Maggot Debridement Therapy in Necrotizing Fasciitis Reduces the Number of Surgical Debridements
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 organisms2, 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?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.
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Case Report: Implications for a Patient Diagnosed with Fournier?s Gangrene
Abstract: Purpose: Fournier?s gangrene (FG) is a soft-tissue infection of the perineum. The purpose of this case report was to illustrate the role of a physical therapist in treating the wounds of a patient diagnosed with FG, as such research is not currently found in the literature. Intervention: The patient received antibiotic therapy, fluid resuscitation, nutritional support, surgical debridements, physical therapy for wound care and functional mobility training, split-thickness skin grafting, and patient education. Outcomes: The patient recovered fully, despite comorbidities, complications, and patient noncompliance, which all delayed full closure. Conclusion: Patients diagnosed with FG may recover and return to their pre-morbid level of function if they receive care that is carefully coordinated and aggressively delivered by the members of their interdisciplinary teams.
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Debridement: Rationale and Therapeutic Options
Abstract: Debridement is commonly defined as the process of removing necrotic, devitalized tissue and foreign material from a wound. The presence of necrotic tissue within a wound may impair wound repair processes by stimulating inflammation and delaying granulation and epithelialization. However, the above definition of debridement may not tell the whole story. Debridement may additionally remove senescent cells from the wound bed and nonmigratory cells from the ulcer edge and also remove excessive or abnormal bacteria; all of which may allow for improved availability of growth factors. This supplement will review the rationale for debridement, existing clinical data supporting debridement, and the various debridement options available. The supplement was supported through an unrestricted education grant from Healthpoint Ltd., Ft. Worth, Texas.
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Clinical and Economic Impact of Hydrosurgical Debridement on Chronic Wounds
Abstract: The high-powered parallel waterjet is a new surgical debridement tool that precisely removes tissue using a high-energy water beam. In this retrospective study, 20 patients with chronic wounds who were operatively debrided with the high-powered parallel waterjet were compared with 14 chronic wound patients debrided with conventional instruments. The hydrosurgery patients required a mean of 1.14 surgeries to obtain a prepared wound bed compared to 2.0 surgeries for conventional patients. This improvement in patient outcomes resulted in approximate savings of $2,800 for the hospital, per patient, when using the waterjet. The introduction of this new surgical technology has changed the paradigm for surgical debridement of chronic wounds.
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Necrotizing Fasciitis of the Abdominal Wall as a Post-Surgical Complication: A Case Report
Abstract: Necrotizing fasciitis is an acute surgical condition that demands a prompt and combined treatment. Early recognition, aggressive surgical debridement, and targeted antibiotic therapy significantly affect the overall course of treatment and, ultimately, survival. The authors present a case of a woman with necrotizing fasciitis of the abdominal wall and the course and methods of treatment with particular attention to the microbiological aspect and the use of negative pressure wound therapy as an auxiliary method of closure.
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Effect of the Anabolic Steroid Oxandrolone on the Rate of Catabolism in Acute Necrotizing Fasciitis
Abstract: Acute necrotizing fasciitis is a highly catabolic, life-threatening, soft-tissue infection with necrosis of soft tissue. The degree of lean mass loss, or negative nitrogen balance, corresponds with morbidity, including immune deficiency, weakness, and poor wound healing. Rationale: The anabolic steroid, oxandrolone, decreases nitrogen loss and improves outcome in other catabolic states, especially large traumatic wounds, and may be beneficial in controlling the catabolism of necrotizing fasciitis when added to standard aggressive surgical management. Methods: A total of 21 patients with acute necrotizing fasciitis were enrolled in the study. All patients underwent aggressive surgical debridement within 24 hours of onset, systemic antibiotic management, and nutritional support. Ten patients were also given oxandrolone 20mg/per day beginning on day 4 when nutrition status was adequate. Measurements of mortality, degree of lost body weight, nitrogen loss (g/day), and rate of wound healing (reepithelialization of skin donor site 0.012 inches deep) were obtained and compared between the two groups (ANOVA). Results: Three of 21 patients died, all of sepsis and multiple organ failure, two in the control group. Mean age was 44 years, and 60 percent had diabetes. The initial infection focus was the genitalia and perineum in 60 percent, and the extremities were the next most common focus. There were no demographic differences between the groups, including site of the wound. The variables reflecting the degree of catabolism were significantly improved with oxandrolone. Mean weight loss was 11±3 percent of total in the control versus 5±2 percent with oxandrolone, a significant decrease. Mean net nitrogen loss on days 7 to 14 was also significantly decreased at 15±6g/day versus 5±2g/day with oxandrolone. Donor site healing rate was 14±3 days in the control group versus 10±2 days in the oxandrolone, a significant difference. Mild liver dysfunction was present in one third of patients in each group. Conclusion: The a
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Debridement: Rationale and Therapeutic Options
Abstract: Debridement is commonly defined as the process of removing necrotic, devitalized tissue and foreign material from a wound. The presence of necrotic tissue within a wound may impair wound repair processes by stimulating inflammation and delaying granulation and epithelialization. However, the above definition of debridement may not tell the whole story. Debridement may additionally remove senescent cells from the wound bed and nonmigratory cells from the ulcer edge and also remove excessive or abnormal bacteria; all of which may allow for improved availability of growth factors. This supplement will review the rationale for debridement, existing clinical data supporting debridement, and the various debridement options available. The supplement was supported through an unrestricted education grant from Healthpoint Ltd., Ft. Worth, Texas.
