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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 6  |  Issue : 2  |  Page : 80-84

Outcome analysis of neonatal abscess and necrotizing fasciitis at a tertiary center


Department of Paediatric Surgery, TNMC and BYL Nair Hospital, Mumbai, Maharashtra, India

Date of Web Publication13-Apr-2017

Correspondence Address:
Hemanshi Shah
Department of Paediatric Surgery, TNMC and BYL Nair Hospital, Mumbai Central, Mumbai - 400 008, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcn.JCN_64_16

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  Abstract 

Background: Skin and soft tissue involvement (SSTI) in neonates usually present as pustulosis, cellulitis, abscesses, necrotizing fasciitis, toxic shock syndrome, and staphylococcal scalded skin syndrome. Early diagnosis and appropriate management are essential for a good outcome. The pattern of neonatal skin and soft tissue infections in fifty neonates presenting at a tertiary referral center is described. Materials and Methods: Data of fifty neonates presenting with skin and soft tissue infection were retrospectively analyzed on the basis of age at presentation, sex, weight, subtype of SSTI, anatomical site, predisposing factors, pus culture, blood culture, management, and outcome. Results: The mean age of presentation was 18.42 days. There were 21 males and 29 females. The mean weight at presentation was 2.83 kg. Forty-one patients had localized abscesses; six had necrotizing fasciitis and three neonates had cellulitis. The thigh was the most common area involved in patients with localized abscesses. Back and anterior abdominal wall were the most commonly involved sites in patients of necrotizing fasciitis. Total leukocyte counts were increased in all patients. Blood culture was positive in two patients with necrotizing fasciitis. Secondary suturing was required in one patient with a large raw area in the region of the axilla. Hospital stay ranged from 3 to 4 days for localized abscesses to 10–45 days for necrotizing fasciitis. Conclusion: There has been an increase in the incidence of neonatal soft tissue infections. Immediate recognition and diagnosis are essential to avoid morbidity and mortality.

Keywords: Abscesses, cellulitis, necrotizing fasciitis, neonates


How to cite this article:
Tiwari C, Shah H, Waghmare M, Desale J, Dwivedi P. Outcome analysis of neonatal abscess and necrotizing fasciitis at a tertiary center. J Clin Neonatol 2017;6:80-4

How to cite this URL:
Tiwari C, Shah H, Waghmare M, Desale J, Dwivedi P. Outcome analysis of neonatal abscess and necrotizing fasciitis at a tertiary center. J Clin Neonatol [serial online] 2017 [cited 2019 Jul 21];6:80-4. Available from: http://www.jcnonweb.com/text.asp?2017/6/2/80/204516


  Introduction Top


Neonatal sepsis is a leading cause of neonatal mortality accounting for 12% of the total neonatal deaths in India.[1] Early diagnosis is often challenging due to nonspecific or atypical presentations.[1] Skin and soft tissue involvement (SSTI) is a unique presentation of neonatal sepsis.[1] These usually present as pustulosis, cellulitis, abscesses, necrotizing fasciitis, toxic shock syndrome, and staphylococcal scalded skin syndrome in neonates. We describe the pattern of neonatal skin and soft tissue infections in fifty neonates who presented at a tertiary referral center.


  Materials and Methods Top


Data of fifty neonates (aged 0–28 days) who presented with skin and soft tissue infection over 4 years from January 2012 to December 2015 was retrospectively analyzed on the basis of age at presentation, sex, weight, subtype of SSTI, anatomical site, predisposing factors (if any), pus culture, blood culture, management, and outcome.

Complete blood count was performed for all patients on admission. Blood culture was performed for patients with necrotizing fasciitis. Site, size, and total extent of infection were assessed. Incision and drainage were performed for all patients with abscesses. Release incisions and/or debridement (as appropriate) were performed for patients with necrotizing fasciitis. Pus culture was sent for all patients. Intravenous Augmentin was started in all patients with cellulitis and abscesses. Patients with multiple abscesses and necrotizing fasciitis were started on intravenous piperacillin and tazobactam. Antibiotics were changed as per the culture report. All patients underwent regular dressings.


  Results Top


The mean age of presentation was 18.42 days. There were 21 males and 29 females. The mean weight at presentation was 2.83 kg.

Forty-one patients (82%) presented with localized abscesses [Figure 1]; of these, six patients had abscesses at three or more sites, six patients had necrotizing fasciitis [Figure 2] and [Figure 3], and three neonates presented with cellulitis.
Figure 1: Right thigh abscess in a neonate

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Figure 2: Clinical photograph of necrotizing fasciitis of back and gluteal region with patches of necrosis of epidermis in a neonate

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Figure 3: Clinical photograph of necrotizing fasciitis of back and gluteal region in a neonate

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The thigh was the most common area involved in patients with abscesses (11 patients) followed by back and gluteal region (8 patients), submandibular region (6 patients), and scalp (5 patients). Back (4 patients) and anterior abdominal wall (3 patients) were the most commonly involved sites in patients of necrotizing fasciitis.

