JOURNAL OF INTERNATIONAL ACADEMIC RESEARCH FOR MULTIDISCIPLINARY Impact Factor 2.417, ISSN: , Volume 3, Issue 10, November 2015

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1 STAPHYLOCOCCUS AUREUS NECROTIZING FASCIITIS AND ITS OUTCOME IN IMMUNOCOMPETENT SUBJECTS BESMIRA ZAMA** TRITAN KALO* STELA MUCA* *Service of Infectious Disease, UHC, MT, FSHMT ** Prime Clinic Health No.10, Tiranë, FSHMT ABSTRACT Staphylococcus Aureus Necrotizing Fasciitis and its outcome in immune competent subjects. Background: Necrotizing fasciitis (NF) it is not an often bacterial infection of the superficial fascia and subcutaneous cellular tissue, which has a very rapid progression and potentially fatal outcome, most of the time accompanied by systemic signs of toxicity. Usually, a combination of aerobic (streptococci and staphylococci) and anaerobic bacteria is the leading cause of NF, which often lead in a very severe progression of the disease. Methods: This is an open study of NF, in order to evaluate the involvement of Staphylococcus aureus as a monobacterial cause of NF, and outcome of disease in 7 immunocompetent subjects treated among 15 cases of NF treated in the Service Infectious Diseases, UHC Mother Theresa, Tirana, Albania during the period of time between April 2010 and December In all seven patients we performed an ultrasound-examination and in three of them the MRI, as well. Several bacterial cultures from the tissues involved, blood and urines as well as samples of nasopharynx and pulmonary secretion were performed in order to clarify the causal agent of NF. Results: NF was localized in upper extremities (4 cases) and in lower extremities (3 cases). The microorganism insolated was Staphylococcus aureus. Severe sepsis was observed in 5 patients (71.42% of cases), which evaluated towards septic shock in 4 of them (57.14 % of cases). The Multiple Organ Failure (MOF) was present since the first twenty-four hours in two of them, which leads to death at the third and fourth day of their hospitalization, despites of the treatment at the Intensive Care Unit of our Service (Mortality rate = 28.57%). In Conclusion: Necrotizing fasciitis even in immunocompetent subjects leads inevitably sometimes towards a severe sepsis and very often in MOF accompanied by a very high mortality rate (12.5% -87% of cases), which asks for an early bedsides diagnosis and a promptly and aggressive surgical intervention. KEYWORDS: Necrotizing Fasciitis, Immunocompetent Subjects, Staphylococcus Aureus, Outcome. 71

2 Necrotizing fasciitis which is commonly known as flesh-eating disease or like flesh eating bacteria syndrome is very rarely infection of subcutaneous cellular tissue and superficial fascia. Necrotizing fasciitis has a very rapid progression and potentially fatal outcome, most of the time accompanied by systemic signs of toxicity. Usually a combination of aerobic (streptococci and staphylococci ) and anaerobic bacteria is the leading cause of NF often lead in a very severe progression of the disease. NF is possible to affect patients of any age, without any "preference" to sex or race. NF is usually localized in the perineum, lower limbs or the abdominal followed by surgery or trauma, particularly in individuals with systemic disease basis, such as: diabetes mellitus, arteriosclerosis, kidney failure or chronic malnutrition. In adults NF is observed in the lower limbs, and then the trunk and head. In neonatal care and in the children the majority of lesions were reported in the trunk. Ratio male / female FN is 2-3: 1, and the average age ranging from 38 to 44 years. (1, 4, 7) Materials and Methods: Our study is an open retrospective study realized in order to assess the involvement and the role of Staphylococcus aureus as an agent monobacterial in causing Necrotizing fasciitis in subjects immunocompetent and evolution / performance of this nosology in these subjects. The material is based on epidemiological data, clinical, biological and imaging of 7 subjects with FN among 15 such followed and treated in the Service of Infectious Diseases, and not only, UHC "Mother Theresa" in Tirana, during the period: April December Carefully are analyzed their dates related with the time of appearance of the symptoms and the time of their appearance in hospital, risk factors, the association with other pathologies, the location of the FN, the extention, clinical symptoms significantly of a severe sepsis or septic shock, biological parameters at the entrance and along the evolution of the disease, imaging dates in the few patients where is possible realization of a Echography of soft tissue or magnetic rezonance imaging (MRI), biological data as hemocitograma, biological balance of renal function, hepatic, acid-base balance, electrolytes, blood, Blood cultures, cultures from the throat or pulmonary secretions, uroculture and bacterial cultures of wounds, etc. In seven patients was conducted a soft tissue ultrasound and three of them even MRI Union. With the purpose of isolation causes was conducted several blood cultures, throat, pulmonary secretions, wounds, urine. Results: Four of the seven patients presented to the hospital on the second day of the clinical symptoms, two on the third and only one of them on the fifth day. One of the patients presented on the third day and the patient presented on the fifth day, had its fatal conclusion. 72

