Abstract and Case Report

Abstract

Necrotizing fasciitis is a rare but potentially lethal bacterial infection of the fascial and subcutaneous tissues. Mortality rates of this condition remain high, ranging from 6%-76%.[1] Bacterial cultures may show a wide variety of organisms,[2] but Group A Streptococcus (Streptococcus pyogenes) is the causative agent in up to 71% of all human cases.[3,4] The treatment consists of urgent radical surgical debridement in combination with broad-spectrum antibiotic therapy.[5] Maggot debridement therapy (MDT) has been proven to be very effective in the treatment of gram-positive bacterial infections.[6,7,8,9] The present study reports on the results of 15 patients with necrotizing fasciitis treated with surgical debridement and antibiotic therapy in combination with MDT from November 2001 to November 2005. A detailed case report of 1 patient is presented.

Case Report

A 46-year-old man with no relevant medical history besides an appendectomy and a perianal fistula more than 20 years before current presentation was referred to the authors' hospital with a Fournier's gangrene after he was first examined in the emergency department of the referring hospital. The patient had a history of smoking and consumed about 36-56 g of alcohol daily (3-4 units). The patient presented with a red and tender right scrotum, which in retrospect, had been present for 7 days. His general practitioner had treated him with oral CiprofloxacinAE over the preceding 4 days for a presumed infected sebaceous gland in the right groin. The patient was taken to the operating room after administration of broad-spectrum antibiotic therapy with netilmycin amoxicillin, and metronidazole. An extensive area of fasciitis was found predominantly on the right side of the abdomen, scrotum, and perineum. A large part of the abdominal skin (including abdominal fascia) and scrotum were excised (Figure 1). Initial gram-staining showed a mixed culture. Definitive cultures showed bacteroides, diphtheroids, and Enterococcus faecalis. Six surgical debridements were performed over the following 10 days.

(Enlarge Image) Figure 1. After debridement and fasciectomy of the abdominal fascia, perineum, and scrotal fascia.

It was decided to perform MDT because sepsis persisted and the wound did not show any signs of healing. An average of 20-30 sterile Lucilia sericata maggots were placed in each biobag (VitapadAE, Polymedics Bioproducts, B.V.B.A. Peer, Belgium) on the wound (Figure 2). The patient was treated with the maggots for 19 days. A total of 1,200 maggots were applied. The wound was well granulated after the maggot treatment (32 days after initial presentation to the authors' hospital). The wound was partially closed secondarily and a mesh graft was used to close the rest of the wound. Postoperative course was uncomplicated following this last operation. The patient was discharged from the hospital, returned to work, and has remained in good condition for more than 3 years after the last operation (Figure 3).

(Enlarge Image) Figure 2. The biobags (Vitapads®) are placed on the wound. The wound edges are secured with an adhesive tape in order to prevent maggot escape.