Four patients with thigh abscesses had a history of injection at the site. Although no conclusive history could be obtained from the other patients with abscess, some subclinical focus or hematogenous infection, especially in those with multiple abscesses, may be implicated. Two patients had a history of intravenous extravasation and presented with necrotizing fasciitis. Three patients with necrotizing fasciitis had a history of hyperbilirubinemia requiring Neonatal Intensive Care Unit admission and phototherapy. Mother of one patient with necrotizing fasciitis was a known diabetic on oral hypoglycemic agents.

Blood transfusion was required in three patients of necrotizing fasciitis with low hemoglobin. Two patients with necrotizing fasciitis had low platelet counts requiring platelet transfusion. Total leukocyte counts were increased in all patients. Blood culture was positive in two patients with necrotizing fasciitis for Escherichia coli and Acinetobacter. There was no growth in the other patients.

History of intravenous extravasation, hyperbilirubinemia, and diabetic mother coupled with low platelet counts requiring transfusion and positive blood culture in two patients point toward sepsis as the cause of necrotizing fasciitis in these neonates. Patients with cellulitis may have some trivial trauma un-noticed by the parents.

Methicillin-sensitive Staphylococcus aureus (MSSA) was cultured in 19 patients (38%); methicillin-resistant S. aureus (MRSA) in three patients and Klebsiella pneumoniae in two patients. There was no growth seen in pus cultures of 23 patients (46%).

All patients underwent daily dressings till wound granulation. Collagen was applied on the raw areas of two patients. Secondary suturing was required in one patient with a large raw area in the region of the axilla. None of the patients required skin grafting.

Patients with cellulitis and abscesses were discharged within 3–4 days. Patients with necrotizing fasciitis required prolonged hospital stay ranging from 10 to 45 days. There was no mortality in this study.


  Discussion Top


There has been a dramatic increase in the incidence of skin and soft tissue infections in the pediatric age group in the past decade.[2],[3],[4] The number of pediatric patients requiring incision and drainage has also been doubled.[4] This increase is thought to be largely due to the emergence of Community-acquired MRSA.[2]

Streptococcus and Staphylococcus species are the most common causes of skin and soft tissue infections in the pediatric age group.[2] Immunosuppressed children, neonates, patients with chronic diseases (e.g., diabetes), recent surgical interventions, and placement of orthopedic devices are particularly at an increased risk for the development of such infections.[2] The tradition of using “sigri” for warming cots (Khatiya-Indian wooden bed with an interwoven lace of coir rope) of mothers and vigorous oil massaging of neonates also contribute to cellulitis and necrotizing fasciitis in neonates, especially in the cold peripheries of India.

Most of such infections are the result of the local invasion, but may also be caused by hematogenous spread.[5],[6] Across all ages from neonate to adolescent, Streptococcus and Staphylococcus species remain the most common causes of infection. S. aureus and Streptococcus pyogenes infections are often caused by local invasion, whereas Haemophilus influenzae and Streptococcus pneumoniae are usually spread by hematogenous routes.[7] In local invasion, bacteria normally present on the healthy skin and enter through defects in the epidermal layer to cause infection. Clinical presentation depends on the layer of skin involved and may range from cellulitis, abscesses or necrotizing fasciitis.

Cellulitis involves the deeper dermis and subcutaneous fat. S. aureus and S. pyogenes account for most cases, with an increasing prevalence of S. aureus, particularly MRSA.[2] It is generally caused by local invasion after defect or injury to the skin.[2] It can even be caused by hematogenous spread in neonates and the immunosuppressed.[2] Cellulitis most commonly affects lower extremities where injuries to the skin are more common. It presents as local inflammation at the site leading to warmth, edema, tenderness, erythema and sometimes limited mobility.[2],[3] It is sometimes difficult to distinguish early cellulitis from an insect bite. In the case of insect bites, the inflammatory reaction is typically very well circumscribed, smaller and associated with pruritus. In mild cellulitis, monotherapy against MSSA and S. pyogenes is often sufficient;[2],[3] however, in severe cellulitis or when associated with suppuration, MRSA coverage should be considered.[2],[3]

Abscesses present as erythematous and painful lesions with fluctuation or purulent drainage. In neonates and infants, abscesses are more commonly found in diaper and buttock areas, making it important to entirely expose these patients.[2],[8] Several recent studies have assessed the utility of bedside ultrasound in aiding the physician in the diagnosis of abscesses, especially when the abscess is subclinical.[2],[3],[4],[5],[6],[7],[8],[9],[10] One study in 2008 showed that 88% of pediatric abscesses cultured S. aureus, with 85% of those being MRSA.[2],[11] In this study, 41 neonates had abscesses; of which six had multiple abscesses. The factors associated were evident only in four neonates with a history of injection at the site. Though no conclusive history could be obtained from the other patients with abscess, some subclinical focus or hematogenous infection, especially in those with multiple abscesses, may be implicated.

