Fulminant fatal necrotising fasciitis in an extremely preterm infant

A 23+0 week gestation twin girl weighing 465 g was born via spontaneous vaginal delivery. On postnatal day 4, a small area of broken skin was noted on her back. Flucloxacillin and gentamicin were commenced and Cavilon cream was applied. Vancomycin was substituted after blood culture grew Staphylococcus epidermidis. A skin swab isolated skin flora only. By postnatal day 10, the lesion had worsened with a haemorrhagic petechial appearance and multiple abscesses (figure 1). Staphylococcal impetigo was suspected and fusidic acid cream, mupirocin and paraffin ointment were added. Repeat blood culture grew Klebsiella oxytoca and meropenem was added. By day 12, there were extensive necrotic and gangrenous areas with ecchymotic ‘lakes’ of pus covering her head, back, groin and arms (figure 2). Necrotising fasciitis was diagnosed. Repeat skin swab grew Klebsiella oxytoca, Enterococcus faecalis, Staphylococcus haemolyticus and Aspergillus flavus. Surgical debridement was considered unfeasible due to her extreme prematurity and progressive septic deterioration. Following a multidisciplinary team meeting including parents, intensive care was withdrawn on day 12.