Necrotizing Soft Tissue Infection of the Forearms in a Patient Using Intravenous Heroin: Case Report of Advanced Wound Management Improving Dressing Tolerance and Expediting Skin Graft

Necrotizing soft tissue infection (NSTI), formerly termed necrotizing fasciitis, is a rare, rapidly spreading soft tissue infection that is a surgical emergency. The infection often begins insidiously within the fascial layer and is followed by rapid involvement of musculature, subcutaneous fat, and overlying skin.¹ Described as far back as the time of Hippocrates, NSTIs continue to pose challenges in timely diagnosis, as they often are initially thought to be cellulitis. The delay in diagnosis leads to challenges in wound management, but aggressive management appears to be associated with survival.² Despite advances in medicine, the mortality rate due to NSTI remains near 20% with significant morbidity for those patients who survive.¹ Although conditions such as diabetes, obesity, and trauma to the skin increase susceptibility, the opiate epidemic has been correlated with a rise in NSTIs among persons who inject drugs.^2-5 Drug injection leads to introduction of bacteria into the skin, causing local skin infections. A cohort study in South London showed that these skin infections are one of the most common indications for seeking medical care among persons who use intravenous (IV) drugs.⁵ IV drug use, particularly skin-popping or subcutaneous injection, results in vascular sclerosis with a resultant environment of hypoxia and warmth ideal for bacterial multiplication and spread.³ Diagnosis of an NSTI may be made more rapidly among patients who use IV drugs due to an increase in associated abscesses that prompt earlier intervention.² Following diagnosis, care for patients with NSTI is multifaceted and includes an aggressive antibiotic regimen, debridement, and serial dressing changes.

The purpose of this case report is to describe the use of consultation with wound specialists and a dressing regimen in a patient with NSTI and a history of IV and subcutaneous heroin use. The rate of granulation and the patient’s tolerance to dressing changes secondary to decreased pain from these dressings significantly expedited the time to graft and wound healing.

Necrotizing soft tissue infection often initially presents with erythema, swelling, and warmth at the site as well as fever. The hallmark sign is described as “pain out of proportion to exam,” with other findings including crepitus on palpation or the classic “dishwater” drainage from a wound.⁶ Pathophysiology involves inoculation of a bacterium with subsequent toxin release. In the population of persons who misuse opiates, common organisms include Streptococcus pyogenes (Group A Streptococcus), Klebsiella spp, Clostridium spp, Escherichia coli, Staphylococcus aureus, and Aeromonas hydrophila.³ Toxins mediate an inflammatory response within walls of the microvasculature, resulting in thrombosis. A vicious cycle of T-cell activation and proliferation with subsequent cytokine production occurs to cause rapid tissue death and spread of infection. Rapid initiation of antibiotics in conjunction with debridement of devitalized tissue remains the mainstay of treatment.¹

Wound coverage becomes the primary challenge after wide excisional debridement. A variety of techniques have been utilized and include leaving the wound open to air with cleaning and placing hydrocolloid or petrolatum dressings, wet-to-moist dressings, and negative pressure wound therapy. Leaving wounds open to air after initial debridement to allow for close monitoring and assessment has been shown to be an efficacious strategy to reduce pain medication needs due to the lack of dressing changes.⁷ Hydrocolloid or petrolatum dressings prevent drying of the wound bed but may cause more pain as overlying gauze dressings are often needed to ensure apposition. Wet-to-dry dressings, which are often impregnated with solutions such as povidone/iodine or sodium hypochlorite, are commonly used after initial debridement. These dressings, however, are often a source of pain as the solutions are cytotoxic and may feel caustic to the patient, thereby increasing narcotic pain medication use.^8-12 Applying negative pressure devices that require less frequent changes and still allow for contraction of the wound with granulation is another common method of wound management.⁷ Recent retrospective reviews explored the efficacy of instillation vacuum devices; these devices allow for the advantages of vacuum sealing with instillation of wound cleansing products in the wound.^13,14 However, all vacuum therapy requires patient adherence to ensure formation of a healthy bed of granulation tissue.

