A 27-year-old pregnant woman underwent cesarean section for chorioamnionitis due to Escherichia coli. Later, she presented local signs of necrotizing soft tissue infection (NSTI) around the surgical scar and developed signs of circulatory shock requiring supportive therapy, intravenous ceftriaxone and early extensive surgical debridement. The patient fully recovered after multiple surgeries. All the bacteriological samples showed the presence of Escherichia coli with the same antibiotic resistance profile than in the amniotic fluid. Gynecological procedures are known to be risk factors for NSTI but, to our best knowledge, no monomicrobial infection due to Escherichia coli was reported in that setting.
Keywords: Necrotizing fasciitis; Monobacterial; Escherichia coli; Caesarean section; Case report
Abbreviations: NSTI: necrotizing soft tissue infection; EUCAST: European committee on antimicrobial susceptibility testing; ICU: Intensive care unit; LRINEC: laboratory risk indicator for necrotizing fasciitis; IVIG: intravenous immune globulin.
Necrotizing fasciitis is a rare but highly fatal disease characterized by rapidly progressive tissue destruction associated with signs of systemic toxicity that could evolve to a circulatory shock. Prevalence ranges from 0.3 to 15 cases per 100,000 population . Necrotizing fasciitis belongs to the group of necrotizing soft tissue infections (NSTI) along with necrotizing cellulitis and necrotizing myositis. Treatment is urgent and based on extensive debridement combined with broad-spectrum intravenous antibiotic therapy. Most of NSTI are caused by polymicrobial infection (type I) by both anaerobic and aerobic bacteria, usually Bacteroides, Clostridium, or Peptostreptococcus in combination with Escherichia coli, Enterobacter, Klebsiella or Proteus . Monomicrobial NSTI (type II) is usually caused by Group A Streptococcus or other beta-hemolytic streptococci . Staphylococcus aureus can also be isolated. In half of the cases, there is a clear entry point on the skin. In the other half, it is probably a hematogenous translocation from a pharyngeal infection. Pregnancy and gynecological procedures are known to be risk factors for NSTI and necrotizing fasciitis has already been reported as a rare but serious complication of caesarean section [4,5] but, to our knowledge, no monomicrobial infection due to Escherichia coli has been reported in this setting.
Figure 1: Picture of the lower abdomen of the patient at day 1 of admission in ICU: the patient presented intense pain around the surgical scar and purple discoloration of the skin on the right side of the scar. There was no collection on palpation of the area and no flowing liquid from the scar.