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Tan JH, Koh BTH, Hong CC, Lim SH, Liang S, Chan GWH, Wang W, Nather A. A comparison of necrotising fasciitis in diabetics and non-diabetics. Bone Joint J 2016; 98-B:1563-1568. [DOI: 10.1302/0301-620x.98b11.37526] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Accepted: 07/11/2016] [Indexed: 12/18/2022]
Abstract
Aims Diabetes mellitus is the most common co-morbidity associated with necrotising fasciitis. This study aims to compare the clinical presentation, investigations, Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score, microbiology and outcome of management of this condition in diabetic and non-diabetic patients. Patients and Methods The medical records of all patients with surgically proven necrotising fasciitis treated at our institution between 2005 and 2014 were reviewed. Diagnosis of necrotising fasciitis was made on findings of ‘dishwater’ fluid, presence of greyish necrotic deep fascia and lack of bleeding on muscle dissection found intra-operatively. Information on patients’ demographics, presenting symptoms, clinical signs, investigations, treatment and outcome were recorded and analysed. Results A total of 127 patients with surgically proven necrotising fasciitis were included in this study. In all, 78 (61.4%) were diabetic and 49 (38.6%) were non-diabetic. Diabetics tended to have polymicrobial infections (p = 0.03), renal impairment (p < 0.001), end-stage renal disease (p = 0.001) and multiple co-morbidities (p < 0.001). They presented atypically, with less tenderness (p = 0.042) and less hypotension (p = 0.034). This resulted in higher rates of misdiagnosis (p = 0.038) and a longer time to surgery (p = 0.05) leading to longer hospital stays (p = 0.043) and higher rates of amputation (p = 0.045). However, the rate of mortality is comparable (p = 0.525). A LRINEC score of > 8 appears to be more sensitive in diabetic patients (p < 0.001). However, the increased sensitivity in diabetic patients may be related to hyperglycemia and electrolyte abnormalities associated with renal impairment in these patients. Conclusion The LRINEC score must be used with caution in diagnosing necrotising fasciitis in diabetic patients. A high index of suspicion is key to the early diagnosis and subsequent management of these patients. Cite this article: Bone Joint J 2016;98-B:1563–8.
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Affiliation(s)
- J. H. Tan
- National University Hospital, 1E
Kent Ridge Road, NUHS Tower Block Level 11, 119228, Singapore
| | - B. T. H. Koh
- National University Hospital, 1E
Kent Ridge Road, NUHS Tower Block Level 11, 119228, Singapore
| | - C. C. Hong
- National University Hospital, 1E
Kent Ridge Road, NUHS Tower Block Level 11, 119228, Singapore
| | - S. H. Lim
- National University Hospital, 1E
Kent Ridge Road, NUHS Tower Block Level 11, 119228, Singapore
| | - S. Liang
- National University Hospital, 1E
Kent Ridge Road, NUHS Tower Block Level 11, 119228, Singapore
| | - G. W. H. Chan
- National University Hospital, 5
Lower Kent Ridge Road, Main Building Level
1, 119074, Singapore
| | - W. Wang
- National University Hospital, 1E
Kent Ridge Road, NUHS Tower Block Level 11, 119228, Singapore
| | - A. Nather
- National University Hospital, 1E
Kent Ridge Road, NUHS Tower Block Level 11, 119228, Singapore
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Ghezala HB, Feriani N. [Postoperative necrotizing fasciitis: a rare and fatal complication]. Pan Afr Med J 2016; 23:123. [PMID: 27279950 PMCID: PMC4885698 DOI: 10.11604/pamj.2016.23.123.8734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Accepted: 03/18/2016] [Indexed: 11/18/2022] Open
Abstract
Les complications pariétales post opératoire peuvent être exceptionnellement majeures et graves menaçant le pronostic vital. La fasciite nécrosante est une infection rare de la peau et des tissus sous-cutanés profonds, se propageant le long des fascias et du tissu adipeux. Elle est surtout causée par le streptocoque du groupe A Streptococcus pyogènes mais également par d'autres bactéries telles que Vibrio vulnificus, clostridium perfringens ou Bacteroides fragilis. La fasciite nécrosante est une véritable urgence médicochirurgicale. Nous rapportons dans ce travail une observation très rare d'une gangrène pariétale abdominale survenant chez une patiente de 75 ans au cinquième jour post-opératoire d'un kyste de l'ovaire. L’évolution était marquée par l'installation d'un état de choc septique réfractaire rapidement fatal à J3 de la prise en charge.
