Post-cesarean necrotizing fasciitis caused by surgical site infection

Necrotizing fasciitis (NF) is a rare, but rapidly progressive, potentially life-threatening soft tissue infection, with an incidence of 0.15-0.55 cases per 100,000 population. The gynecological-obstetric literature describes cases of NF due to surgical site infection (SSI) after cesarean delivery. This article discusses issues in the medicolegal evaluation of NF and the importance of prophylactic procedures, risk management protocols, and prompt diagnosis of this condition. Two cases of post-cesarean NF due to SSI are reported. In both cases the responsibility lay with the hospitals and the medical staff owing to failure to adopt adequate SSI prophylaxis and to establish a timely diagnosis despite the presence of known risk factors (emergency procedure, diabetes, overweight). Medicolegal evaluation of medical liability for NF due to SSI requires scrupulous analysis of criteria for establishing a causal relationship. With regard to the burden of proof, the hospital and the medical staff are required to provide “rigorous evidence” that they are extraneous to the cause of the infection. Omission of adequate prophylactic procedures and infection risk management protocols, and failure to establish prompt diagnosis, particularly when known risk factors are present, are not sufficient to demonstrate that a nosocomial bacterial infection cannot be prevented or predicted, even though it may be predicted to the extent that it is a predictable risk known to the hospital. In brief, it is impossible to exclude a causal connection between omitted actions and the serious consequences of infection.