3 The average age of patients was 41 years, and six of the seven patients belonged to male sex ratio (M / F = 1.6). FN was located in the upper extremity in four cases and lower extremities in three cases. Isolated organism was Staphylococcus aureus. Severe sepsis was observed in 5 patients (71.42% of cases), which led into shock septic in four of them (57.14% of cases). Insufficiency Multiorganore (MOF) was present in 24 hours in two of them, which led to their death respectively on the third and fourth of hospitalization, regardless of their treatment very careful in Unit Intensive Care Service our (mortality rate = 28.57% of the cases included in the study).vesicles filled with the liquid sero- haemorrhagic, Leucocytes over 14,000 l in, Azotemia over 150 mg / ml, Natremia under 135 mmol / L, Trombocithopeny under 50,000 l in, as indices of gravity in the evolution of disease observed 5 (five) of patients, or 71.42% of the cases, but only two of them were fatal.staphylococcus aureus was isolated in four cases in blood cultures and in two of them even wound simultaneously in two cases were isolated only in wounds and in one case was isolated simultaneously in nasopharyngeal cultures of pulmonary secretions. Large amount of liquide between fascies and their inspissate were records that were observed more frequently in ultrasound and MRI examinations of patients. In all patients the treatment was based on the use of Vancomycine as monotherapy only in two cases, which clinically and biologically presented easier and combined with Matronidazol and Gentamicyne of five other cases, badges clinico-biological sepsis heavy. Only in one case it was needed surgical intervention simultaneously, how to reduce the effect of a comparative syndrome s tissue, as well as for the removal of necrotic tissue. 73

4 Discussions: B. Wilson was the first that used in 1952 the term "Fasceitis necrotiizing" in its reporting of 23 cases of adults affected by this syndrome, 88% of whom had an infection caused by Staphylococcus aureus, to highlight the phenomenon of necrosis muscular fascies the extent of infection along it, irrespective of the etiology of the cause of this infection. He emphasized the fact that "cutaneous gangrene is not always present, but fascial necrosis is a constant of this syndrome occurred." (8). FN has a classification based on its etiologic agents, clinical manifestations and predisposing factors. FN type I appear as an ulcer limited surface area, the range of gas present slow and often in subcutaneous tissue. FN has a multisystemic touch. generally caused by Staphylococcus aureus and Clostridium species of sp. Type II shows the destruction of the subcutaneous cellular tissue and fascies,multisystemic touch, progression of rapid necrosis, shock, gangrene and multiorganore insufficiency. In this group of etiologic agents are Gram-Negative bacteria, Anaerobes, Enterococci and Beta Bemolytic Streptococcus Group A. (1, 5, 7) NF nature is often more polimicrobic. The combination of aerobic bacteria (Streptococcus sp. And Staphylococcus sp.) and an anaerobic (Clostridium sp., Vibrio sp.) leads in most cases to the rapid progression and severe disease. In monomicrobial aspects this disease has very high mortality caused most often by invasive Streptococcus, Streptococcus pyogenes of which is the species most frequently isolated. Most cases are bad diagnosed because the symptoms of the beginning of FN resemble with other minor injuries of the skin and subcutaneous tissue, and any of these symptoms does not exclude the presence of self FN simultaneously. (3) Risk factors for a FN are: diabetes, kidney failure chronic, chronic liver disease, heart failure and circulatory arterial or venous peripheral chronic alcoholism, kidney failure, malnutrition, age over 60 years, the use for a long time corticosteroids which reduces the body's resistance to infections, obesity, presence of cuts in the skin including scars surgical, recently switching to chickenpox or other viral 74

