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(BNDH) and Necrotizing Fasciitis (NF) in
Surgical Area at CHU-Kara (Togo)
1Department of General Surgery, teaching hospital of Kara , CHU-Kara, Togo
2Department of General Surgery, CHU-Sylvanus Olympio de Lomé, Togo
3Department of dermatology, teaching hospital of Kara, CHU-Kara, Togo
Submission: July 26, 2018;Published: September 21, 2018
*Corresponding author: Dossouvi Tamegnon, General Surgeon, Department of General Surgery, CHU-Kara, Togo, Email: firstname.lastname@example.org
How to cite this article: Dossouvi T,Moumouni Abd-el K, Amavi A, Mouhari T A, Amouzou E G, Dosseh D. Bacterial Necrotizing Dermohypodermitis (BNDH)
and Necrotizing Fasciitis (NF) in Surgical Area at CHU-Kara (Togo). Open Access J Surg. 2018; 9(5): 555772. DOI: 10.19080/OAJS.2018.09.555772.
The necrotizing fasciitis is a serious infection which may affect any part of the body. However, inferior limbs are mostly concerned. The objective of our study is to define epidemiological, clinical and evolution of BNDH-NF in general surgery department of Kara-CHU (Togo). We have unregistered 56 case of BNDH and 20 cases of NF. Neglected traumatic injury is the main predisposing factor of necrotizing fasciitis in our study. The diagnosis is mainly clinical, but the use of computed tomography allowed to assess lesion extension. Early surgical debridement is a key factor for successful recovery.
Bacterial dermo-hypodernitis are infection of the deep skin layers (dermis and hypodermis) that include non-necrotizing infections (mainly erysipelas) and necrotizing infections characterized by dermis, hypodermis and deep facia necrosis in case of necrotizing fasciitis. Although there is currently no consensus about the treatment of these infections, it is generally recognized that bacterial necrotizing dermohypodermitis and necrotizing fasciitis (BNDH-NF) are serious infections that may be life-threatening and required emergency medico-surgical treatment. Epidemiologic data about these serious infections are nearly inexistent. In occidental countries, BNDH-NF are rare with incidence of 1 case for 1,00,000. In sub-Saharan Africa, studies on BNDH are rare and focus on non-necrotizing infections in hospital medical ward in the big cities (capitals). Data are nearly inexistent in secondary cities where the people have rural activities. The objective of our study is to define epidemiology, clinical characteristics and outcome of BNDH-NF in general surgery ward of Kara-CHU (Togo).
This study is a retrospective study based on the files of all patients admitted for BNDH and NF in general surgery ward of Kara CHU from January 1st, 2014 to October 31st, 2016 (34 months period). Kara CHU is a reference center of the North part of Togo and the population is mainly rural. All the files of
patients diagnosed with BNDH-FN were included in the study. The diagnosis of BNDH-FN was clinical and based on the aspect of surgical excision (extension to the deep fascia) .
Study parameters were sociodemographic (age, gender, profession), clinical data (time to admission, medical history, general examination, route of entry of the infection, topography), complementary exam (complete blood count, erythrocyte sedimentation rate, bacteriology of samples), treatment and outcome.
Time to admission was the time between the beginning of the symptoms and admission to surgery ward .
When the deep fascia was not involved in the surgical excision, the diagnosis was BNDH. When the deep fascia was involved, the diagnosis was NF . Necrotizing lesion of perineum and scrotum were classified as Fournier gangrene. All the files were manually processed and registered in a database. The data were analyzed using épi info software. The data were anonymized in the database.
Over the 34 months of the study, 86 cases of BNDH-NF out of 1285 patients hospitalized (frequency of 6.7%) were admitted in the general surgery ward of Kara CHU (56 cases of NF 20 cas of BNDH and 10 cases of Fournier gangrene). The number of cases was high between May and October Figure 1. There were
54 males and 32 females (sex ratio 1,7). Mean age was 55,6 years
(from 17 to 88-year-old). The profession of the patients was
mainly farmer (53,5), then housekeeper (38,4%) (Table 1).
The mean time to admission was 7 days (5 to 21 days)
. Most of the patient (n+76) were auto medicated and the
others (n=10) had a previous medical consultation before being
transferred or referred. Ten patients took at least a NSAID before
admission. Most of the patient (n=63) did not have any relevant
medical history  (Table 2) (Figure 2).
Upon admission, all the patients had fever, 6 patients had
alteration of general state (6.9%) of which 4 had HIV infection,
7 patients had septic shock (8.1%). Except Fournier gangrene
localized on perineum and external genital organs, other
localization was on the lower limbs  (Table 3).
The route of bacterial entry was found in 45 cases (52.3%).
This was lower limbs injury in 38 cases (neglected traumatic
injury in 35 cases , toes intertrigo in 3 cases), upper limbs
injuries in 4 cases (all were neglected traumatic injuries), dental
abscess in 2 cases (NF cacio-cervico-thoracic) and 1 case if anal
fistula in a patient with Fournier gangrene  (Figure 3).
