NECROTIZING FASCIITIS IN CHILDREN - PROMPT RECOGNITION AND AGGRESSIVETHERAPY IMPROVE SURVIVAL

Necrotizing fasciitis (NF) is a bacterial infection of the soft tissue s with a fulminant course and a high mortality rate. The authors perio rmed a review to define the diagnosis, bacteriology, and management of NF in the pediatric population. This report of 20 cases treated over 18 years represents the largest reported pediatric experience. These i nfections were attributable to secondary infection of varicella lesion s (5), omphalitis (4), extremity lesions (4), perineal infections (3), head and neck lesions (2), inguinal herniorrhapy (1), and breast absc ess (1). Nineteen of the 20 children were healthy, without chronic dis ease or immunosuppression. All patients presented with an altered sens orium and signs of systemic toxicity. Fever (40%), tachycardia (70%), and abnormal white blood cell count (50%) were not uniformly present. There was marked tissue edema in all patients, with a characteristic p eau d'orange appearance in 18. Seven infections were caused by strepto coccus; the remainder were polymicrobial, involving multiple aerobes a nd anaerobes. Initial gram stain was of limited utility; in 14 of 19 c ases the result was negative or showed only one of many organisms pres ent. Fifteen patients survived and five died. All survivors underwent aggressive surgical debridement within 3 hours of admission. The survi vors required of a mean of 3.8 operations. Fascial excision of up to 3 5% of total body surface area was required. One patient required amput ation, two had colostomies, and six required extensive skin grafting f or reconstruction. All five patients who died had delayed initial mana gement. Conclusion: NF is a serious cause of death in previously healt hy children. The diagnosis should be considered in the presence of any soft tissue infection presenting with signs of toxicity and marked wo und edema, even in the absence of fever or abnormal white blood cell c ount. Immediate surgical debridement and coverage with penicillin, an aminoglycoside, and metronidazole are essential. Subsequent changes in antibiotics should be based on culture data because gram stain result s are not reliable. More than one operation is required in almost all cases. Copyright (C) 1996 by W.B. Saunders Company