Aggressiveness - The key to a Successful Outcome in Necrotizing Soft Tissue Infection.

16 patients with necrotizing soft tissue infections were managed during last three years in various service hospitals. The experience indicates that there is considerable overlap in clinical findings and bacteriology. The infections seem to be variations of the same disease process, a spreading necrotizing infection. The number of these patients suggests that there is an increasing incidence of this entity. Staphylococcus and coliforms were the commonest organisms cultured in most of these patients. Because of the high mortality rate upto 50% as reported, we advocate aggressive and early treatment of this condition. Urgent radical exploration, excision of all necrotic tissue and adequate drainage of the deep fascial planes was done in all patients until healthy tissue planes were reached. A strong index of suspicion aids early diagnosis which ensures a favourable outcome. Our study indicates that the lower gastrointestinal tract should be considered as a possible cause of infection in all patients with synergistic gangrene. The involvement of the perineum and scrotum was most common. All these patients were treated with a common approach of resuscitation, broad spectrum antibiotics, immediate surgical excision of all necrotic tissue, aggressive nutritional therapy and early skin coverage with 20% mortality. The infection was primary in 8, postsurgical in 4 and following trauma in 4 cases. In majority of patients, Staphylococcus with beta haemolytic streptococci and E coli were the organisms isolated initially. Mortality was highest in intensive infections extending the abdomen and chest. Aggressive, effective and early treatment of necrotizing soft tissue infections is imperative to prevent a fatal outcome. Urgent radical exploration by the most experienced surgeon available is essential and includes wide excision of all necrotic tissue and adequate drainage of the deep fascial planes until indubitably healthy tissue is experienced. The surgeon must be prepared to proceed to a laparotomy, diverting colostomy or a suprapubic cystotomy where there exists any element of doubt. Aggression is also of significance in resuscitation, early institution of empirical broad spectrum antibiotic therapy, elaborate repeated daily dressings with hydrogen peroxide and to allow further debridement till the process is controlled.