Necrotizing fasciitis is an uncommon, rapidly progressive soft tissue infection that represents a true surgical emergency. It has a low incidence of around 0.4 per 100,000 cases; however, when it occurs, the outcome can be devastating.1 Clinically, there are 4 types of necrotizing fasciitis, with the first 2 types being the most commonly encountered. Type I is a polymicrobial infection; it is often a mix of aerobic and anaerobic bacteria, especially species such as Staphylococcus aureus, Streptococci pyogenes, Escherichia coli, Bacteroides, and Clostridium. Type II is a monomicrobial infection; most of the cases in this type are caused by Streptococcus pyogenes, or group A Streptococcus.2 The third type is a rare marine infection caused by gram-negative organisms such as Vibrio vulnificus.3,4 Type IV necrotizing fasciitis is a fungal infection type, most often seen in trauma and burn patients.5 A rising culprit in monomicrobial necrotizing fasciitis—as well as in cases of polymicrobial necrotizing fasciitis—is methicillin-resistant Staphylococcus aureus.3,6–8 By region, monomicrobial necrotizing fasciitis is more common in the extremities as opposed to the polymicrobial, which tends to be the characteristic of necrotizing fasciitis in the perineum and abdomen.4 By location, the most common areas for necrotizing fasciitis to occur are the abdominal wall, lower extremities, and perineum.9
Necrotizing fasciitis mortality rates range from 6% to more than 70%, depending on infection type, extent, and other patient features such as comorbidities.10–13 Patients are managed with prompt, radical surgical debridement as well as critical care support. They often require multiple surgical interventions throughout the duration of their hospitalization in addition to surgical reconstruction with skin grafting or flap coverage. The cost of treatment for patients with necrotizing fasciitis is substantial; an individual incurs direct hospital in-patient charges that average from $50,000 to $150,000 USD or more per case, accruing additional costs related to postdischarge reconstructive procedures.14–18 The debridement and reconstruction are often provided by different surgical teams, although occasionally a single specialty performs both the primary management and the reconstruction.
One relatively recent study reported statistics from a single burn unit that oversees management and reconstruction of patients with necrotizing fasciitis. The investigators found that they were able to provide definitive cure and reconstruction in a cost-effective manner in their population of patients, most of whom had undergone primary debridement at an outside facility. From the results of their study, the authors advocated for regionalization, or specialization, of the treatment of necrotizing fasciitis as a means to control cost and improve outcomes.16
We present 3 index cases of upper extremity necrotizing fasciitis for which our service functioned in both roles: the initial debridement and the subsequent reconstruction. Additionally, we present a retrospective analysis of all patients with necrotizing fasciitis not initially admitted to our service but eventually treated during reconstruction by surgeons affiliated with the Loma Linda University (LLU) Department of Plastic Surgery during an 8-year period from 2004 to 2012. In the analysis, we compare the upper extremity necrotizing fasciitis cases managed by plastic surgery alone in a case-matched series to those managed by a multidisciplinary team.
Fifty-four necrotizing fasciitis cases evaluated and treated by our department, covering both LLU Medical Center (a Level I Trauma Center) and Riverside County Regional Medical Center (a Level II Trauma Center), were reviewed for total charges, length of hospital stay, length of intensive care unit (ICU) stay, and number of procedures. In addition, the Acute Physiology and Chronic Health Evaluation (APACHE) II score on admission was calculated for each patient. The data gathered were analyzed for overall values and 3 index cases of upper extremity necrotizing fasciitis managed primarily by the plastic surgery team are presented in greater detail then used in a case-matched series to compare multidisciplinary management versus management by plastic surgery alone of upper extremity necrotizing fasciitis.
Our first case was a 33-year-old man admitted to LLU Medical Center initially with a history of acute pancreatitis. He was discharged home with a midline catheter to his right arm that became infected, leading to a readmission with necrotizing phlebitis, necrotizing fasciitis, and compartment syndrome of the right arm. On admission to plastic surgery, his APACHE II score was 3. He underwent 4 procedures during his admission. The initial 2 involved debridement and fasciotomies. The third procedure involved primary closure of a portion of the wound with placement of Integra. The final procedure was the last of his staged reconstructions and the patient underwent placement of a 25 × 7-cm split-thickness skin graft to the remaining areas of open wound. The patient was discharged after a total length of stay of 37 days.
The second case was a 70-year-old man with end-stage renal disease admitted for necrotizing fasciitis of the right hand with an admission APACHE II score of 21. He initially underwent hand fasciotomies and debridement of the dorsum of the right hand and forearm as well as volar debridement of the right ring and middle fingers. He then underwent a subsequent right upper arm fasciotomy with more debridement. After resolution of the fasciitis, the patient underwent closure of the fasciotomy sites and approximation of the incisions of the middle and ring figure. All lesions were closed with local tissue or allowed to heal secondarily. The patient had a total length of stay of 17 days. Due to the preservation of uninfected tissue that could be used for reconstruction, he did not require skin grafting and, after discharge, did not return with any complications related to his necrotizing fasciitis. At follow-up appointments, the patient demonstrated excellent range of motion in elbow, wrist, and hand despite the extensive debridement and multiple fasciotomies. His only concern after reconstruction was some intrinsic tightness over the dorsum of the hand secondary to the fasciotomies, but he did not desire surgical intervention to treat this.
