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Necrotising Fasciitis 133

• prevention and control of malnutrition; Evidence-Based Research
Table 21.2 presents a study of treatment of necrotising fasciitis in children
• prevention of all childhood immunisable diseases, such as measles,
through national mass immunisation programmes; and in Africa during a four-year period. Table 21.3 presents a study of the
advantages of early recognition and prompt treatment of NF in children.
• education on early recognition and treatment of NF.
Table 21.3: Evidence-based research.
Table 21.2: Evidence-based research.
Title Necrotising fasciitis in children: prompt recognition and
Title Necrotising fasciitis: experience with 32 children aggressive therapy improve survival
Authors Legbo JN, Shehu BB Authors Moss LR, Musemeche CA, Kosloske AM
Institution Department of Surgery, Usmanu Danfodiyo University Institution University of New Mexico, School of Medicine, Albuquerque,
Teaching Hospital, Sokoto, Nigeria New Mexico, USA; Ohio State University School of
Medicine, Columbus, Ohio, USA
Reference Ann Trop Paediatr 2005; 25:183–189
Reference J Pediatr Surg 1996; 31:1142–1146
Problem Presentation and outcome of treatment of NF in children.
Problem Recognition and treatment of NF in children.
Intervention Wound debridement, direct wound suturing, skin grafting,
local flap reconstruction, antibiotics. Intervention Surgical debridement, below-knee amputation, colostomy,
primary wound closure, split skin grafting.
Comparison/ In the four-year period of this study, 32 of 56 patients (57.1%)
control treated with NF were children aged 6 days to 12 years Result A total of 20 children with NF were treated over a period of
(quality of (mean, 2 years). The common presenting features were 18 years. The disease was observed in a wide variety of
clinical settings covering the entire paediatric age range.
evidence) pain (84.4%), fever (78.1%), irritability (40.6%), and tissue
necrosis with undermining and surrounding cellulitis/oedema Characteristics suggestive of diagnosis included marked
(100%). Three patients (9.4%) presented with moderate tissue oedema, which was uniformly present, and almost
to severe jaundice, and 13 (40.6%) were malnourished all sites had a characteristic peau d’orange appearance.
according to clinical, anthropometric, and laboratory Bulla, petechiae, skin necrosis, and crepitus are strongly
measures. Precipitating factors included pustules/boils in suggestive of NF, but these were present in only a few cases.
12 (37.5%) patients, intravenous scalp cannulation in 3 Nineteen of the 20 patients were healthy before onset of
(9.4%), trauma in 2 (6.3%), and colostomy in 1 (3.2%). In 14 the illness. White blood cell counts were not sensitive or
patients (43.8%), no factors could be identified. Duration of specific in establishing diagnosis. Bacteriology was variable,
symptoms ranged from 3 to 19 days (mean, 6.4 days). The as both aerobic and anaerobic bacteria were isolated. An
involved body surface area ranged from 2% to 16% (mean, average of 3.8 surgical debridements were required for each
5.9%). The trunk was the most frequently involved (50%), patient (range, 1–15). The surgical findings were typical.
followed by the head/neck (28.1%), upper limbs (21.9%), The subcutaneous tissue was grey and nonbleeding, with a
lower limbs (6.3%), and perineum (6.3%). Bacteria identified watery discharge. The fascia ranged from viable to necrotic,
by aerobic culture included Staphylococcus aureus in 23 depending on the severity of infection. The skin was viable
(71.9%) patients, streptococci in 19 (59.4%), Escherichia coli early in the course of these cases. Skin necrosis was a
in 15 (46.9%), Pseudomonas aeruginosa in 12 (37.5%), and late sign, Failure to gain local control of the infection before
Klebsiella pneumoniae in 8 (25%). In 21 (65.6%) patients, systemic organ failure from sepsis proved uniformly fatal. All
infection was polymicrobial, and in 3 (9.4%), no organism patients who had positive blood cultures, renal failure, adult
was cultured. Anaerobic and fungal cultures were not respiratory distress syndrome, or disseminated intravascular
undertaken routinely. Routine HIV screening (enzyme-linked coagulation died.
immunosorbent assay, or ELISA) of all patients was negative.
Outcome/ Mortality was 25%. The 15 survivors all underwent
Outcome/ Septicaemia was the commonest complication, occurring in effect aggressive surgical debridement within 3 hours of
effect 71.9%, and mortality was 9.4%. Hospital stay was long, at a admission, whereas the 5 who died all had inadequate initial
mean of 27.6 days (range, 14–96 days). management.
Historical This is one of the occasional reports of NF in children in Historical This report has shown that early recognition and prompt
significance/ Africa including a large number of patients. The exclusion of significance/ institution of treatment gives good survival in this rapidly
comments children with cancrum oris and Fournier’s gangrene means comments progressive disease. It also emphasizes the differences
that the number could have been even higher. The study has between NF in children as compared to adults.
shown that although NF is thought to be rare in children, it
is more common than expected in the sub-Saharan African
setting and carries a high morbidity and mortality. This report
provides a good insight into the clinical profile of this condition
in the African setting.

Key Summary Points

1. NF is generally not common but does appear more common in 4. Success in treatment depends on prompt resuscitation,
children in sub-Saharan Africa than previously thought. adequate surgical debridement(s), and adequate supportive
therapy.
2. NF is frequently polymicrobial.
5. NF is associated with high morbidity (complications, multiple
3. Presentation varies widely from simple cellulitis to toxic shock.
surgeries, prolonged hospital stay) and high mortality.

References
1. Wilson B. Necrotizing fasciitis. Am Surg 1952; 18:416. 3. Archampong EQ. Microbial infections in surgery. In: Badoe EA,
Archampong EQ, da Rocha-Afodu JT, eds. Principles and Practice
2. Howard R J, Pesa M E, Brennaman B H, Ramphal R. Necrotizing
soft tissue infections caused by marine vibrios. Surgery 1985; of Surgery Including Pathology in the Tropics. Assemblies of God
98:126. Literature Centre, 2000, Pp 11–40.