Healing Beyond the Operating Room: Bedside Strategies for Necrotizing Fasciitis

Introduction

Necrotizing fasciitis (NF), a severe subtype of necrotizing soft-tissue infection [1], is a rare and potentially life-threatening condition characterized by the involvement of subcutaneous fat, superficial and deep fascia, and, in some cases, muscle tissue [2]. The worldwide occurrence of NF ranges from 0.3 to 15 cases per 100 000 individuals, with a higher prevalence in men [3,4]. NF is classified into 2 types: polymicrobial and monomicrobial. Polymicrobial NF is more common, typically involves the torso, and affects patients with comorbidities, whereas monomicrobial NF occurs in the extremities of otherwise healthy individuals [5]. The clinical picture usually consists of erythema, edema, severe pain, and fever; however, this presentation lacks specificity, resulting in frequent misdiagnosis [1].

The diagnosis of NF requires a prompt and decisive approach, but the absence of highly specific and sensitive confirmatory tests constitutes a substantial challenge. Commonly used diagnostic methods include imaging (eg, ultrasonography, magnetic resonance imaging), the “finger test,” and basic blood tests. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score may also be helpful, particularly in determining the probability of NF [1,4]. Treatment options are limited. The crucial first step is surgical debridement of necrotic tissue, combined with antibiotic therapy.

Debridement should be as radical as possible to remove all necrotic tissue. The primary clinical challenge lies in managing deep and extensive wounds, often located in complex anatomical regions. Initial treatment should focus on controlling septic shock through the excision of infected tissue. Subsequent management should aim for wound closure when feasible or, alternatively, defect coverage with flaps, grafts, or skin substitutes. Comprehensive treatment requires multiple complementary approaches. Systemic antibiotics, resuscitation, nutritional support – including enteral access, which plays a key role – are critical components of patient care. Equally important is local wound management, which may involve surgical debridement, necrectomy, antiseptics, appropriate dressings, negative pressure wound therapy (NPWT), hyperbaric oxygen therapy, skin grafts, or their combinations [1,6].

Despite advances in surgical techniques, protocols for low-risk wound management after primary debridement remain insufficient, particularly in cases of extensive abdominal NF. High-risk patients with comorbidities may not tolerate repeated operations or general anesthesia. In such situations, standard reconstructive procedures can carry substantial risks [7]. Thus, there is a need to explore alternative bedside strategies that may safely support wound healing outside the operating room. Proper management of NF is essential for patient survival and long-term quality of life, given that delayed treatment can lead to amputation or multiorgan failure [1]. Techniques that do not require an operating room may greatly reduce costs, minimize surgical risks, and increase patient comfort. This report describes the treatment of a patient with NF who underwent all post-debridement care in the hospital room, using negative pressure therapy and kinesiotaping. This approach demonstrates a potential shift toward less invasive but effective treatment strategies.

Case Report

A 52-year-old woman with multiple comorbidities, including type 2 diabetes and obesity (body mass index=52 kg/m2), was referred from the emergency department to the internal medicine ward for high-dose anticoagulant treatment of pulmonary thrombosis. During hospitalization, rapidly progressing skin lesions on the abdomen were observed. Initially, they appeared as blisters on an erythematous base and quickly evolved into ulcers to the right of the umbilicus. The patient reported that a glucagon-like peptide-1 analog had been administered at the site where lesions developed. On admission, she was in poor general health; she had experienced shortness of breath, a subfebrile temperature (37.3°C), chest pressure, and anuria for 2 days. Physical examination revealed hypotension (85/65 mmHg), muffled breath sounds, crepitations, clinically significant lower-extremity edema, and induration of the abdominal wall soft tissues.

Laboratory tests showed anemia (10.3 g/dL), hyperglycemia (270 mmol/L), elevated serum creatinine (4.54 mg/dL), and elevated inflammatory markers: white blood cells (24.19 G/L [ie, 24.19 cells×109/L), C-reactive protein (410 mg/L), and procalcitonin (5.1 ng/mL). Ultrasonography indicated numerous hyperechoic areas corresponding to gas bubbles in the right lower abdominal wall. The examination also revealed reduced and blurred echogenicity of superficial tissues, consistent with diffuse inflammatory changes. Blood samples and a swab from the ulcer were collected for aerobic and anaerobic cultures.