Our third index case was a 50-year-old man who presented with necrotizing fasciitis of the left arm and chest and severe sepsis. He was admitted with an APACHE II score of 15. He underwent multiple procedures beginning with a fasciotomy of the left upper arm anterior and posterior compartments, forearm deep and superficial flexor compartments, and extensive fasciotomy of the triceps, biceps as well as debridement of the entire area including the left chest. The next day he underwent a fasciotomy of the left chest, flank, and abdomen with wound VAC placement. During his hospitalization, he underwent 3 more procedures for irrigation, debridement, and preparation for skin grafting. In addition to the procedures, during the initial phase of his stay, he required ICU admission on pressors and in acute renal failure. After an extensive debridement, fasciotomies, and supportive care, his sepsis and acute renal failure resolved and the patient was able to be weaned from pressors. After discharge, he underwent 1 additional procedure for closure and skin grafting as well as 1 scar contracture revision. For the extent and severity of his necrotizing fasciitis, his clinical outcome was exceptional when compared with his intraoperative condition (Fig. 1).
Patients managed primarily by the plastic surgery team demonstrated slightly higher than average APACHE II scores as compared to patients managed by multiple services for their necrotizing fasciitis. The average APACHE II score for patients managed by plastic surgery was 12, whereas the patient managed by a multidisciplinary approach had an average APACHE II score of 9. In a case-matched series of upper extremity patients with necrotizing fasciitis managed by multidisciplinary teams, the patients admitted directly to plastic surgery had shorter average lengths of stay, shorter lengths of ICU stays, and decreased total number of procedures (Table 1), resulting in decreased average total hospital charges. In addition, there were no amputations among the cases treated primarily by the plastic surgery service. The patients managed primarily by plastics also required smaller areas of reconstruction with skin grafting—despite large initial areas of debridement—when compared to those whose reconstructive teams differed from the team performing the debridement. The 3 cases presented also demonstrated these trends, particularly in the third case as equivalent cases managed by multiple teams often underwent amputations and/or suffered severe morbidity with decreased function even after extensive reconstruction (Table 2).
With the high possible morbidity and mortality rates, rapid and aggressive treatment is necessary in the management of patient with necrotizing fasciitis.4,19 Surgical debridement is absolutely required and should be combined with other treatment modalities such as IV antibiotics and supportive care. The initial debridement is usually extensive, ranging from minimal areas and fasciotomies to limb amputation, depending on extend of the infection spread, with repeat debridement often necessitated.4,13,19 Supportive care must also include pain management, nutritional support, and close monitoring for sepsis or progression to multisystem organ failure.4 In addition, hyperbaric oxygen treatments may be useful to improve the course for patients with necrotizing fasciitis.4,20
Clearly, the potential for high morbidity and mortality from necrotizing fasciitis warrants prompt and aggressive debridement. However, surgeons must find an appropriate balance between the necessary aggressive measures and over debridement resulting in increased morbidity. The differences noted in upper extremity necrotizing fasciitis between the single-specialty management and the multidisciplinary management outcomes can likely be contributed to the preservation of salvageable tissue overlying the infected fascia in the case treated by a single specialty. In true necrotizing fasciitis, the fascial layer is affected most severely with minimal surrounding tissue involvement. Because of this, the tissue above and below the fascia can potentially be spared during debridement. Sparing of this tissue leads to drastically improved outcomes as it can be used for reconstruction after the resolution of the infection. In addition, planning for reconstruction can begin much sooner in the hospitalization course with early involvement of the reconstructive team.
Along with benefiting the patient through improved outcomes, there is a clear economic incentive to minimize hospital and ICU length of stay, as well as to shorten the reconstructive period with a reduced number of procedures. A single day of hospitalization at the institutions included in this study costs more than $1500, with a single surgical ICU day costing more than $3000. These costs do not include additional procedures, tests, or medications required during the hospitalization. For comparison, the average difference in stay between the patients managed by plastic surgery versus by multidisciplinary teams was 10.5 days for the ICU and 13.9 days for the regular floor hospitalization, translating to more than $31,500 and $20,850 in cost before factoring in the additional cost of the higher number of reconstructive procedures in the multidisciplinary-managed patient population.
Necrotizing fasciitis has a profound impact on the lives of the patients it affects. Improved economic and clinical outcomes—as indicated by the reduced lengths of overall and ICU stay, the reduced number of procedures, none of the cases requiring amputation, and the reduced need for skin grafting—may be attainable when the surgeon eventually performing the reconstruction also provides the initial debridement of necrotizing fasciitis or, at the very least, is involved in the care and management planning process. We propose that, in the interest of improved patient and economic outcomes, a closer collaboration between the reconstructive team and primary managing service be established.
Most plastic surgery teams will not be the primary managing team for patients with necrotizing fasciitis. In fact, a recent large retrospective review suggested that management by burn and trauma surgeons—areas in which some, but not all plastic surgeons are specially trained—is likely to decrease the morbidity of patients with necrotizing fasciitis.12 However, earlier consultation to our specialty as well as improved collaboration between plastic surgery and the managing teams could result in some of the gains demonstrated in this case series and help all parties involved to flourish in this era of accountable care.
We advocate for improved communication between teams providing patient care to patients with necrotizing fasciitis, particularly between the teams initially managing the patients and the reconstructive team if they are not one and the same. In addition, we advocate defining—as early in the course as possible—whether the patient has true necrotizing fasciitis or if the infection extends into surrounding tissue as well. If the case is true necrotizing fasciitis, the authors suggest sparing overlying tissue in a method that will improve reconstruction and decrease patient morbidity.
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Keywords:© 2014 by Lippincott Williams & Wilkins
necrotizing fasciitis; upper extremity; management; economics; cost analysis; patient safety; collaboration; wound reconstruction; case series