5 illnesses that cause a rash. FN is not limited only for the patients with immunodeficiency or any other specific group so everyone with or without any health problems can develope FN. Approximately half of the cases with FN from streptococcus happen mainly in previously healthy young people. The gateway of the initial infection can come from almost any cause and FN can happen: after a local trauma, surrounding a foreign body in surgical wounds after a trauma easy eyelids, as a complication of biopsy transthoracic, after a biopsy of the skin, the way drilling needle in drug users, as complication of a thrombosis of the cavernous sinus, after episodes of freezing, then a bite of insects or snakes, the ulcers venous chronic legs, fractures open bone in skin abscesses or burning of the skin, after the varicella, or it may be idiopathic like FN as in the case of the scrotum or penis (Fournier syndrome). However in many cases it can not be done FN association of these factors. (1, 5, 6) Classic signs of a FN are: a sharp pain and unusual way the wound, cutting or lymph locoregional, symptoms similar eith flue which recorded a few hours after an injury or surgery. The initial appearance of lesions various from a rash until the appearance of erythema, strengthening of the lesion and cellulite. The skin appeared with a violet colour with the presence of vezicles and necrosis. The crepitacions are not common, but fever, tachycardia and leukocytosis with deviation to the left (three characteristic signs of a sepsis) are commonly. Thrombocitopeny is observed in almost half of cases. The basic element is the rapidly spread of facial necrosis with the presence of a sero-blood exudate, often with very bed smell. Passage of a metal lame smoothly along fascial plan is a specific clinical sign of the disease. It happens expressed tissue edema, which spreads rapidly in fascial muscle causing vascular thrombosis of the subcutaneous tissue necrosis and skin. Musculs may also be affected by FN. The death is usually caused by sepsis of FN from serious respiratory insufficiency, renal insufficiency, or insufficiency multiorganore (IMO). Even with the best treatment possible mortality remains high, 25%.In general medium mortality ranges from 8% to 73% (in adults from 8% to 85%, and mortality in newborns this can take up to 87.5%). Cases with FN complicated with sepsis and renal insufficiency have a high mortality rate up to 73%. Higher mortality related to infectious microorganisms have infections from SAMR and the other multirezistant organisms. (1, 4, 7) The diagnose of FN is very necessary because its progression is very fulminant. Except clinico-biological elements which help in diagnosis of FN we ought to value the contribution of imaging examinations for determining the diagnosis. Some are of the opinion that there is a limited use of ultrasonography in the diagnose of the FN. The limitation is from the difficulty of exploring areas too deep 75

6 anatomical. However, in some publications the authors find that ultrasonography has a sensitivity of 88% and a specificity of 93% (a positive prediktive value of 83%). Their criteria include thickening of subcutaneous tissue accompanied by accumulating a quantity of fluid a fascies inflammatory along with a thickness greater than 4 mm, compared with normal foot or leg. In identifying the FN, the findings in examinations with magnetic resonance (RM) assist in the identification of fascial deep involvement, as well as the identification of fascial necrosis. RM also plays a role in determining the extent of involvement of affected fascia, giving valuable assistance in evaluating perioperator. (2) A successful management and treatment of cases with FN are: (1) broad-spectrum antibioterapia, (2) aggressive surgical treatment, and (3) supportive therapy. The treatment with a single antibiotic as Vancomycine is a good therapy for streptococcus and staphylococcus infections. Betha-lactamides are used to cover Pseudomonas and aerobic. When we diagnose the patient with FN, except the start of treatment with antibiotics and supportive treatment is necessary the surgery for removing necrotic tissue. In case of the FN of limb it need the amputation because it can be irreversible necrosis and gangrened, or due to high toxicity usually happens in such cases. Immediate surgical intervention provides a greater chance of survival. The surgical intervation of necrotizing tissue wounds and assessment must be done every day. (5, 6). For many years the hyperbaric oxygen (HBO2) is used to support the recovery of patients who were undergoing cardiac surgery and to treat the gazoze gangrene clostridium (Type I of FN) and poissoning by carbon monoxide (CO). By creating the possibility of introduction of the treatment with hyperbaric oxygen in our country is added another successful treatment of patients with FN, except the treatments described above. Bibliography: 1. Anaya DA, Dellinger EP. Necrotizing soft-tissue infection: diagnosis and management. Clinical Infectious Diseases, 2007, 44(5), Arslan A., et al. Necrotizing fasciitis: unreliable MRI findings in the preoperative diagnosis. Eur J Rad. 2000, 36, Giuliano A, Lewis F Jr, Hadley K, et al. Bacteriology of Necrotizing Fasciitis. Am J Surg 1977, 134, Hasham S, Matteucci P, Stanley PRW, Hart NB. Necrotising fasciitis. BMJ, 2005, 330(7495), Hsiao GH, Chang CH, Hsiao CW, Fanchiang JH, Lee SH. Necrotizing soft tissue infections. Surgical or conservative treatment? Dermatol Surg, 1998, 24(2), Miller JD. The importance of early diagnosis and surgical treatment of necrotizing fasciitis. Surg Gynecol Obstet, 1983, 157, Sarani B, Strong M, Pascual J, Schwab CW. Necrotizing fasciitis: current concepts and review of the literature. JAm Coll Surg, 2009, 208(2), Wilson B. Necrotizing fasciitis. Am Surg. 1952; 18: