Management of Group B Streptococcus Necrotizing Fasciitis Secondary to Puncture Wound in Diabetic Patient Using Xenograft* Therapy

Introduction: Necrotizing soft tissue infection (NSTI) targets the skin, subcutaneous tissue, or muscle and can rapidly spread to adjacent tissue planes due to poor blood supply.1 NSTIs are classified into three different bacteriologic classes. Type I is polymicrobial, often from skin or mucous membranes.2 Type II is monomicrobial, described as “flesh eating bacteria” in healthy individuals.2 Type III, or gas gangrene, is caused by Clostridium species.2 Group B Streptococcus is a minor pathogen of NSTI in adults, however, it has become increasingly more prevalent in recent years.3 Standard treatment consists of IV antibiotics, serial debridement, and supportive care.Methods: A 53-year-old male with history of uncontrolled Type II diabetes mellitus (HgA1c 15.1%) and CKD presented with a worsening left foot wound from a rusty thumbtack puncture. The patient was septic on admission with notably elevated white blood cell (WBC) count of 26,000/mcL, glucose of 800 mg/dL, and a calculated LRINEC score of 12, indicating high suspicion for NSTI. Initial ED course included Tetanus prophylaxis, fluids, insulin, and broad-spectrum antibiotics. CT imaging demonstrated soft tissue emphysema with extensive fascial involvement. Emergent incision and drainage with amputation of third and fourth rays were performed for source control. Serial debridement with application of Veraflow negative pressure wound therapy (NPWT) was subsequently required. The patient ultimately underwent left foot transmetatarsal amputation due to extensive soft tissue loss. Partial closure was obtained by skeletonizing the fifth digit for an advancement flap and residual defects were covered with meshed Xenograft* and NPWT for secondary intention healing. The patient was systematically cleared for discharge to an rehabilitation facility following appropriate Xenograft* integration and resolution of infection. Results:Wound cultures showed polymicrobial growth of Group B streptococcus, Enterococcus faecalis and Citrobacter koseri. Infectious disease recommendations included six-week course of IV antibiotic therapy. The patient continued extended NPWT with biweekly dressing changes and aggressive glycemic control, both crucial in optimizing wound healing potential. The patient achieved functional ambulatory status five months postoperatively.Discussion: NSTIs remain challenging to treat as delays in care can result in significant tissue loss, amputation, and even mortality. This case demonstrates the importance of prompt diagnosis and intervention. Thorough operative debridement with adjunctive treatments such as NPWT and Xenograft* application can achieve functional limb salvage. A multidisciplinary approach involving infectious disease, endocrinology, and vascular specialists is essential for achieving positive outcomes. This strategy enhances wound healing, prevents cardiovascular events, and reduces overall mortality rates in severe infections.References:1. Smith GH, Huntley JS, Keenan GF. Necrotising myositis: a surgical emergency that may have minimal changes in the skin. Emerg Med J. 2007 Feb;24(2):e8. doi: 10.1136/emj.2006.041723. PMID: 17251603; PMCID: PMC2658222. 2. Meleny Fl. Hemolytic Streptococcus Gangrene. Arch Surg. 1924;9(2):317–364. doi:10.1001/archsurg.1924.01120080083007 3. Graux E, Hites M, Martiny D, Maillart E, Delforge M, Melin P, Dauby N. Invasive group B Streptococcus among non-pregnant adults in Brussels-Capital Region, 2005-2019.