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Affiliation(s)
- Hassen Ben Ghezala
- Service de Réanimation Médicale, Faculté de Médecine de Tunis, Hôpital de Zaghouan, Zaghouan, Tunisie
| | - Najla Feriani
- Service de Chirurgie Générale à la Faculté de Médecine de Tunis, Hôpital de Zaghouan, Zaghouan, Tunisie
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53
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van Stigt SFL, de Vries J, Bijker JB, Mollen RMHG, Hekma EJ, Lemson SM, Tan ECTH. Review of 58 patients with necrotizing fasciitis in the Netherlands. World J Emerg Surg 2016; 11:21. [PMID: 27239222 PMCID: PMC4884415 DOI: 10.1186/s13017-016-0080-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 05/23/2016] [Indexed: 12/05/2022] Open
Abstract
Background Necrotizing fasciitis is a rare, life threatening soft tissue infection, primarily involving the fascia and subcutaneous tissue. In a large cohort of patients presenting with Necrotizing fasciitis in the Netherlands we analysed all available data to determine the causative pathogens and describe clinical management and outcome. Methods We conducted a retrospective, multicentre cohort study of patients with a necrotizing fasciitis between January 2003 and December 2013 in an university medical hospital and three teaching hospitals in the Netherlands. We only included patients who stayed at the Intensive Care Unit for at least one day. Results Fifty-eight patients were included. The mortality rate among those patients was 29.3 %. The central part of the body was affected in 28 patients (48.3 %) and in 21 patients (36.2 %) one of the extremities. Most common comorbidity was cardio vascular diseases in 39.7 %. Thirty-nine patients (67.2 %) were operated within 24 h after presentation. We found a type 1 necrotizing fasciitis in 35 patients (60.3 %) and a type 2 in 23 patients (39.7 %). Conclusions Our study, which is the largest study in Europe, reaffirmed that Necrotizing fasciitis is a life threatening disease with a high mortality. Early diagnosis and adequate treatment are necessary to improve the clinical outcome. Clinical awareness off necrotizing fasciitis remains pivotal.
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Affiliation(s)
- Sander F L van Stigt
- Department of Surgery, Traumasurgery Radboud University Medical Center, Geert Grooteplein-Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Janneke de Vries
- Department of Medical Microbiology, Radboud University Medical Center, Geert Grooteplein-Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Jilles B Bijker
- Department of Anesthesiology, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP Ede, The Netherlands
| | - Roland M H G Mollen
- Department of Surgery, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP Ede, The Netherlands
| | - Edo J Hekma
- Department of Surgery, Rijnstate Hospital, Wagnerlaan 55, 6815 AD Arnhem, The Netherlands
| | - Susan M Lemson
- Department of Surgery, Slingeland Hospital, Kruisbergseweg 25, 7009 BL Doetinchem, The Netherlands
| | - Edward C T H Tan
- Department of Surgery, Traumasurgery Radboud University Medical Center, Geert Grooteplein-Zuid 10, 6525 GA Nijmegen, The Netherlands
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Endo A, Matsuoka R, Mizuno Y, Doi A, Nishioka H. Sequential necrotizing fasciitis caused by the monomicrobial pathogens Streptococcus equisimilis and extended-spectrum beta-lactamase-producing Escherichia coli. J Infect Chemother 2016; 22:563-6. [PMID: 26912298 DOI: 10.1016/j.jiac.2016.01.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 01/13/2016] [Accepted: 01/21/2016] [Indexed: 11/19/2022]
Abstract
Necrotizing fasciitis is a rapidly progressing bacterial infection of the superficial fascia and subcutaneous tissue that is associated with a high mortality rate and is caused by a single species of bacteria or polymicrobial organisms. Escherichia coli is rarely isolated from patients with monomicrobial disease. Further, there are few reports of extended-spectrum beta-lactamase (ESBL)-producing E. coli associated with necrotizing fasciitis. We report here our treatment of an 85-year-old man who was admitted because of necrotizing fasciitis of his right thigh. Streptococcus equisimilis was detected as a monomicrobial pathogen, and the infection was cured by amputation of the patient's right leg and the administration of antibiotics. However, 5 days after discontinuing antibiotic therapy, he developed necrotizing fasciitis on his right upper limb and died. ESBL-producing E. coli was the only bacterial species isolated from blood and skin cultures. This case demonstrates that ESBL-producing E. coli can cause monomicrobial necrotizing fasciitis, particularly during hospitalization and that a different bacterial species can cause disease shortly after a previous episode.
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Affiliation(s)
- Akiko Endo
- Department of General Internal Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minami-machi, Minatojima, Chuo-ku, Kobe, Hyogo 650-0047, Japan
| | - Ryosuke Matsuoka
- Department of Pathology, Kobe City Medical Center General Hospital, 2-1-1 Minami-machi, Minatojima, Chuo-ku, Kobe, Hyogo 650-0047, Japan
| | - Yasushi Mizuno
- Department of General Internal Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minami-machi, Minatojima, Chuo-ku, Kobe, Hyogo 650-0047, Japan
| | - Asako Doi
- Department of General Internal Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minami-machi, Minatojima, Chuo-ku, Kobe, Hyogo 650-0047, Japan; Department of Infectious Disease, Kobe City Medical Center General Hospital, 2-1-1 Minami-machi, Minatojima, Chuo-ku, Kobe, Hyogo 650-0047, Japan
| | - Hiroaki Nishioka
- Department of General Internal Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minami-machi, Minatojima, Chuo-ku, Kobe, Hyogo 650-0047, Japan; Department of Infectious Disease, Kobe City Medical Center General Hospital, 2-1-1 Minami-machi, Minatojima, Chuo-ku, Kobe, Hyogo 650-0047, Japan.