Management of disease in persons who use IV drugs presents unique challenges for providers and patients.¹⁵ Pain control issues can prove difficult not only in acute postsurgical pain management, but in ensuring healing of surgical wounds as the dressing changes required for large surgical wounds can elicit pain. In addition to the addiction itself, poor clinical outcomes in opiate users may be compounded by a mistrust of medical professionals and nonadherence to treatment plans as well as fear of withdrawal and pain. Hospital inefficiencies may be misinterpreted as intentional failure to treat acute pain. The additional acute pain associated with the necessary frequent dressing changes increases aversion and subsequent nonadherence.¹⁵ Among providers treating patients with a history of IV drug use, there may be a fear of being deceived by the patient, leading to underdosing of necessary pain medication.¹⁵ Additionally, chronic opioid users have increased pain sensitivity as a result of alterations in somatosensory responses to pain medication administration. This can lead to a paradoxical increase in the pain following necessary opioid administration with wound care that makes pain challenging to control in these patients.¹⁶

A 29-year-old female with a medical history significant for recurrent methicillin-resistant Staphylococcus aureus abscesses and social history significant for IV and subcutaneous heroin use and daily cigarette use presented to the emergency department with an infection in her arms. The patient had been admitted to the medical service approximately 2 months prior for soft tissue infection of the bilateral upper extremities. At that time, the wounds were described as large, circumferential regions of necrosis extending from approximately the elbows down to the wrists. At that time, surgical debridement had been recommended; however, the patient refused treatment and left the hospital against medical advice. Based on further records review, it appeared that she had first been treated for this infection at an outside facility with oral trimethoprim-sulfamethoxazole for a diagnosis of cellulitis. The patient reported that she had completed the antibiotic course but had not followed-up after this or after the initial inpatient admission.

At the time of the second presentation with bilateral forearm infection, the patient was hemodynamically stable without leukocytosis (Figure 1). She had moderate anemia and mild hyponatremia, but the remainder of her laboratory test results were unremarkable. Results of a urine drug screen were positive for fentanyl. A computed tomography (CT) angiogram of the extremities demonstrated extensive necrotizing infection with subcutaneous emphysema and findings concerning for possible osteomyelitis. Broad-spectrum antibiotic coverage with vancomycin and piperacillin-tazobactam was started before the patient was taken urgently to the operating room for extensive debridement of the bilateral upper extremities on hospital day 1. After debridement, the wounds measured 30 cm × 15 cm on the right upper extremity and 15 cm × 14 cm on the left upper extremity (Figure 2).

Daily dressing changes of petroleum gauze with antibiotic ointment were performed on hospital days 2 to 4 postdebridement days 1 to 3). However, the patient reported that these were “excruciating” despite the use of IV hydromorphone patient-controlled analgesia and nonnarcotic pain medications (Figure 3). The initial pain regimen included the hydromorphone patient-controlled analgesia, scheduled acetaminophen, and a transdermal fentanyl patch. Additional as-needed doses of hydromorphone were available to the patient for acute pain associated with dressing changes

The acute surgical wound service (ASWS) was consulted on hospital day 4 (postdebridement day 3) because of the complexity of the wounds and the pain experienced by the patient during dressing changes. The ASWS developed a coordinated wound care plan with twice-weekly dressing changes that included premedication with IV hydromorphone for pain control. The dressings applied on hospital days 4 and 7 (postdebridement days 3 and 6) consisted of abdominal pads soaked with hypochlorous acid–preserved wound cleanser (Vashe, Urgo Medical North America) to cleanse the wound followed by carboxymethylcellulose fiber with 1.2% ionic silver (Aquacel Ag Extra, ConvaTec, Inc.) covered by hydrocellular foam (Allevyn Life, Smith & Nephew, Inc.) to promote a moist healing environment. The patient tolerated this dressing placement without need for additional narcotic analgesics beyond the hydromorphone premedication.

Healthy granulation tissue was noted at the first dressing change 3 days later (hospital day 7, postdebridement day 6) (Figure 4). Given the rapid improvement, the patient underwent split-thickness skin grafting 4 days later (hospital day 10, postdebridement day 9). The grafts were secured with negative pressure wound therapy. These vacuum dressings were removed on postgraft day 8 (hospital day 18); there was 100% uptake of the grafts at time of removal (Figure 5). The patient completed a course of piperacillin-tazobactam. She was being treated for opiate withdrawal by the addictions service but ultimately decided to leave the hospital against medical advice on hospital day 20 (postdebridement day 19, postgraft day 10).

