Amputation and good intensive care unite treatment! If you don't do it, you will lose your patient!

The critical issues are whether there is an adequate arterial supply .....and a duplex Doppler scan is not very accurate in a swollen leg. Ideally you need to know whether the tibial and foot arteries are diseased are patent. difficult where there is impaired renal function except with a CO2 angio. The most important issue is to get rid of the swelling in the leg which can be done with TOTAL bed rest - not getting up to toilet or showering and a compression bandage on the leg. Necrotising fasciitis is merely the spread of bacteria up swollen fascial planes. Control of oedema will allow the antibiotics get to the bacteria that are otherwise swimming in the interstitial tissue. To do a below knee amputation in a 48 year old is a very bad outcome of bad medical treatment and happens far too frequently. Focus on getting the oedema controlled and then you may only have to amputate the great toe.

Maybe the following papers will help you:

its well known that the early suspecion of NF is the key to save the pt life & to salvage the limb,in that particular case scenario seen after 5days of heavy IV antibiotics with provisional diagnosis of (diabetic foot infection )without significant clinical improvemnt when you would think of something else & why??

Total bed rest and compressing bandage of severe swelling leg in the patient with renal failure, CABG, and possible PVD may case the rising of IVV and pulmonary edema. All these on the ground acute on chronic uncontrolled infection and possibly the ischemic leg. Amputation and good intensive care this is the clue for the rescue of the patient in the specific case.

Hi Abed,, Necrotising fascitis usually managed with iv antibiotics and surgical debridement. In your case it is already chronic deep seated bone infection along with acute involvement of soft tissues. Culture sensitivity in your case might help in choosing the antibiotics. Iv meropenem might help. Surgical debridement might also help. Amputation is last option. Thanks

Unfortunately, I suppose that you published your question too late. Your patient in the sepsis and very probable - septic shock. The extensive surgical debridement along with intensive care and AB treatment was required as emergency intervention 5 days ago. It may be necrotizing or non-necrotizing infection, cellulitis or fasciitis - anyway surgical intervention is indicated. Amputation is an option if patient not improve after debridement (s).

Thank you dear ZUIDEMA,

NON of us have seen many of NF cases, BUT Im sure those who had seen one they will agree that its NOT easy to catch the diagnosis in the very 1st case the only thing that might help is high index of suspecion , in the above mentioned case was under trt by surgical& orthopedic team as a case of complex diabetic foot cellulitis complicating longstanding bigtoe osteomelitis,ON reviewing the case after 5days of failed conservative therapy with clinical presentation of high fever unusal sever pain , limb swelling with blisters & pathcy leg discloration rasied the question why its not NF??

the reason that the antibiotics have made no difference may well be because there is an impaired arterial supply and just adding more antibiotics will not help. We amputate too many legs because we ignore the arterial supply. Swelling is also a huge problem is never well managed. If you all keep thinking just about antibiotics treatment of this common problem will not improve.

IHD, CABG, DM, PVD, renal failure, acute non-controlled deep spread infection, severe swelling of the leg, sepsis - it's doesn't matter now if it NF or other -FAST GOOD TECHNICAL AMPUTATION (PIROGOV TECHNICK) and ICU ARE THE TREATMENT OF CHOIS IN THIS CASE (if already not to late!).

How is the patient now? Tazocin should have been converted (e.g vancomycin + meropenem?) antifungal Treatment (i.v flukonazol) would be appropriate. One of the main issues, i think, only" doppler us and patent vessels " is not satisfying enough to dismiss underlying peripheral arterial diaease. Just a reminding... I would love to learn how did the patient do?

appreciate all comments was mentioned by colleaques regarding the managment of that case , with HTN,uncontrolled daibetes , post recent CABG ,acute renal impairment and longstanding RT big toe osteomyelitis,,,,considering all issues regading early surgical debridemnt,switch the antimicrobial therapy, ICU care, limb vascularity, control of comorbidties.

the maint points are:

1.Surgical debridemnt was the key point to controll the sepsis & to clinch the diagnosis with chrachteristic finding of abscesnce of bleeding on cutting the tissue, separation along fascial plan (+ve finger test)e, sick looking fascia .finding was proved by histopathlogy test.

2.amputation of the big toe OR not ? was questionable BUT it was done during the first debridemnt session. showed good healing during the post op course

3.shall we consider it as an example of NF triggerred by the longstanding untreated osteomyelitis of the big toe?I think ,the answer is yes.

4.care of the wide area of sever tissue loss of the limb rentering OR for dressing under Anesthesia & reconstructive plastic procedures done by plastic surgeon colleague .

5.pt now able to ambulate on his leg back again with accepted function of the limb.

thanks for all who interested to read this article & for those who gave comments.