A 44-year-old woman with a medical history of chronic renal failure on haemodialysis since 2005. In April 2010 she underwent a renal transplant from a cadaver donor, following immunosuppressive treatment. On the fourth postoperative day, the patient presented with fever, worsening general condition and erythematous lesions on the right flank, which rapidly evolved with the appearance of phlyctenas and skin necrosis. The Nephrology Department performed a biopsy and culture of the lesions and requested the collaboration of our department.
Given the clinical suspicion of necrotising fasciitis, it was decided to start intravenous (IV) antibiotic therapy and perform immediate surgical debridement up to the muscular plane, without including it, covering an area of approximately 25 X 25 cm in the right flank and ribcage. We adjusted the immunosuppressive treatment, maintaining only Prograf (Tacrolimus) and suspending Mycophenolate and Dacortin, and started broad-spectrum intravenous antibiotic treatment with Ciprofloxacin (400 mg/12 hours), Teicoplanin (400 mg/12 hours), Clindamycin (600 mg/6 hours) and Tobramycin (50 mg/12 hours). Samples obtained for culture were positive for Escherichia coli. After debridement, treatment was started with negative pressure therapy with VAC® system for 13 days at 125 mmHg and cures every 48 hours.
Once the problem area was clean, granulated and free of infection (13 days after debridement), it was covered with autologous partial-thickness skin grafts again associated with VAC® therapy with Granofoam dressing at 125 mmHg for 10 days, with the first dressing on the fourth day and then every 48 hours. In the first treatment after grafting, we found that the graft was properly attached and with no signs of acute complications such as haematoma or infection, which led us to withdraw antibiotic treatment and restart the suspended immunosuppressant treatment, as recommended by the Nephrology Department.
After 24 days of hospitalisation, the patient was discharged by our department and continued under a regime of outpatient occlusive dressings using antibiotic tulgrase and gauze impregnated with povidone iodine. The first outpatient plastic surgery appointment was made 2 weeks after hospital discharge (18 days post-grafting), at which time the problem area was found to be healed. At 6 months, we performed an evolutionary control.
The therapeutic combination of IV antibiotics, the suppression of 2 of the 3 immunosuppressants that the patient was taking due to her kidney transplant, surgical debridement and VAC® therapy accelerated the wound cleaning and contraction process, as well as helping the autologous partial skin grafts to take hold quickly and completely, and the patient had acceptable skin coverage. The patient was offered the possibility of implanting 2 skin expanders and performing a more aesthetic reconstruction later, but the patient declined the offer as she was satisfied with the current result.