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Chen IW, Yang HM, Chiu CH, Yeh JT, Huang CH, Huang YY. Clinical Characteristics and Risk Factor Analysis for Lower-Extremity Amputations in Diabetic Patients With Foot Ulcer Complicated by Necrotizing Fasciitis. Medicine (Baltimore) 2015; 94:e1957. [PMID: 26554804 PMCID: PMC4915905 DOI: 10.1097/md.0000000000001957] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Patients with diabetes are at a higher risk of having diabetic foot ulcers (DFUs) or necrotizing fasciitis (NF). The present study aims to examine the clinical characteristics and associated risk factors for lower-extremity amputation (LEA) in patients with DFU complicated by NF.We retrospectively reviewed patients treated at a major diabetic foot center in Taiwan between 2009 and 2014. Of the 2265 cases 110 had lower-extremity NF. Limb preservation outcomes were classified as major LEA, minor LEA, or limb-preserved. Clinical characteristics, laboratory data, and bacterial culture results were collected for analysis.Of the 110 patients with NF, 100 had concomitant DFUs (NF with DFU) and the remaining 10 had no DFU (NF without DFU). None of the NF patients without DFU died nor had their leg amputated. Two NF patients with DFU died of complications. The amputation rate in the surviving 98 NF patients with DFU was 72.4% (46.9% minor LEA and 25.5% major LEA). Seventy percent of the NF patients without DFU had monomicrobial infections (60% with Streptococcus species), and 81.4% NF patients with DFU had polymicrobial infections. Anaerobic organisms were identified in 66% of the NF patients with DFU. Multinomial logistic regression analysis revealed an association between high-grade Wagner wound classification (Wagner 4 and Wagner 5) and LEA (adjusted odds ratio [aOR] = 21.856, 95% confidence interval [95% CI] = 1.625-203.947, P = 0.02 and aOR = 20.094, 95% CI = 1.968-205.216, P = 0.01 for major and minor LEA, respectively) for NF patients with DFU. In addition, a lower serum albumin level was associated with major LEA (OR = 0.066, P = 0.002).In summary, once DFUs were complicated by NF, the risk of amputation increased. Empirical treatment for NF patients with DFU should cover polymicrobial infections, including anaerobic organisms. The high-grade wound classification and low serum albumin level were associated with LEA.
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Affiliation(s)
- I-Wen Chen
- From the Division of Endocrinology and Metabolism, Department of Internal Medicine (I-WC, H-MY, C-HH, Y-YH), Molecular Infectious Disease Research Center, Division of Pediatric Infectious Diseases, Department of Pediatrics (C-HC); and Division of Trauma Plastic Surgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City, Taiwan (J-TY)
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Draft Genome Sequence of a Necrotoxigenic Escherichia coli Isolate. GENOME ANNOUNCEMENTS 2015; 3:3/5/e01152-15. [PMID: 26430054 PMCID: PMC4591326 DOI: 10.1128/genomea.01152-15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Here, we present the draft genome sequence of a necrotoxigenic Escherichia coli strain isolated from a patient following a very rapidly evolving, lethal necrotizing fasciitis.
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57
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Gallois C, Hauw-Berlemont C, Richaud C, Bonacorsi S, Diehl JL, Mainardi JL. Fatal necrotizing fasciitis due to necrotic toxin-producing Escherichia coli strain. New Microbes New Infect 2015; 8:109-12. [PMID: 26693024 PMCID: PMC4652023 DOI: 10.1016/j.nmni.2015.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 05/29/2015] [Accepted: 06/08/2015] [Indexed: 01/23/2023] Open
Abstract
We report a fatal case of necrotizing soft tissues infection caused by an Escherichia coli strain belonging to phylogenetic group C and harbouring numerous virulence factors reported to be part of a pathogenicity island (PAI) such as PAI IIJ96 and conserved virulence plasmidic region.