Those findings led to an initial diagnosis of abdominal necrotizing inflammation of the skin and soft tissues of streptococcal etiology. Based on this assessment, the patient began antibiotic therapy consisting of crystalline penicillin, clindamycin, and cotrimoxazole. However, after 3 days of therapy, inflammatory parameters remained elevated (Figures 1, 2), and the abdominal wall lesions continued to expand, prompting a surgical consultation.

Considering the evidence of necrosis, elevated inflammatory markers, and appearance of the lesions, the surgeon diagnosed NF (Figure 3A) and recommended emergency surgery with resection of necrotic tissue.

The patient was transferred to the surgical department, where radical wound debridement was immediately performed. Necrotic skin and adipose tissue were resected down to the fascia, covering an area measuring 20×30 cm with an average depth of approximately 12 cm (Figure 3B). Subcutaneous pockets of pus were thoroughly irrigated, and a betadine dressing was applied. NPWT was considered; however, due to a high risk of bleeding, it was not initiated on the first day. Instead, the wound was packed with povidone-iodine compresses, which served both as packing and antiseptic treatment. The following day, microbiological results were obtained. Blood culture findings were negative; however, swabs from the ulcers contained aerobic bacteria (Staphylococcus haemolyticus, Streptococcus anginosus) and anaerobic bacteria (Prevotella buccae).

On the second postoperative day, the packing was removed, and the wound bed was assessed. No signs of bleeding or clinically significant necrosis were identified, permitting initiation of NPWT. A polyurethane sponge was placed into the wound; beginning with the first application, the skin edges were gently stretched to reduce wound size and minimize dehiscence. A Renasys® Smith & Nephew pump provided continuous negative pressure of −120 mmHg, with dressing changes every 2 to 3 days.

After 7 days and 3 dressing changes, temporary sutures were applied to further reduce dehiscence. To improve exudate drainage and prevent pus accumulation deep within the wound, a customized instillation system was introduced. An elastomeric infusion pump was connected to the wound, administering a hypochlorous acid solution (Microdacyn 60 Wound Care®) (Figure 3C, 3D). The vacuum dressing was changed after 4 days; another change was conducted 3 days later, along with placement of additional sutures to further approximate the skin edges. A small subcutaneous residual abscess above the wound was drained and connected to the main wound through a plastic drain, enabling NPWT-assisted cleansing (Figure 3E). From the second NPWT dressing change onward, wound edge approximation was prioritized with kinesiotaping and anti-dehiscence sutures, resulting in a substantial reduction in wound surface area (Figure 3E, 3F). All procedures described above, excluding the initial necrectomy in the operating room, were performed under local anesthesia (2% lignocaine, 6–10 mL per procedure) in the patient’s room.

Five weeks after the operation, the patient was discharged in good health with instructions for wound management and further follow-up. At the 3-month follow-up, complete wound closure was observed (Figure 3G). The patient remains in good health and is preparing for bariatric surgery. Ongoing surgical management is underway.

Discussion

BEDSIDE MANAGEMENT OF NF:

In the present case, surgical intervention was initially delayed. On the first day, the infection was misdiagnosed as superficial necrosis and managed only with intravenous antibiotic therapy. However, the patient’s worsening clinical condition – including rising inflammatory markers, increasing necrosis, and progression of infection – prompted an urgent surgical consultation and immediate operative intervention.

According to current guidelines, urgent operative debridement followed by serial re-explorations is the basis of appropriate NF management [8]. Patients typically require 5 to 40 reoperations, depending on the adequacy of the initial debridement and presence of comorbidities [9]. This approach results in multiple visits to the operating room and substantially increases hospitalization costs [10]. Although our case demonstrates a conservative approach, we note that abdominal wall defects offer suitable reconstructive options, including skin grafts, biological mesh, or local flaps [11]. These techniques may shorten healing time but carry surgical risks [12], particularly in high-risk patients such as the individual described in the present report. A recent systematic review by Rivera Gastelum et al identified complication rates as high as 31.5% after reconstructive surgery for abdominal wall necrosis secondary to severe infections; some studies indicated even higher rates, up to 46%. The review emphasized that, although reconstruction can restore abdominal integrity, the procedures involved require advanced surgical expertise and prolonged operative time; moreover, they are associated with high morbidity, especially in patients with multiple comorbidities [13].