Incision and drainage with the packing of the abscess cavity offer cure. Antibiotic therapy and pus culture are therapeutic adjuncts. Studies in the literature suggest that in typical cases involving healthy patients, cure rates from incision and drainage are high, regardless of which bacteria are causing the infection, and thus it is not necessary to identify the specific cause.[2],[12],[13]

Necrotizing fasciitis is primarily an adult disease.[14] Although relatively rare in neonates, it has a fulminant course with a high mortality rate.[14] It was first described in detail in 1924 by Meleney and the term “necrotizing fasciitis” was introduced by Wilson in 1952.[14],[15],[16]

Necrotizing soft tissue infections have been classified into two categories based on causative organisms.[2],[17] Type 1 infections are polymicrobial caused by anaerobes, Gram-negative rods and Gram-positive cocci. Type 2 necrotizing soft tissue infections are caused by S. pyogenes alone or in combination with S. aureus. Type 2 infections are less common, occur in healthy and young patients and are being increasingly reported in children.[2],[18] Primary necrotizing fasciitis, which implies a lack of a known causative factor or any identifiable portal of entry for bacteria, is rarely reported in neonates.[14] These may be caused by some unrecognized infections in the epidermis with systemic bacterial invasion.[14] In this study, all six neonates with necrotizing fasciitis had sepsis as implicated by the history of intravenous extravasation (two neonates), hyperbilirubinemia (three neonates), and diabetic mother (one neonate) coupled with low platelet counts requiring transfusion and positive blood cultures in two neonates.

In the neonate, the site of involvement is usually dependent on the etiologic factor.[14] For instance, when the causative factors are omphalitis and balanitis, the site of involvement is usually the abdominal wall. In cases involving the breast and associated with fetal monitoring, the thorax and the scalp are sites involved, respectively.[14]

Necrotizing fasciitis should be diagnosed early so that immediate surgical debridement may be performed as required. This offers the best chance for survival.[14] Marked tissue edema, rapid progression of inflammation, and signs of systemic toxicity are the diagnostic clues.[14] The location of the infection and the surrounding skin should be noted accurately, and well-demarcated edges should be differentiated from the nondistinct ones.[2] Streaking erythema or lymph node involvement usually signify severe infection. Evidence of bone or joint involvement should also be noted.[2] Orbital cellulitis, deep tissue infection, and mastoiditis must be kept in mind in cases of facial cellulitis.[2]

Reports in the literature have not recommended the routine use of C-reactive protein (CRP), white blood cell count (WBC), and blood cultures.[2],[19] There has been a lot of debate regarding the utilization of CRP as a better indicator of bacterial infection in pediatric patients, with some studies suggesting that CRP has a better predictive value than WBC.[2],[20] Ultrasonography, computed tomography, and magnetic resonance imaging have been reported in the literature to be useful in the diagnosis of necrotizing fasciitis.[14]

Moss et al. have recommended that the antibiotic therapy should be a combination of penicillin or a cephalosporin for Gram-positive, an aminoglycoside for Gram-negative, and clindamycin or metronidazole for the anaerobic organism.[14],[21] However, some cases may be monomicrobial, and hence, it is important to retrieve wound cultures results as promptly as possible to give appropriate antibiotic therapy. McHenry et al. revealed that a prolonged lapse time between hospital admission and operative debridement was the only potential determinant associated with an unfavorable outcome in necrotizing fasciitis, stressing the importance of prompt and adequate surgery.[14],[22]

Supportive care includes aggressive fluid resuscitation and pain control.[14],[23] The use of hyperbaric oxygen therapy is controversial.[14],[24]


  Conclusion Top


Neonatal skin and soft tissue infections are on the rise, especially in the developing countries. Immediate recognition and diagnosis of such infections are essential to avoid morbidity and mortality. Improved health-care facilities providing good perinatal and postnatal care, immunization, parental education, recognition, and avoidance of harmful practices will reduce the incidence of such infections.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kali A, Sivaraman U, Sreenivasan S, Stephen S. Neonatal sepsis and multiple skin abscess in a newborn with Down's syndrome: A case report. Australas Med J 2013;6:91-3.  Back to cited text no. 1
    