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Affiliation(s)
- C Gallois
- Medical Intensive Care Unit, Paris, France
| | | | - C Richaud
- Department of Microbiology, European Georges Pompidou Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - S Bonacorsi
- IAME, UMR 1137, INSERM, Paris, France ; IAME, UMR 1137, Université Paris Diderot, Sorbonne Paris Cité, Paris, France ; AP-HP, Hôpital Robert-Debré, Service de Microbiologie, Centre National de Référence associé Escherichia coli , Paris, France
| | - J-L Diehl
- Medical Intensive Care Unit, Paris, France
| | - J-L Mainardi
- Department of Microbiology, European Georges Pompidou Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, Paris, France
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58
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Glass GE, Sheil F, Ruston JC, Butler PEM. Necrotising soft tissue infection in a UK metropolitan population. Ann R Coll Surg Engl 2015; 97:46-51. [PMID: 25519266 DOI: 10.1308/003588414x14055925058553] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Necrotising soft tissue infection (NSTI) is a rare but life threatening diagnosis. Geographic, economic and social variances influence presentation and prognosis. As the current literature does not reflect a UK metropolitan population, we conducted a retrospective chart review to establish pertinent features relevant to our practice. METHODS Patients with histologically confirmed diagnoses of NSTI presenting to two London teaching hospitals between January 2007 and July 2013 were included in the study. Features of presentation, surgical and medical management, microbiological findings and outcome were evaluated. RESULTS Twenty-four patients with histologically confirmed NSTI were included. Two age clusters were identified, with means of 46 years (standard deviation [SD]: 10 years) and 80 years (SD: 6 years). Pain, erythema and sepsis were common findings. Hypertension, hypercholesterolaemia and type II diabetes mellitus were common co-morbidities. A third of younger patients had human immunodeficiency virus or hepatitis C, with a quarter dependent on drugs and/or alcohol. The mean Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score was 5.8 (SD: 3.3). The lower extremities, groin and perineum were common sites of infection. Fourteen patients required inotropic support and seventeen required transfusions. The median number of surgical procedures was 5 (range: 1-17). Group A Streptococcus was the most frequently identified pathogen. Five patients died. Being elderly, female sex and failure to use clindamycin as a first-line antibiotic were associated with significantly higher mortality. CONCLUSIONS In contrast to other recent series, group A streptococcal monomicrobial NSTI remains the most common presentation in our population. Survival is anticipated in young patients, regardless of premorbid status. Elderly patients have a poor prognosis. The negative predictive value of the LRINEC score is questioned. Use of clindamycin as a first-line antibiotic is supported.
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Affiliation(s)
- G E Glass
- Royal Free London NHS Foundation Trust, UK
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Bohm K, Ward CM. Necrotizing Soft-Tissue Infection of the Thumb: A Case Report. JBJS Case Connect 2015; 5:e22. [PMID: 29252576 DOI: 10.2106/jbjs.cc.n.00129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
CASE We present the case of a fifty-three-year-old man who presented with a necrotizing soft-tissue infection (NSTI) of the thumb, which tracked along the flexor pollicis longus tendon into the space of Parona. In this case report, we review the clinical and laboratory findings diagnostic of NSTI as well as the appropriate initial treatment for this challenging problem. CONCLUSION NSTI is a rare, life-threatening condition that must be identified and treated promptly for optimal results. In our patient, although we amputated the necrotic thumb, we were able to salvage the remaining hand and wrist despite more proximal involvement.
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Affiliation(s)
- Kyle Bohm
- Department of Orthopaedics, University of Minnesota, Regions Hospital, 640 Jackson Street, MS 11503L, St. Paul, MN 55101.
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60
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Tsai YH, Shen SH, Yang TY, Chen PH, Huang KC, Lee MS. Monomicrobial Necrotizing Fasciitis Caused by Aeromonas hydrophila and Klebsiella pneumoniae. Med Princ Pract 2015; 24:416-23. [PMID: 26066555 PMCID: PMC5588256 DOI: 10.1159/000431094] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 05/04/2015] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To compare specific characteristics and clinical outcomes of monomicrobial necrotizing fasciitis caused by Aeromonashydrophila and Klebsiella pneumoniae. MATERIAL AND METHODS Cases of monomicrobial necrotizing fasciitis caused by A. hydrophila (n = 11) and K. pneumoniae (n = 7) over an 8-year period were retrospectively reviewed. Differences in mortality, patient characteristics, clinical presentations, and laboratory data were compared between the A. hydrophila and the K. pneumoniae groups. RESULTS The clinical signs and symptoms at the time of presentation did not differ significantly (p > 0.05) between the two groups. The A. hydrophila group had a significantly shorter interval between contact and admission (1.55 ± 0.52 vs. 5.14 ± 2.12 days, p < 0.001) and significant lower total white blood cell counts (10,245 ± 5,828 vs. 19,014 ± 11,370 cells/mm(3), p < 0.045) than the K. pneumoniae group in the emergency room. Hepatic dysfunction was associated with mortality in patients with A. hydrophila infection, while diabetes mellitus was associated with mortality in patients with K. pneumoniae infection. Overall, 5 (45.5%) patients in the A. hydrophila group and 3 (42.8%) in the K. pneumoniae group died. CONCLUSION The initial clinical course of A. hydrophila monomicrobial necrotizing fasciitis was characterized by more rapidly progressive disease than that of the K. pneumoniae infection. Patients with hepatic dysfunction and necrotizing fasciitis should be suspected of having A. hydrophila infection, and diabetic patients with necrotizing fasciitis should be suspected of having K. pneumoniae infection initially.
