AbstractWe report a case of a mono-microbial post-cesarean necrotizing fasciitis caused by methicillin resistant Staphylococcus aureus, in a low-risk healthy woman who presented with acute fulminant infection, sepsis and features of multi-organ dysfunction syndrome on sixth post-operative day. CASE MANAGEMENT DISCUSSION- PRESENTATION AND SHARING OF INFORMATION ON COMPLICATED SKIN AND SOFT TISSUE INFECTION Rommel Q.
Aggressive management with multiple surgical debridement and supportive therapy was the key to favorable outcome in this case.IntroductionNecrotizing fasciitis (NF) is a severe infection of the skin, subcutaneous tissue and superficial fascia, which has a fulminant course and a potentially fatal outcome [1, 2].
Post-operative patients account for 20% of cases, though in many the infection follows trivial trauma.Most of the cases of post-operative NF in obstetrics and gynecology have been reported before the era of prophylactic antibiotics [7]. Early diagnosis and surgical intervention can reduce the morbidity and mortality associated with the condition. Usually, the risk factors associated with this condition include diabetes, anemia, malnourishment, intravenous drug abuse and immunosuppressive state [3, 4].
In most of the previous studies obesity, hypertension and diabetes have been implicated as risk factors [7] but recent case reports [5, 6] have highlighted the possible role of post-operative NSAID (non steroidal anti-inflammatory drug). But it is unclear whether it masks the signs and symptoms of NF or actually cause NF [5, 6]. Use of non-steroidal anti-inflammatory drugs in early post-operative period has also been reported as a risk factor in some cases [5, 6].Few cases of NF have been reported in the obstetric population.

We are of the opinion that NSAIDs delay the diagnosis rather than causing NF as they are routinely used for post-operative pain management.Bacteriology of the infection was mono-microbial with MRSA isolated from wound swab and it was consistent with the Type II variety of NF usually seen post-childbirth. She delivered a healthy male baby with 3?kg birth weight and mother was discharged on third post-operative day. Pus culture showed methicillin resistant Staphylococcus aureus (MRSA) and antibiotic revision was done with addition of amikacin. The LIRNEC score for this patient was 5; scores more than 8 usually show a good positive predictive value for diagnosis of NF [9].
She presented again on sixth post-operative day with discharge from the wound site with excruciating pain, difficulty in breathing and abdominal distension. Low scoring may be due to the routine prophylactic antibiotic therapy given in cesarean patients.Aggressive and multiple surgical debridement despite patient's unstable condition should be done as there is no role of wait and watch policy. At the time of admission, the patient was ill looking, febrile, tachypneic and tachycardic. The patient was kept on intravenous fluids initially and after 72?hours feeds were started and it was gradually built up and she was eventually shifted to high protein diet. Leaving the abdomen open as in this case, timely performed serial debridement followed by delayed secondary closure with good supportive treatment where the key to favorable outcome.
As the patient refused skin grafting, regular dressing was done and re-suturing was done on 35th day and at discharge her condition was significantly improved (Fig.

Individualization of therapy should also be done to address specific risk factors like malnutrition and anemia.
On local examination, the skin around the incision site was edematous, indurate and ecchymosed with suture in situ (Fig. Though we could not find any specific risk factors in our patient, we are of view that surgery itself was a risk factor in our case.NF in post-partum patients is a challenge from both diagnosis and management perspective. Ultrasound done showed clumped bowel loops with thickened and edematous wall with thickened omentum and mesentery. Assessing the relationship between the use of non steroidal anti-inflammatory drugs and necrotizing fasciitis caused by group A Streptococcus. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections.

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