Necrotising fasciitis

With a higher incidence of necrotising fasciitis than elsewhere in the UK, ophthalmologists at the Manchester Royal Eye Hospital have become all too familiar with periocular manifestations of this disfiguring and potentially fatal bacterial infection. Compromised immunity resulting from alcohol excess, intravenous drug abuse, malnutrition, homelessness, immunosuppressive medications and trauma are major predisposing risk factors. However, the exact cause of the apparent increase in the Manchester catchment area 
are not fully obvious, Mr Micheal O’Rourke FRCSI(Ophth), FEBO, PhD, oculoplastic and orbital fellow, told the Annual Conference of the Irish College of Ophthalmologists in 
Galway, Ireland. Good outcomes can be achieved with prompt diagnosis and early treatment while planning immediate surgical debridement, he said. Mr O’Rourke presented a retrospective series of six patients with periocular necrotising fasciitis managed by the oculoplastic and orbital service at the Manchester Royal Eye Hospital in the previous 12 months. This series represents data accumulated by fellows at the unit in this time period including Ms Egle Rostron, Ms Varajini Joganathan, Mr Ate Altenburg and Mr Micheal O’Rourke under the consultant care of Mr Aruna Dharmasena, Mr Paul Cannon, Ms Anne Cook, Mr James Laybourne and Mr Saj Ataullah. The patients included five men and one woman with a mean age of 43 years. The most obvious predisposing factor was immune stress and compromise. One 37-year-old male patient who consumed excessive alcohol and previously used intravenous drugs was also seropositive for hepatitis C. Another 36-year-old male patient had self-discharged with facial trauma the day prior to requiring readmission. The series also included a 30-year-old homeless alcoholic patient and another homeless man with bipolar schizophrenia. Another patient was a 60-year-old male who had diabetes and was receiving steroids for vasculitis. Pathogens identified from swabs and blood cultures include group A-β haemolytic Streptococcus in four cases, Staphylococcus in one and one case was culture negative. The onset of symptoms was rapid in all patients. Five required immediate admission to the intensive treatment unit and emergency surgical debridement. The mean number of procedures was 4.3 including debridement and reconstructions, with some patients still undergoing complex reconstructions. There were no mortalities, which is likely attributable to early and intensive management achieved. Necrotising fasciitis is a serious bacterial infection that spreads rapidly along fascial planes with high morbidity and mortality. The reported incidence of periocular necrotising fasciitis is 0.24 cases per 1,000,000 per annum in the UK. The Greater Manchester Area has a population of 2.55 million; the six cases reported during this one-year study period therefore represents an annual incidence of 2.35 cases per million, nearly 10 times higher than the reported UK average. In response to the increased incidence of the condition, local management guidelines have been designed to improve patient care. The guidelines emphasise early recognition of the characteristic signs and symptoms of this condition in pre-disposed patients, prompt intravenous administration of broad spectrum antibiotics, repeat debridements as necessary until perfused viable tissue is reached and delayed reconstruction in collaboration with other facial surgeons including maxillofacial surgeons and ENT surgeons. Michael O’Rourke: maorourk@tcd.ie, 
micheal.orourke@mft.nhs.uk

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