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Affiliation(s)
- Yao-Hung Tsai
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Puzi City, Taiwan, ROC
- College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC
- *Yao-Hung Tsai, MD, Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, No. 6, West Sec, Chia-Pu Road, Puzi City, Cha-I 613 Taiwan (ROC), E-Mail
| | - Shih-Hsun Shen
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Puzi City, Taiwan, ROC
- College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC
| | - Tien-Yu Yang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Puzi City, Taiwan, ROC
| | - Po-Han Chen
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Puzi City, Taiwan, ROC
| | - Kuo-Chin Huang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Puzi City, Taiwan, ROC
- College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC
| | - Mel S. Lee
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Puzi City, Taiwan, ROC
- College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC
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Sartelli M, Malangoni MA, May AK, Viale P, Kao LS, Catena F, Ansaloni L, Moore EE, Moore FA, Peitzman AB, Coimbra R, Leppaniemi A, Kluger Y, Biffl W, Koike K, Girardis M, Ordonez CA, Tavola M, Cainzos M, Di Saverio S, Fraga GP, Gerych I, Kelly MD, Taviloglu K, Wani I, Marwah S, Bala M, Ghnnam W, Shaikh N, Chiara O, Faro MP, Pereira GA, Gomes CA, Coccolini F, Tranà C, Corbella D, Brambillasca P, Cui Y, Segovia Lohse HA, Khokha V, Kok KY, Hong SK, Yuan KC. World Society of Emergency Surgery (WSES) guidelines for management of skin and soft tissue infections. World J Emerg Surg 2014; 9:57. [PMID: 25422671 PMCID: PMC4242587 DOI: 10.1186/1749-7922-9-57] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 09/26/2014] [Indexed: 12/16/2022] Open
Abstract
Skin and soft tissue infections (SSTIs) encompass a variety of pathological conditions ranging from simple superficial infections to severe necrotizing soft tissue infections. Necrotizing soft tissue infections (NSTIs) are potentially life-threatening infections of any layer of the soft tissue compartment associated with widespread necrosis and systemic toxicity. Successful management of NSTIs involves prompt recognition, timely surgical debridement or drainage, resuscitation and appropriate antibiotic therapy. A worldwide international panel of experts developed evidence-based guidelines for management of soft tissue infections. The multifaceted nature of these infections has led to a collaboration among surgeons, intensive care and infectious diseases specialists, who have shared these guidelines, implementing clinical practice recommendations.
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Affiliation(s)
- Massimo Sartelli
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, Macerata, 62019 Italy
| | | | - Addison K May
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee USA
| | - Pierluigi Viale
- Clinic of Infectious Diseases, St Orsola-Malpighi University Hospital, Bologna, Italy
| | - Lillian S Kao
- Department of Surgery, The University of Texas Medical School, Houston, USA
| | - Fausto Catena
- Emergency Surgery Department, Maggiore Parma Hospital, Parma, Italy
| | - Luca Ansaloni
- General Surgery I, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Ernest E Moore
- Department of Surgery, Denver Health Medical Center, Denver, USA
| | - Fred A Moore
- Department of Surgery, University of Florida, Gainesville, Florida USA
| | - Andrew B Peitzman
- Department of Surgery, University of Pittsburgh, Medical Center, Pittsburgh, USA
| | - Raul Coimbra
- Department of Surgery, UC San Diego Health System, San Diego, USA
| | - Ari Leppaniemi
- Department of Abdominal Surgery, University Hospital Meilahti, Helsinki, Finland
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Walter Biffl
- Department of Surgery, University of Florida, Gainesville, Florida USA
| | - Kaoru Koike
- Department of Primary Care & Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Carlos A Ordonez
- Department of Surgery, Fundación Valle del Lilí, Universidad del Valle, Cali, Colombia
| | - Mario Tavola
- Department of Anesthesia and ICU, Villa Scazzi Hospital, Genoa, Italy
| | - Miguel Cainzos
- Department of Surgery, University of Santiago de Compostela, Santiago de Compostela, Spain
| | | | - Gustavo P Fraga
- Division of Trauma Surgery, Hospital de Clinicas, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Igor Gerych
- Department of Surgery 1, Lviv Regional Hospital, DanyloHalytskyLviv National Medical University, Lviv, Ukraine
| | | | - Korhan Taviloglu
- Department of General Surgery, Istanbul Doctor's Center, Istanbul, Turkey
| | - Imtiaz Wani
- Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Sanjay Marwah
- Department of Surgery, Pt BDS Post-graduate Institute of Medical Sciences, Rohtak, India
| | - Miklosh Bala
- General Surgery and Trauma Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Wagih Ghnnam