In the present case, although the patient tolerated general anesthesia during initial debridement, the procedure was mandatory due to the rapid progression of necrosis and was performed on an emergency basis. Given the patient’s body mass index, diabetes, and anticoagulation therapy for pulmonary embolism, the risks associated with major reconstructive surgery were deemed unacceptably high. Therefore, we utilized a minimally invasive bedside treatment strategy, selected after multidisciplinary evaluation that considered the patient’s overall stability, wound characteristics, and anticoagulation status. All procedures after primary debridement were performed at the patient’s bedside and were limited to controlled superficial tissue removal and wound management under strict clinical supervision, consistent with recent trends favoring minimally invasive operative methods [14,15]. Additionally, performing treatment in the patient’s own room served as an infection control measure by minimizing risks of cross-contamination from the operating room and surgical ward.

Published research indicates that NPWT is a safe and effective alternative, particularly for patients with multiple comorbidities who may not adequately tolerate repeated surgical procedures [16,17]. Although NPWT is often considered most beneficial in anatomically constrained regions, such as the lower extremities, recent work supports its effectiveness in managing complex or contaminated abdominal wounds [18]. A recent meta-analysis of 1655 patients demonstrated that NPWT significantly reduced the risk of surgical site infection compared with primary closure in abdominal surgery (odds ratio, 0.15; 95% confidence interval [CI], 0.02–0.87) [19].

Studies have shown that bedside management may decrease hospitalization time and accelerate wound healing [20,21]. Mayberry underscored the value of a bedside approach in the treatment of severe trauma and necrotizing infections, highlighting benefits such as improved patient stabilization, reduction of intra-abdominal hypertension, and prevention of abdominal compartment syndrome. Furthermore, staged procedures performed at the bedside may minimize complication risk compared with full surgical interventions [22].

Another potential advantage of bedside wound management is greater patient involvement in the healing process. The performance of debridement in a familiar and consistent environment, such as the patient’s room, may improve psychological well-being. This approach also allows the patient to better understand the healing process and the procedures conducted, increasing comfort and potentially improving compliance [23]. We recommend involving family members in wound care training before discharge, consistent with the approach in the present case. This practice facilitates smoother transition to home care, while increasing acceptance and confidence in wound management for both the patient and their family. It offers a valuable opportunity to initiate discussions and ensure that family members are adequately prepared for proper dressing changes and long-term care.

ROLE OF NPWT:

NPWT, first introduced in 1997, has been adopted as an effective method for the management of complex wounds, including NF. A wide range of NPWT options – such as single-use, closed-incision, and endoscopic approaches – has transformed the management of surgical complications [24]. The application of NPWT removes edematous fluid from the wound and decreases swelling without requiring daily dressing changes. The insulating effect of the device keeps the wound warm and moist, which supports the healing process. NPWT also stimulates granulation tissue formation, a critical component of wound closure, particularly in cases where extensive tissue loss precludes primary closure [25].

Studies have shown that NPWT may reduce overall care costs. For example, in an investigation by Brennfleck et al comparing NPWT with conventional wound treatment (CWT) for subcutaneous abdominal wound healing impairment (SAWHI), the mean per-patient cost of NPWT within 42 days was €116.07 higher than that of CWT (€2034.98 vs €1918.91). However, when wound closure rates were considered, the cost per closed wound with NPWT was nearly half that of CWT (€4324.34 vs €8480.32) [26]. Moreover, in the SAWHI Randomized Clinical Trial, the mean time to wound closure was significantly shorter in the NPWT group than in the CWT group (36.1 vs 39.1 days; 95% CI, 1.6–4.4; P<0.001). The wound closure rate within 42 days was also higher with NPWT (35.9% vs 21.5%; 95% CI, 6.6%–22.2%; P<0.001) [27]. A recent prospective study by Moreno Gijón et al evaluated NPWT efficacy in patients undergoing abdominal surgery and showed a significant reduction in surgical site infection compared with CWT (6.1% vs 17.2%; odds ratio, 0.31; 95% CI, 0.14–0.71; P=0.005). NPWT was associated with lower rates of skin dehiscence (5.4% vs 7%; odds ratio, 0.51; 95% CI, 0.29–0.90; P=0.02) and shorter median hospitalization (9 vs 12 days; P=0.03), although not all secondary outcome differences were statistically significant [28]. These findings suggest that NPWT contributes not only to faster wound healing but also to reduced nursing workload and decreased hospital resource utilization.

