NECROTIZING FASCIITIS

By Dr Bertha Woon

The majority of women are too shy to talk about breast pain and swelling, and would not seek medical attention for such small matters. They believe that breast pain is common and most women have high pain thresholds. By the time they seek medical attention, the pain is usually very severe. Let me explain why seeing a doctor early on in the disease process minimizes complications.

Everyone has skin commensals. The commonest skin commensals are Staphylococcus aureus and Staphylococcus epidermidis. No bacteria can enter the breast tissue to cause infections if the nipples are intact and not cracked. When infection does occur, it usually starts with a little redness and mild breast pain. Left untreated, the condition can progress to mastitis, breast abscess, multiloculated abscess, septicaemia and even necrotizing fasciitis.

The common predisposing conditions for breast infection include: cracked nipples following exertional exercise like running marathons, using gym towels that have not been sterilized, cracked nipples during breast-feeding or multi-resistant bacteria such as MRSA (Methicillin Resistant Staphylococcus aureus) and Pseudomonas aeruginosa.

Patients who see me for a consultation can divided into 3 main groups: lactating women, non-lactating women and pregnant women.

Breastfeeding mothers are the majority of my patients with breast infection. Often, they have already been to the emergency department or their family physicians prior to seeing me, but the problem had not been solved. If they see me early, and breast ultrasound only shows mastitis, then appropriate antibiotics may be the only treatment required. If they present at a later stage with a breast abscess, they may require serial pus aspirations under ultrasound guidance, in addition to antibiotics, guided by the culture and sensitivity of the pus. Most patients who see me have a high bacterial load, that would need multiple aspirations of pus.

If someone waits too long to see me, the abscess can become multiloculated. At this stage, the problem becomes complicated. Surgery would be required to drain the pus and debride the wound. As breast milk is a very good culture medium for bacteria, lactating women would be required to stop breast-feeding, otherwise the surgical wound will not close. Serious cases require multiple operations for drainage and washout with daily packing with ionic silver impregnated ribbon dressing, in order to speed up healing. The most severe cases require debridement and washout every 3 to 4 days, plus ionic silver-impregnated sponge dressing aided by vacuum-assisted negative pressure wound closure closed system, that speeds up healing by as much as 40%.

In my experience, the worst case I have seen was someone who developed necrotizing fasciitis. This lady was healthy and was 8 days post-delivery of her baby when she developed high fever, breast swelling and redness with extreme pain. Blisters developed within 6 hours of admitting her. I immediately operated on her to remove the necrotic tissue and applied the vacuum assisted negative pressure dressing. She was very ill and required to be in the intensive care unit for a week. She required multiple operations. The bacteria that infected her was a variant MRSA, that produced a toxin that digested the surrounding tissues. Up to one third of her breast was affected. In the end, she managed to overcome this illness and her wound was skin grafted after 3 months. She has completely recovered.