- Department of Surgery Mansoura, Faculty of medicine, Mansoura University, Mansoura, Egypt
| | - Nissar Shaikh
- Department of Anesthesia and ICU, Hamad Medical Corporation, Doha, Qatar
| | - Osvaldo Chiara
- Emergency Department, Niguarda Ca'Granda Hospital, Milan, Italy
| | - Mario Paulo Faro
- Department of General and Gastrointestinal Surgery, Trauma and Emergency Surgery Division, ABC Medical School, Santo André, SP Brazil
| | - Gerson Alves Pereira
- Emergency Surgery and trauma Unit, Department of Surgery, Ribeirão, Preto Brazil
| | - Carlos Augusto Gomes
- Hospital Universitário Therezinha de Jesus, Faculdade de Ciências Médicas e da Saúde de Juiz de Fora (SUPREMA), Universidade Federal de Juiz de Fora (UFJF), Minas Gerais, Brasil
| | | | - Cristian Tranà
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, Macerata, 62019 Italy
| | - Davide Corbella
- Department of Anestesiology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | | | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Helmut A Segovia Lohse
- II Cátedra de Clínica Quirúrgica, Hospital de Clínicas, Universidad Nacional de Asunción, San Lorenzo, Paraguay
| | | | - Kenneth Yy Kok
- Department of Surgery, Ripas Hospital, Bandar Seri Begawan, Brunei
| | - Suk-Kyung Hong
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Ulsan, Seoul, Republic of Korea
| | - Kuo-Ching Yuan
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan
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Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A. Current concepts in the management of necrotizing fasciitis. Front Surg 2014; 1:36. [PMID: 25593960 PMCID: PMC4286984 DOI: 10.3389/fsurg.2014.00036] [Citation(s) in RCA: 209] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 08/24/2014] [Indexed: 01/18/2023] Open
Abstract
Necrotizing fasciitis (NF) is a severe, rare, potentially lethal soft tissue infection that develops in the scrotum and perineum, the abdominal wall, or the extremities. The infection progresses rapidly, and septic shock may ensue; hence, the mortality rate is high (median mortality 32.2%). Prognosis becomes poorer in the presence of co-morbidities, such as diabetes mellitus, immunosuppression, chronic alcohol disease, chronic renal failure, and liver cirrhosis. NF is classified into four types, depending on microbiological findings. Most cases are polymicrobial, classed as type I. The clinical status of the patient varies from erythema, swelling, and tenderness in the early stage to skin ischemia with blisters and bullae in the advanced stage of infection. In its fulminant form, the patient is critically ill with signs and symptoms of severe septic shock and multiple organ dysfunction. The clinical condition is the most important clue for diagnosis. However, in equivocal cases, the diagnosis and severity of the infection can be secured with laboratory-based scoring systems, such as the laboratory risk indicator for necrotizing fasciitis score or Fournier's gangrene severity index score, especially in regard to Fournier's gangrene. Computed tomography or ultrasonography can be helpful, but definitive diagnosis is attained by exploratory surgery at the infected sites. Management of the infection begins with broad-spectrum antibiotics, but early and aggressive drainage and meticulous debridement constitute the mainstay of treatment. Postoperative management of the surgical wound is also important for the patient's survival, along with proper nutrition. The vacuum-assisted closure system has proved to be helpful in wound management, with its combined benefits of continuous cleansing of the wound and the formation of granulation tissue.
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Affiliation(s)
- Evangelos P. Misiakos
- 3rd Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece
| | - George Bagias
- 3rd Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece
| | - Paul Patapis
- 3rd Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece
| | - Dimitrios Sotiropoulos
- 3rd Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece
| | - Prodromos Kanavidis
- 3rd Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece
| | - Anastasios Machairas
- 3rd Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece
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63
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Chauhan A, Wigton MD, Palmer BA. Necrotizing fasciitis. J Hand Surg Am 2014; 39:1598-601; quiz 1602. [PMID: 24861383 DOI: 10.1016/j.jhsa.2014.04.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Accepted: 04/12/2014] [Indexed: 02/02/2023]
Affiliation(s)
- Aakash Chauhan
- Division of Hand and Upper Extremity Surgery, Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, PA
| | - Michael D Wigton
- Division of Hand and Upper Extremity Surgery, Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, PA
| | - Bradley A Palmer
- Division of Hand and Upper Extremity Surgery, Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, PA.