Additionally, NPWT has shown benefits in reducing bacterial colonization in wounds. Research by Li et al demonstrated that NPWT led to a greater reduction in bacterial load compared with gauze-treated wounds (34.6±5.5% vs 141.9±15.4% of baseline, respectively) [29]. This feature may be particularly useful among patients with diabetes, in whom wound infection can significantly delay the healing process.

Combining NPWT with antiseptic fluid instillation, especially in deep, pocket-like post-necrectomy wounds, can further enhance therapeutic effectiveness. In the present case, hypochlorous acid solution was used because it is safe for deep wounds and helps prevent fluid accumulation.

KINESIOTHERAPY IN WOUND APPROXIMATION:

Kinesiotherapy has been widely used for more than 50 years in physical therapy, sports medicine, and rehabilitation, but its uses in wound healing remain underexplored. This technique involves the application of specialized tapes comprising longitudinally intertwined flexible fibers, which are placed on the skin with a specific level of traction [30].

During wound healing, tapes are applied symmetrically around the incision, perpendicular to the longitudinal wound axis. In our department, tapes have been used for many years to reduce dehiscence and tissue tension, particularly as supportive therapy for large wounds. They are especially helpful in abdominal wounds with loss of domain. Elastic tape provides continuous tension that gently approximates wound edges and supports closure [31]. A study by Ratajczak et al highlighted multiple benefits of dynamic kinesiotherapy in abdominal wound healing. This technique offers a simple and cost-effective method that accelerates wound closure. It also reduces pain, facilitating coughing and deep breathing, thereby lowering the risk of pneumonia. Additionally, unlike conventional hernia belts, kinesiotape does not compress the entire abdomen and does not limit patient mobility. Its waterproof nature allows unrestricted bathing and showering, improving quality of life [31]. In the present case, dynamic kinesiotherapy used in conjunction with anti-dehiscence sutures led to a substantial reduction in wound size. Based on these findings, this simple and noninvasive method may be particularly useful for large wounds that initially cannot be closed due to extensive tissue loss.

LIMITATIONS:

This report has several important limitations. First, the bedside conservative approach described here, although effective in the present case, may be inappropriate for some patients with NF, particularly those who are younger, constitute better surgical candidates, or require a faster recovery. Total healing time exceeded 3 months, which may be unacceptable in settings where definitive closure or reconstructive procedures are feasible and safe. Additionally, this strategy relied on close clinical monitoring, experienced wound care management, and high patient compliance over an extended period, factors that may not be achievable in all care settings. Bedside procedures also carry risks, including the possibility of inadequate wound debridement or impaired healing, especially among patients receiving anticoagulant therapy. Moreover, although this approach emphasizes infection control and reduces surgical risk, it may not achieve the long-term aesthetic outcomes associated with reconstructive techniques. The specific contribution of kinesiotaping to the healing process cannot be definitively assessed without comparative data. Further studies are needed to evaluate its targeted therapeutic role in wound management. These limitations underscore the importance of individualized treatment planning and multidisciplinary decision-making in the management of complex NF cases.

Conclusions

This report highlights an alternative approach to NF management. A hallmark of this strategy is the use of procedures that can be performed entirely at the patient’s bedside. These methods may reduce the need for multiple operative interventions, potentially lowering healthcare costs, minimizing surgical risks, and improving patient quality of life. Central to this approach were NPWT, continuous instillation of hypochlorous acid solution, and kinesiotaping, all of which substantially contributed to wound healing and patient recovery. The successful outcome in this case suggests that a bedside approach can be a viable treatment strategy for high-risk patients. Further research is required to expand the application of these methods and clarify their full therapeutic potential.