Postsurgical care of patients with recreational opioid use requires innovation to balance wound healing and appropriate pain control.¹⁵ More frequent dressing changes may cause trepidation and nonadherence in patients already extremely sensitive to pain. In a single- institution, comparative, observational, retrospective analysis of medically complicated patients with complex or grossly infected wounds, it was shown that a regimen combining effective wound cleansing with a hypochlorous acid–preserved wound cleanser, which is a less caustic coverage option, allowed for fewer dressing changes and optimized wound healing.¹⁴ This resulted in a less traumatic dressing change for the patient and minimized the amount of narcotic pain medication necessary.

We can compare the current case with a case series detailing wound management among 5 patients with wounds from skin-popping who were treated at a large metropolitan medical center.¹⁷ Similar wounds were treated in each of the patients, with all patients undergoing initial sharp excisional debridement and antibiotic therapy.¹⁷ The authors reported a 40% limb-loss rate, and the other patients were subjected to daily dressing changes. Among the 3 patients with open wounds, 2 declined skin grafting and 1 underwent serial debridement before closure with a skin graft. This patient had successful graft uptake, much like the patient we report on in this case study.¹⁷

As wound care regimens for this patient population evolve, dressings may continue to improve from the easily applied but not beneficial wet-to-dry gauze or even vacuum-assisted devices to wound care products that promote healing and minimize pain.^8-12 Although traditional dressings may cleanse the wound or promote granulation, they also may cause trepidation about and nonadherence to the treatment plan in patients who are already hypersensitive to pain because of the more frequent dressing changes required. Promoting a moist healing environment through methods such as the one reported in the current case report, or with the use of hydrocolloid or alginate dressings, is key to rapid wound healing and reduction of pain with dressing changes.^18,19 In the authors’ experience, consulting wound specialists early in a patient’s treatment course is beneficial. Collaboration with acute wound specialists, such as ASWS services, promotes wound optimization while minimizing frequency of dressing changes. Development, education, and implementation of novel uses of existing or new wound care products can benefit providers and patients.

This case report has several limitations. First, it reports on only a single successful case of complex wound management. The methods reported here may not be generalizable to a broader patient population. Second, the scarcity of literature on this topic makes it difficult to compare this case with similar cases at other institutions. Third, the patient left against medical advice. This prevented the authors from detailing the clinical course beyond the first few postoperative weeks.

Subcutaneous and IV opioid use can lead to difficult-to-treat NSTIs. The current case of a patient with an NSTI and history of IV and subcutaneous heroin use reflected how patients in this population present unique challenges in pain management and postoperative care because of patients’ tolerance to narcotic pain medications. A coordinated wound care plan was developed by the ASWS that entailed twice-weekly dressing changes, which included premedication with IV hydromorphone for pain control. The dressings consisted of abdominal pads soaked with hypochlorous acid–preserved wound cleanser followed by carboxymethylcellulose fiber with 1.2% ionic silver covered by hydrocellular foam to promote a moist healing environment. The patient tolerated this dressing placement without need for additional narcotic analgesics beyond the hydromorphone premedication. This case demonstrated the importance of consulting wound care professionals early in the treatment course and using an effective dressing regimen that allowed for better pain tolerance, minimized narcotic use, and promoted effective granulation.

Dr Gallagher is a wound specialist coordinator, Acute Surgical Wound Service; Dr Desai is a surgical critical care fellow, Surgical Critical Care; Dr Alberto is a general surgery resident, Department of General Surgery; and Dr Cardenas is a trauma and critical care surgery attending and wound care specialist, Surgical Critical Care and Acute Surgical Wound Service, Christiana Care Health System. Newark, DE.

Address all correspondence to: Kathy Gallagher, DNP, APRN-FNP, CWS, WCC, FACCWS, 4735 Ogletown-Stanton Road, Medical Arts Pavilion II, Suite 3301, Christiana Care Health System, Newark, DE 19713; tel: 302-545-7003; fax: 302-623-4375; email: kathy.e.gallagher@gmail.com.