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Navinan MR, Yudhishdran J, Kandeepan T, Kulatunga A. Necrotizing fasciitis--a diagnostic dilemma: two case reports. J Med Case Rep 2014; 8:229. [PMID: 24965382 PMCID: PMC4086700 DOI: 10.1186/1752-1947-8-229] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 04/22/2014] [Indexed: 12/02/2022] Open
Abstract
Introduction Necrotizing soft tissue infections can affect various tissue planes. Although predisposing etiologies are many, they mostly center on impaired immunity occurring directly or indirectly and loss of integrity of protective barriers which predispose to infection. The nonspecific presentation may delay diagnosis and favor high mortality. Case presentation Two case vignettes are presented. The first patient, a 44-year-old healthy South Asian man with a history of repeated minor traumatic injury presented to a primary health care center with a swollen left lower limb. He was treated with antibiotics with an initial diagnosis of cellulitis. Because he deteriorated rapidly and additionally developed intestinal obstruction, he was transferred to our hospital which is a tertiary health care center for further evaluation and management. Prompt clinical diagnosis of necrotizing soft tissue infection was made and confirmed on magnetic resonance imaging as necrotizing fasciitis. Urgent debridement was done, but the already spread infection resulted in rapid clinical deterioration with resultant mortality. The second patient was a 35-year-old South Asian woman with systemic lupus erythematous receiving immunosuppressive therapy who developed left lower limb pain and fever. Medical attention was sought late as she came to the hospital after 4 days. Her condition deteriorated rapidly as she developed septic shock and died within 2 days. Conclusions Necrotizing fasciitis can be fatal when not recognized and without early intervention. Clinicians and surgeons alike should have a greater level of suspicion and appreciation for this uncommon yet lethal infection.
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65
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Dapunt U, Klingmann A, Schmidmaier G, Moghaddam A. Necrotising fasciitis. BMJ Case Rep 2013; 2013:bcr-2013-201906. [PMID: 24326439 DOI: 10.1136/bcr-2013-201906] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A patient in his late 50s who suffered from necrotising fasciitis is described in this case report. The patient first presented at the chest pain unit, where he reported of respiratory distress and showed systemic signs of an infection. Because of progressive skin lesions indicative of necrotising fasciitis on both the lower extremities, the patient was immediately rushed into surgery and was treated at the intensive care unit. Despite receiving immediate treatment, the patient died of this rapidly spreading infectious disease. Because of the fast advance of this disease, we would like to emphasise the importance of early recognition of symptoms.
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Affiliation(s)
- Ulrike Dapunt
- Department of Orthopaedics and Trauma Surgery, Heidelberg University, Heidelberg, Germany
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66
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Necrotizing Fasciitis of the Cervical Region following Extravasation Injury. Case Rep Med 2012; 2012:941578. [PMID: 23251188 PMCID: PMC3521693 DOI: 10.1155/2012/941578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2012] [Revised: 10/06/2012] [Accepted: 10/24/2012] [Indexed: 11/17/2022] Open
Abstract
Necrotizing fasciitis is a rapidly progressive soft tissue infection that can cause local tissue destruction, necrosis, and life threatening severe sepsis. Necrotizing fasciitis in the head and neck region caused by an extravasation injury is rare. This paper reports a patient with necrotizing fasciitis of the cervical region caused by an extravasation injury which required an early surgical debridement.
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67
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Abstract
Monomicrobial necrotizing fasciitis (type II) is typically caused by group A streptococcus alone or in combination with Staphylococcus aureus. Escherichia coli has been isolated from polymicrobial or Fournier's gangrene but has rarely been reported in monomicrobial necrotizing fasciitis. We describe the clinical characteristics and outcomes of seven cases of monomicrobial E. coli necrotizing fasciitis and/or severe soft tissue infection diagnosed at a single institution during an 18-month period. Four isolates from three patients and two isolates from two patients with type I polymicrobial severe soft tissue infection (controls) were assayed by the randomly amplified polymorphic DNA (RAPD) analysis for fingerprinting and PCR amplification of primers in order to detect cytotoxic necrotizing factor 1 and 2 (cnf1 and cnf2) genes. All patients had some type of immune suppression. The limb was the most commonly involved organ. In all cases, E. coli was isolated as a monomicrobial pathogen from blood, fascia, or both. All patients died during hospitalization, three within the first 48 h. The RAPD amplification assay showed a high degree of genetic diversity among the "flesh-eating" strains and controls. The cnf1 toxin gene was identified in two out of three cases, but not in the controls. cnf2 was not detected in any of the patients. E. coli may be responsible for life-threatening necrotizing fasciitis. Further research is needed to reveal relevant risk factors, reservoirs, and modes of transmission of cnf1 E. coli.