2.
Lindquist B, Wang NE, Felter RA. Diagnosis and treatment of skin and soft tissue infections. Pediatr Emerg Med Rep 2015;20(7):69-79.   Back to cited text no. 2
    
3.
Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis 2014;59:e10-52.  Back to cited text no. 3
    
4.
Lopez MA, Cruz AT, Kowalkowski MA, Raphael JL. Trends in resource utilization for hospitalized children with skin and soft tissue infections. Pediatrics 2013;131:e718-25.  Back to cited text no. 4
    
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Cherry J, Demmler-Harrison G, Kaplan S, Steinbach W, Hotez P. Feigin and Cherry's Textbook of Pediatric Infectious Diseases. US: Saunders; 2013.  Back to cited text no. 5
    
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Fleisher GR, Ludwig S. Textbook of Pediatric Emergency Medicine. Philadelphia: Lippincott Williams and Wilkins; 2010.  Back to cited text no. 6
    
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Rajan S. Skin and soft-tissue infections: Classifying and treating a spectrum. Cleve Clin J Med 2012;79:57-66.  Back to cited text no. 7
    
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Holsenback H, Smith L, Stevenson MD. Cutaneous abscesses in children: Epidemiology in the era of methicillin-resistant Staphylococcus aureus in a pediatric emergency department. Pediatr Emerg Care 2012;28:684-6.  Back to cited text no. 8
    
9.
Iverson K, Haritos D, Thomas R, Kannikeswaran N. The effect of bedside ultrasound on diagnosis and management of soft tissue infections in a pediatric ED. Am J Emerg Med 2012;30:1347-51.  Back to cited text no. 9
    
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Sivitz AB, Lam SH, Ramirez-Schrempp D, Valente JH, Nagdev AD. Effect of bedside ultrasound on management of pediatric soft-tissue infection. J Emerg Med 2010;39:637-43.  Back to cited text no. 10
    
11.
Magilner D, Byerly MM, Cline DM. The prevalence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) in skin abscesses presenting to the pediatric emergency department. N C Med J 2008;69:351-4.  Back to cited text no. 11
    
12.
Ladde JG, Baker S, Rodgers CN, Papa L. The LOOP technique: A novel incision and drainage technique in the treatment of skin abscesses in a pediatric ED. Am J Emerg Med 2015;33:271-6.  Back to cited text no. 12
    
13.
Abrahamian FM, Shroff SD. Use of routine wound cultures to evaluate cutaneous abscesses for community-associated methicillin-resistant Staphylococcus aureus. Ann Emerg Med 2007;50:66-7.  Back to cited text no. 13
    
14.
Hsieh WS, Yang PH, Chao HC, Lai JY. Neonatal necrotizing fasciitis: A report of three cases and review of the literature. Pediatrics 1999;103:e53.  Back to cited text no. 14
    
15.
Meleney FL. Hemolytic streptococcal gangrene. Arch Surg 1924;9:317-64.  Back to cited text no. 15
    
16.
Wilson B. Necrotizing fasciitis. Am Surg 1952;18:416-31.  Back to cited text no. 16
    
17.
Jamal N, Teach SJ. Necrotizing fasciitis. Pediatr Emerg Care 2011;27:1195-9.  Back to cited text no. 17
    
18.
Miller LG, Perdreau-Remington F, Rieg G, Mehdi S, Perlroth J, Bayer AS, et al. Necrotizing fasciitis caused by community-associated methicillin-resistant Staphylococcus aureus in Los Angeles. N Engl J Med 2005;352:1445-53.  Back to cited text no. 18
    
19.
Stevens DL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ, et al. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis 2005;41:1373-406.  Back to cited text no. 19
    
20.
Pulliam PN, Attia MW, Cronan KM. C-reactive protein in febrile children 1 to 36 months of age with clinically undetectable serious bacterial infection. Pediatrics 2001;108:1275-9.  Back to cited text no. 20
    
21.
Moss RL, Musemeche CA, Kosloske AM. Necrotizing fasciitis in children: Prompt recognition and aggressive therapy improve survival. J Pediatr Surg 1996;31:1142-6.  Back to cited text no. 21
    
22.
McHenry CR, Piotrowski JJ, Petrinic D, Malangoni MA. Determinants of mortality for necrotizing soft-tissue infections. Ann Surg 1995;221:558-63.  Back to cited text no. 22
    
23.
Green RJ, Dafoe DC, Raffin TA. Necrotizing fasciitis. Chest 1996;110:219-29.  Back to cited text no. 23
    
24.
Brown DR, Davis NL, Lepawsky M, Cunningham J, Kortbeek J. A multicenter review of the treatment of major truncal necrotizing infections with and without hyperbaric oxygen therapy. Am J Surg 1994;167:485-9.  Back to cited text no. 24
    


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