Multidrug resistance have been frequently reported in recent days and threatens the effectiveness of successful treatment of infections especially using empiric antibiotics. The incidence of MDR microbes is on the rise over the past decades, meanwhile many studies still advocate for early broad-spectrum empiric or combination antibiotic therapy [9]. Godebo et al. in a study to determine multidrug resistance rate of bacterial isolates that caused wound infections in a specialised centre in SSA, showed that overall MDR among gram positive and gram negative bacterial isolates were 77 and 59.3% respectively [13]. The selection of appropriate antimicrobial agents for any suspected NF must take into account the nature of patient’s exposure and local epidemiologic data [9]. Empiric antibiotic therapy is limited because it cannot be used in the context of MDRO. This is the situation in this case report as culture and sensitivity results revealed resistance to all the antibiotics previously used. Some pathogens also possess the ability to develop new or ongoing resistance during treatment [9], further complicating the blind use of antibiotics. Progressive necrosis of soft tissues despite the empiric use of antibiotic therapy is a big indicator of MDR and warrants early culture and sensitivity to enable the use of susceptibility-guided antibiotic therapy. Routine and early culture and sensitivity is a means for early detection of MDRO and early use of susceptibility-guided antibiotic therapy should be done at the level of referring hospitals. This does not only reduce morbidity and mortality, but also reduces the length of hospital stay and the cost of hospitalisation.
The key to successful management of patients with necrotizing soft tissue infections relies on early recognition, prompt and aggressive surgical debridement with targeted antibiotic therapy [3, 10, 14]. Early diagnosis of NF remains a challenge partly due to nonspecific skin findings causing it to be misdiagnosed as cellulitis [2, 5, 14]. This patient was initially managed as cellulitis prior to referral, and this delayed the diagnosis of NF. Such delays in recognition and treatment will result in greater soft tissue lost and increased risk of morbidity and mortality [5, 14]. Early clinical differentiation between NF and cellulitis is important for early surgical management. Kobayashi et al. showed that delays in surgical treatment of > 12 h are associated with an increased number of surgical debridement, higher incidence of septic shock and acute kidney injuries in patients with necrotizing soft tissue infections [15]. Unusual location of soft tissue infections, lack of associated co-morbidities and/or risks factors, absence of any history of preceding trauma or an obvious breech in the continuity of skin or mucosa, or a low Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score thus excludes the diagnosis of NF [2, 4]. Our patient presented no specific risk factors for NF and no history of initiating trauma or breech in skin continuity but however developed a life threating NF.
Although NF is associated with a high morbidity and mortality, early diagnosis and surgical debridement have shown a favourable outcome making it not just a medical but also a surgical emergency [5]. The decision for surgical debridement often comes late due to late diagnosis. The LRINEC scoring system is used to assist in early diagnosis of NF [5]. This is the only validated diagnostic tool for NF currently in use and carries a positive predictive value of 92% [16]. This tool is based on six parameters at the time of presentation; C-reactive protein, total white cell count, haemoglobin, serum sodium, creatinine and glucose. A LRINEC score of 6 or more confers a higher risk of NF [16]. The LRINEC scoring system has not yet achieved wide-spread use due to some investigations like C-reactive protein which requires over 24 h for the results and is absent in most resource-limited settings. The controversial views of some authors with many papers questioning its usefulness in early recognition of LRENIC in recognising NF have also limited it use [2, 17]. Many studies have validated the ability of the LRINEC in detecting NF and differentiating it from other soft tissue infections like cellulitis that may clinically present in a similar fashion while others haven’t [16, 18]. The LRINEC score is not adequately sensitive despite its high specificity, and consequently a low LRINEC score cannot be used to eliminate the diagnosis of NF [2, 19]. According to Patel and associates, the diagnosis of NF still heavily relies on clinical findings such as pain, fever and hemodynamic instability [2]. In our patient, we gathered a LRINEC score of 6 suggestive of NF despite the unavailability of C-reactive protein, warranting a surgical exploration. Modifying the LRINEC scoring system to include both clinical and laboratory findings is therefore necessary to improve the specificity and sensitivity of this scoring system and make it more useful in resource limited settings.
Multidrug resistance has become a public health issue with national and global dimensions. There are many factors that contribute to the development of antibiotic resistance including the absence of quality assurance and antibiotic surveillance in most parts of SSA. Treatment with sensitive antibiotics is not always evident in resource-limited settings due to cost and unavailability of most antibiotics. The existence of very few centres that can conduct cultures and sensitivity in most countries in SSA have prompted the inevitable use of empiric or combined antibiotics. Due to the poor socioeconomic status of patients, expensive antibiotics are avoided for empiric treatment and can only be prescribed only following antimicrobial culture and sensitivity, however very few patients also afford for culture and sensitivity. Due to lack of government policies restricting over-the-counter sales of drugs especially antibiotics, many patients have resorted to the use of self-prescribed antibiotics prior to consultation which lead to usage of poor quality of drugs, sub-therapeutic doses and non-respect of therapeutic durations.
In recent years where MDR is frequently reported in many parts of the world, we recommend the adoption and use of Center for Infectious Disease Control guidelines for management of MDRO. According to these guidelines, the following strategies are inevitable means to prevent, curb or reduce MDR: administrative support in terms of government policies limiting the sales of over-the-counter antibiotics, creation of antibiotics surveillance departments in the public health ministries and education of the masses on the judicious use of antimicrobial agents. The diversity of potential pathogens resistant to commonly prescribed antibiotics underscores the importance of sustained and standardized antimicrobial resistance surveillance and antibiotic stewardship programmes in developing countries [20], yet these programs are grossly absent in SSA.