糖尿病合并坏死性筋膜炎9例治疗经验

Experience in treating 9 cases of diabetes mellitus combined with necrotizing fasciitis

目的总结糖尿病合并坏死性筋膜炎的治疗经验。方法回顾性分析2018年9月至2020年12月贵州医科大学附属医院整形烧伤外科收治的糖尿病合并坏死性筋膜炎患者的临床资料。入院后首先进行血糖控制,经验性应用抗生素抗感染,并进行营养支持治疗;24~72 h内行手术扩创或切开引流,术中收集坏死组织及脓性渗出物行病原微生物培养及药敏试验;扩创术后于创面安装负压封闭引流装置进行引流,联合1.5%过氧化氢溶液冲洗创面,或联合皮下放置多根引流管引流。如果术后感染未得到控制,需再次行扩创处理。在创面清洁、肉芽组织新鲜状态下,采用大腿外侧中厚皮片移植修复。观测坏死性筋膜炎实验室检查风险指标(LRINEC)并评分,包括C反应蛋白、白细胞计数、血红蛋白、血钠、血肌酐、血糖,总分0~13分,评分≥6分应积极怀疑为坏死性筋膜炎;观察创面感染控制情况,统计扩创次数、创面修复方式、截肢情况、住院时间,并对创面愈合情况和坏死性筋膜炎复发情况进行随访。结果共纳入9例患者,其中男7例,女2例;年龄39~81岁;糖尿病病程为0.5~10年;上肢1例,下肢6例,会阴部1例,会阴部合并下肢1例;LRINEC评分≥8分5例,6~7分4例。4例经过1次、3例经过2次、2例经过3次手术扩创后,创面感染得到控制,达到清洁、肉芽组织新鲜状态;7例创面以厚中厚皮片移植修复后愈合,1例创面行薄中厚皮片移植后有散在的点状反复渗液,换药后愈合,1例右小腿中段截肢。微生物培养结果及抗生素应用情况:2例为金黄色葡萄球菌感染,予头孢他啶2000 mg静脉滴注,2次/d;1例为假丝酵母菌感染,予氟康唑400 mg静脉滴注,1次/d;2例为粪肠球菌、2例为屎肠球菌感染,均予哌拉西林他唑巴坦钠4500 mg静脉滴注,3次/d;2例为大肠埃希菌感染,予左氧氟沙星500 mg静脉滴注,1次/d。9例患者住院时间为24~56 d。出院时,LRINEC均较入院时明显改善,LRINEC评分为0~2分。随访3个月至2年,1例随访6个月后患肢创面再次出现感染,经抗感染、换药后愈合;其余病例创面愈合良好,无复发。结论糖尿病合并坏死性筋膜炎采取综合控制血糖的同时进行手术治疗,并联合负压封闭引流和1.5%过氧化氢溶液冲洗创面,以及足量足疗程的抗生素治疗,可控制病情,促进创面愈合,并减少病死率和截肢率。

ObjectiveTo summarize the treatment experience of diabetes mellitus combined with necrotizing fasciitis.MethodsA retrospective analysis was conducted on the clinical data of patients diagnosed with diabetes mellitus and necrotizing fasciitis who were admitted to the Department of Burns and Plastic Surgery,Affiliated Hospital of Guizhou Medical University between September 2018 and December 2020.Upon admission,initial treatment involved blood glucose management,the administration of empirical antibiotics to combat infection,and concurrent nutritional support therapy.Surgical interventions,including either dilatation or incision and drainage,were promptly performed within 24 to 72 hours.During these procedures,necrotic tissues and purulent exudates were collected for pathogen culture and antibiotic sensitivity testing to guide appropriate treatment.Post-operatively,a negative pressure closed drainage system was installed to facilitate wound drainage,combined with 1.5%hydrogen peroxide solution to flush the wound or subcutaneous placement of multiple drainage tubes to drain the wound.If post-surgical infection persisted,additional dilatations were deemed necessary.Under the condition of clean wound and fresh granulation tissue,the wound was repaired by medium-thickness skin grafting on the lateral thigh.The laboratory risk indicator for necrotizing fasciitis(LRINEC)was checked and scored,including C-reactive protein,white blood cell count,hemoglobin,blood sodium,blood creatinine,and blood glucose levels.The total score was 0-13 points.When the score was≥6 points,necrotizing fasciitis should be actively suspected.Observation of trauma infection control,statistics on the number of dilatations,trauma repair modalities,hospitalization time,and amputations,and follow-up of trauma healing and recurrence of necrotizing fasciitis were recorded.ResultsA total of nine patients were enrolled,consisting of seven males and two females,with an age range of 39 to 81 years.The study population comprised patients with diabetes mellitus,with durations ranging from 0.5 to 10 years.The affected body parts included one upper extremity,six lower extremities,one perineum,and one case involving both a perineum and a lower extremity.LRINEC score≥8 points in 5 cases and 6-7 points in 4 cases.The wound infection was controlled after 1 time dilatations in 4 cases,2 times in 3 cases and 3 times in 2 cases,the infection of the trauma was controlled and reached a clean and fresh state of granulation tissue.In 7 cases,the trauma was healed after repairing with thick-medium-thick dermal grafting;in 1 case,the trauma was repaired by thin-medium-thick dermal grafting with scattered punctate recurring oozing,which was healed after changing the medication;and in 1 case,the right middle calf leg was amputated.Microbiological culture result:2 cases of Staphylococcus aureus treated with intravenous drip of ceftazidime 2000 mg once a day;1 case of Pseudomonas pseudomallei was treated with intravenous drip of fluconazole 400 mg once a day;2 cases of Enterococcus faecalis and 2 cases of Enterococcus faecium treated with intravenous drip of piperacillin and tazobactam sodium 4500 mg 3 times a day,2 cases of Escherichia coli treated with intravenous drip of levofloxacin 500 mg once a day.The duration of hospitalization of 9 patients ranged from^(2)4 to 56 days.At discharge,LRINEC was significantly improved compared with admission,and LRINEC score was 0-2 points.Follow-up ranged from^(3) months to 2 years,relapsed infection happended in the affected limb wound in one case,which healed after anti-infection and dressing change.The other cases healed well without recurrence.ConclusionIn the management of diabetic necrotizing fasciitis,concurrent comprehensive glycemic control and surgical intervention are crucial.The integration of vacuum sealing drainage and the employment of 1.5%hydrogen peroxide for wound cleansing,along with a consistent and prolonged antibiotics reatment course significantly contributes to improved disease control,promote wound healing,leading to reduced mortality and lower rates of amputation.