Necrotizing fasciitis is a life-threatening infection that can rapidly destroy skin, fat, and any tissue that covers muscle. It is sometimes called flesh-eating bacteria disease and, when it occurs on the genitals, Fournier gangrene. Bacteria may enter via minor wounds, surgical wounds, or bruises. The condition is rare but serious, and is associated with comorbidities such as diabetes, cancer, immune suppression, and liver or kidney disease. Quick diagnosis and treatment, including excisional debridement and systemic antibiotics, are essential for patient survival.^1,2 Negative pressure wound therapy with instillation and dwell (NPWTi-d) (V.A.C. Veraflo; 3M+KCI) has increasingly been used to treat these wounds.³ This case series highlights a hypochlorous acid solution (Vashe Wound Solution; Urgo Medical North America) in combination with NPWTi-d to assist in mechanically removing bacteria and necrotic tissue in the wound bed preparation process and manage the infection.

A retrospective chart review was performed to obtain patient information. All patients received systemic antibiotics in addition to prescribed wound therapy, underwent debridement as necessary, were treated with NPWTi-d, instilling hypochlorous acid solution during wound treatment, and had  dressings changed at 48- to 72-hour intervals.

Case 1 (Figure 1, Figure 2, and Figure 3). A 29-year-old woman with a history of intravenous drug use was admitted with necrotizing fasciitis of the left arm and chest. Treatment during the first week of the hospital stay included 5 operating room (OR) trips for debridement and local wound care with packing gauze soaked in Dakin’s solution (Century Pharmaceuticals). Following that, NPWTi-d with hypochlorous acid solution was applied for ongoing wound management. No further debridements were needed, and the wound underwent definitive closure within 6 weeks of admission.

Case 2 (Figure 4 and Figure 5). A 73-year-old man, who was admitted with Fournier gangrene, underwent 12 OR debridements and NPWT dressing changes. NPWTi-d with hypochlorous acid solution was used for 12 days. Care was transitioned to bedside wound packing changes with hypochlorous acid solution-soaked gauze after partial wound closure.

Case 3 (Figure 6, Figure 7, and Figure 8). A 56-year-old man with a history of diabetes mellitus and alcoholism was admitted with left leg necrotizing fasciitis. He underwent extensive surgical debridement with PVP/iodine (Betadine; Avrio Health) packing ×3 in the first 72 hours of his admission. At the third debridement, NPWTi-d with hypochlorous acid solution was placed in the OR. The patient underwent dressing change and wound examination in the OR 48 hours later. The wound base had improved greatly, and an extracellular matrix with PHMB (Puraply; Organogenesis Inc.) was applied followed by NPWT. The patient returned to the OR 72 hours later for primary closure. 

Case 4 (Figure 9 and Figure 10). A 60-year-old man with a history of squamous cell cancer of his right leg after Mohs surgery 1 month prior was admitted with necrotizing fasciitis of the right leg. He underwent excisional debridement of the ankle and thigh, and NPWTi-d with hypochlorous acid  solution was placed. After 72 hours, care transitioned to hypochlorous acid solution soaks before NPWT application at home. His wounds healed within 6 weeks.

These cases highlight the synergistic effect that the combination of NPWTi-d with a hypochlorous acid solution as the instillation solution can have. The combination improved clinical outcomes and resulted in wound healing and closure. Each case involved a complex wound and often a complex patient with comorbidities who was faced with a limb- and life-threatening infection. Each patient showed clinical improvement with the initiation of NPWTi-d with hypochlorous acid solution in addition to intravenous antibiotics; all survived the condition, albeit after long stays in the intensive care and stepdown units. A pH-controlled pure hypochlorous acid solution offers a promising way to manage necrotizing fasciitis, particularly in combination with NPWTi-d. These results mirror those of another study in a similar acute care setting.⁴

Pearls for Practice is made possible through the support of Urgo Medical, Fort Worth, TX (www.urgomedical.com). The opinions and statements of the clinicians providing Pearls for Practice are specific to the respective authors and not necessarily those of Urgo Medical, Wound Management & Prevention, or HMP Global. This article was not subject to the Wound Management & Prevention peer-review process..