One-hundred percent of patient had polynuclear neutrophils
hyperleukocytosis associated to anemia requiring blood
transfusion in 46 patients (53.5%) . Erythrocyte sedimentation
rate was upper to 20mm after 1 hour in all patients. Escherichia
coli was found in 2 cases and Staphylococcus aureus in 6 cases.
The laboratory did not find any germ in the other patients .
The treatment was surgical excision in 79 cases (91.9%),
associated to antibiotic treatment against streptococcus,
staphylococcus and anaerobic bacteria. Dressing was done
every day and then every 48 hours depending on the outcome of
ulceration. Among the patient who had surgery, 51 (all with NF)
had pinch skin graft to improve healing .
The outcome was favorable in all patients except 6 that
presented graft necrosis. However, simple local treatment
allowed a good healing. There was one leg amputation due to
gas gangrene and 6 patients died due to shock upon admission
(5 cases of NF and 1 case of Fournier gangrene). Mean
hospitalization duration was 30 days .
This study described the characteristics of BNDH-NF in 86
patients admitted in general surgery ward of Kara CHU. BNDHFN
were mainly observed in farmers and housekeepers, mainly
in the lower limbs with a traumatic injury as bacterial entry. His
is the first study describing BNDH-NF in surgical ward dealing
mainly with rural population.
The frequency of these serious infection in our study was
high (86 cas over 3 years) and differ from the published data
from sub-Saharan Africa. In Lomé (Togo), Saka et al reported 7
cases over 11 years in dermatology and internal medicine wards;
in Conakry, Cissé M et al.  reported 31 cases over 4,5 years in
the dermatology ward of CHU Donka; and in Dakar, Diédhiou et
al.  reported 58 cases over 5 years in internal medicine ward
 (Figure 4).
The high frequency of BNDH-NF, mainly localized to the
lower limbs, in our study may be explained by the lack of use
of protection by the farmers (boots to work in the fields) [13-
17]. Additionally, there was lack of care about injuries, high level
of auto medication (use of cataplasm on injury that may induce
infections) and socioeconomical precarity of these population
that lead to consult traditional therapist (In Togo, only state
workers have a mandatory medical insurance). The mean age of
the patients in our study was 55 years old. This is in accordance
with literature data (age from 55 to 65 years old). There were no
Several predisposing factors were found in our study:
neglected traumatic injuries, obesity, diabetes, toes intertrigo,
lymphoedema. These predisposing factors were previously
reported in scientific literature. A study performed in sub-
Saharan Africa by Pictché et al.  found that obesity
lymphoedema, cosmetic depigmentation and toes intertrigo are
predisposing factor for erysipelas and consequently NF. This was
confirmed by the study of El Bakali et al. .
NF diagnosis is clinical. NF are polymicrobial, but the
most frequently isolated germ is group A beta-hemolytique
streptococcus . However, this is not in accordance with
the results of our study. Usual biological exam did not provide
more information but allow to assess the consequence of the
disease on the general state. Local and blood bacterial sampling
should be performed to identify the germ and adapt antibiotic
The place of imagery is important in the treatment of NF.
X-ray allow to show gas in soft tissue case of gas gangrene.
Tomodensitometry and MRI are more performing, showing fasci
thickening, fat heterogeneity and presence of gas . However,
MRI is generally not available in an emergency. In this study, the patients were treated based on clinical data, because imagery is
too expensive for our patients.
Treatment of necrotizing fasciitis is based on surgery,
anti-biotherapy and resuscitation. This is a multidisciplinary
treatment that required the involvement of surgeon, anesthetist
and infectiology’s to be effective.
Early surgery is major in the treatment with complete
removal of necrotizing tissues or amputation in case of gas
gangrene. Antibiotic treatment is the second important point. NF
is polymicrobial and bacterial sample is often without findings.
Triple antibiotic treatment is required to stop infection. Antibiotherapy
should associate betalactamines, amino side and
imidazole [20,21]. This may depend on the severity of the
infection. The choice may be done by an infectiology’s with a
good experience. However, there is no infectiology’s in Togo. In
our study, most of the patient received probabilistic treatment
with ceftriaxone, metronidazole and gentamicin by parenteral
route and then amoxicillin-clavulanic acid or macrolide by oral
route of the infection state decreased. The results were satisfying
Then resuscitation unit should manage surgery and
antibiotic treatment for better results because the patients
required hemodynamic, metabolic, nutritional and analgesic
support. Hyperbaric oxygen therapy is an adjuvant treatment in
NF but is only proved to be effective in clostridium gangrene.
Necrotizing fasciitis are rare but serious, because they
may be life-threatening and may lead to disability. Neglected
traumatic injuries was a major predisposing factor in the context
of our study. Treatment is multidisciplinary but early surgery is
major in treatment successfulness.