Outbreak of Severe Skin and Soft Tissue Infection Including Necrotizing Fasciitis, in a Village of Telangana state, India, August 2018

  • Public health surveillance
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Background:
Necrotizing fasciitis (NF) is rare but highly fatal (76% mortality) and associated with diabetes, advanced age, and delays in treatment. A cluster of nine severe skin and soft tissue infections (SSTI), including four NF, reported on July 30, 2018 from Kalwala, Telangana led us to investigate to describe epidemiology, identify risk-factors and provide recommendations.

Methods:
Cases, defined as localized painful swelling and redness in Kalwala resident from December 1, 2017-August 20, 2018, were identified from hospital records, house-to-house survey and medical camp, and categorized: severe (sSSTI), including NF; moderately-severe (msSSTI); and mild (mSSTI), based on hospitalization/surgical interventions. We conducted an unmatched case-control study, enrolling and interviewing sSSTI/msSSTI as cases and mSSTI as controls, to identify risk-factors for severity. We cultured wound samples and assessed infection control practices (ICP) in two hospitals (H1/H2) against standard-checklist; we cultured environmental samples from wound-dressing stations.

Results:
We identified 36 cases (median age: 55 years [range: 17-80]; 78% male), village attack rate 1% (36/4337) and no deaths. In 34 (94%), lower-limbs were involved. 19% were sSSTI and 25% msSSTI. Lymphatic filariasis (LF) was common among cases (69%) and controls (65%). Comorbidities (diabetes or hypertension) (OR=9; 95%CI: 2.0-41.1), poor limb-hygiene (OR=16; 95%CI: 2.8-95.3), poor health-seeking (delayed treatment ≥2days after symptom-onset or ≥2 days between dressing-changes) (OR=5; 95%CI: 1.6-30.8) and consulting H1/H2 for wound-dressing (OR=7; 95%CI: 1.6-30.8) were associated with severity. All seven wound-samples (3mSTI; 1msSTI; 3sSTI) showed atypical poly-microbial growth (Pseudomonas, Proteus, Klebsiella, E coli and Clostridium). ICP assessment revealed 57% compliance (8/14 assessment criteria) and 8/11 samples from wound-dressing stations showed poly-microbial growth.

Conclusion:
Outbreak of severe SSTIs including NF among older males with LF was associated with comorbidities, poor hygiene and health-seeking, and likely contamination during dressing. Limb-hygiene and early treatment of SSTIs were promoted, home/facility-based morbidity management facilitated for LF patients and ICP training initiated.

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