in a few cases. The need for wound coverage was necessary in 74.29% patients.

Conclusion and recommendation Males were affected more than women in all age groups. The limbs were the most affected body part among adults, while the scalp was most affected among infants. The outcome was generally good. Hospital stay was long for most patients. There’s need for a bigger cohort study size over a longer period of time to draw conclusions from it that fully describe the disease process. Training of medical personnel to recognize the early signs of the disease will aid early diagnosis and intervention.