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Necrotizing Fasciitis
Abstract: Necrotizing fasciitis (NF) is a rare, life-threatening infection resulting in necrosis of the skin, subcutaneous tissue, and fascia. Mortality rates have been noted as high as 73 percent. Certain conditions can predispose patients to NF, such as diabetes mellitus, immunosuppressive medications, and AIDS. Patients usually complain of excessive pain as well as constitutional symptoms. Cutaneous findings include diffuse redness and edema progressing to necrosis and hemorrhagic bullae. Because of this rapid progression, it is important to diagnose and treat NF quickly to decrease mortality. Treatment includes broad-spectrum antibiotic coverage, nutritional supplements, hemodynamic support, wound care, and prompt surgical debridement.
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The Application of a Fibroblast Gel Contraction Model to Assess the Cytotoxicity of Topical Antimicrobial Agents
Abstract: Fibroblast culture systems are routinely used to investigate wound contraction under a wide range of experimental conditions. These include the effects of irradiation, inhibition of chronic inflammatory cell mediators, and the biocompatibility of wound management products. In particular, these in-vitro cell systems have been routinely used to assess the cytotoxicity of topical antimicrobial agents and dental materials. L929 cells, derived from an immortalized mouse fibroblast cell line, are internationally recognized cells that are routinely used in in-vitro cytotoxicity assessments. In these studies, it is proposed that equine granulation tissue fibroblasts, cultured from slow healing wounds or from granulating wounds with exuberant granulation tissue removed during normal surgical debridement, may also be used to assess in-vitro cytotoxicity, in particular with respect to topical wound healing products. This model demonstrated that granulation tissue fibroblasts behave similarly to L929 fibroblasts in that they were effective in differentiating the toxicity of a variety of topical iodine-containing formulations. The data presented in this report suggests that currently marketed iodine-containing antiseptic agents show variable toxicity to fibroblasts involved in wound healing. These results suggest that currently available topical iodine antiseptic agents could be detrimental to wound healing if treatment is prolonged.
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The Debridement of Chronic Leg Ulcers by Means of a New, Fluidjet-Based Device
Abstract: Debridement of the ulcer bed is a preliminary, essential step in promoting healing of necrotic and sloughy ulcers. This study reports the authors? experience in ulcer debridement with a new hydrosurgery device based on fluidjet technology (Versajet? Hydrosurgery System, Smith & Nephew, Hull, UK). From November 2003 to May 2005, 142 inpatients, from a setting of 469 patients affected by chronic leg ulcers, were treated with the hydrosurgery device; the remaining 327 patients were treated with moist dressings (control). In 108 cases, an adequately debrided wound bed was achieved with 1 operative procedure; 2 and 3 procedures were required in 27 and 7 patients, respectively. The mean time per procedure was 5.9 ± 3.6 minutes, and the time to complete ulcer debridement (on average 1.3 ± 0.6 days) was considerably shorter than with traditional treatment with moist dressings, thereby producing an equivalent decrease of in-hospital stay. When used by an experienced surgeon, the hydrosurgery device facilitates selective debridement and only removes the tissue centered in the operating window while sparing healthy tissue. Debridement with this device reduces the bacterial burden in the wound. When the hydrosurgery device is set for ?gentle? debridement, patients generally tolerate the associated pain well. The presented results indicate that the hydrosurgery device set at high settings offers a valid alternative to surgical debridement and at low settings can be used for ?gentle? debridement in the ward as an alternative to other debridement methods.
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