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68
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TeBockhorst S, Gurunluoglu R. Four Extremity Necrotizing Fasciitis without Involvement of the Trunk or Head. Am Surg 2012. [DOI: 10.1177/000313481207800406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Seth TeBockhorst
- Rocky Mountain Regional Trauma Center at Denver Health Medical Center University of Colorado Denver, Colorado
| | - Raffi Gurunluoglu
- Rocky Mountain Regional Trauma Center at Denver Health Medical Center University of Colorado Denver, Colorado
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69
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Microbiology and surgical indicators of necrotizing fasciitis in a tertiary hospital of southwest Taiwan. Int J Infect Dis 2012; 16:e159-65. [DOI: 10.1016/j.ijid.2011.11.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Revised: 10/12/2011] [Accepted: 08/26/2011] [Indexed: 11/19/2022] Open
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Liu CT, Chen YC, Chen TH, Ou TY. Necrotizing fasciitis of thigh associated with Escherichia coli bacteremia in a patient on chronic hemodialysis. Hemodial Int 2012; 16:564-7. [PMID: 22304536 DOI: 10.1111/j.1542-4758.2011.00658.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Necrotizing fasciitis is a lethal soft tissue infection for its rapid progression to septic shock. We present a 59-year-old male on chronic hemodialysis (HD). We made the diagnosis of necrotizing fasciitis of the right thigh due to the crepitus from physical examination and subcutaneous emphysema from an X film. He was successfully treated with antibiotics and surgical debridement. The blood and surgical drainage cultures showed Escherichia coli, which is less commonly seen in cutaneous infection. The colonoscopic finding revealed adenomatous polyps. Necrotizing fasciitis in patients on HD requires early diagnosis and aggressive treatment to ensure the favorable clinical outcomes.
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Affiliation(s)
- Chung-Te Liu
- Division of Nephrology, Department of Medicine, Taipei Medical University-Wan Fang Hospital, Taipei, Taiwan
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71
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Roje Z, Roje Ž, Matić D, Librenjak D, Dokuzović S, Varvodić J. Necrotizing fasciitis: literature review of contemporary strategies for diagnosing and management with three case reports: torso, abdominal wall, upper and lower limbs. World J Emerg Surg 2011; 6:46. [PMID: 22196774 PMCID: PMC3310784 DOI: 10.1186/1749-7922-6-46] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Accepted: 12/23/2011] [Indexed: 12/20/2022] Open
Abstract
Necrotizing fasciitis (NF) is an uncommon soft tissue infection, usually caused by toxin-producing virulent bacteria. It is characterized by widespread fascial necrosis primarily caused by Streptococcus hemolyticus. Shortly after the onset of the disease, patients become colonized with their own aerobic and anaerobic microflora from the gastrointestinal and/or urogenital tracts. Early diagnosis with aggressive multidisciplinary treatment is mandatory. We describe three clinical cases with NF. The first is a 69 years old man with diabetes mellitus type II, who presented with NF on the posterior chest wall, shoulder and arm. He was admitted to the intensive care unit (ICU) with a clinical picture of severe sepsis. Outpatient treatment and early surgical debridement of the affected zones (inside 3 hours after admittance) and critical care therapy were performed. The second case is of a 63 years old paraplegic man with diabetes mellitus type I. Pressure sores and perineal abscesses progressed to Fournier's gangrene of the perineum and scrotum. He had NF of the anterior abdominal wall and the right thigh. Outpatient treatment and early surgical debridement of the affected zones (inside 6 hour after admittance) and critical care therapy were performed. The third patient was a 56 year old man who had NF of the anterior abdominal wall, flank and retroperitoneal space. He had an operation of the direct inguinal hernia, which was complicated with a bowel perforation and secondary peritonitis. After establishing the diagnosis of NF of the abdominal wall and retroperitoneal space (RS), he was transferred to the ICU. There he first received intensive care therapy, after which emergency surgical debridement of the abdominal wall, left colectomy, and extensive debridement of the RS were done (72 hours after operation of inquinal hernia). On average, 4 serial debridements were performed in each patient. The median of serial debridement in all three cases was four times. Other intensive care therapy with a combination of antibiotics and adjuvant hyperbaric oxygen therapy (HBOT) was applied during the treatment. After stabilization of soft tissue wounds and the formation of fresh granulation tissue, soft tissue defect were reconstructed using simple to complex reconstructive methods.
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Affiliation(s)
- Zdravko Roje
- Division of Plastic Surgery and Burns, University Hospital Centre Split, Croatia
| | - Željka Roje
- Department of Surgery, University Hospital Dubrava, Zagreb, Croatia
| | - Dario Matić
- Department of Surgery, University Hospital Centre Split, Croatia
| | - Davor Librenjak
- Department of Urology, University Hospital Centre Split, Croatia
| | - Stjepan Dokuzović
- Department of Orthopedic Surgery, University Hospital Dubrava, Zagreb, Croatia
| | - Josip Varvodić
- Deparment of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia
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Steckel H, Baums MH, Tennstedt-Schenk C, Klinger HM. Necrotizing fasciitis of the knee following primary total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2011; 19:2076-9. [PMID: 21647659 DOI: 10.1007/s00167-011-1561-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2011] [Accepted: 05/19/2011] [Indexed: 10/24/2022]
Abstract
Necrotizing fasciitis is a rare, life-threatening and rapidly spreading soft-tissue infection that results in necrosis of the muscle, fascia and surrounding tissue. It can be result of a polymicrobial synergistic infection or a streptococcal infection. The authors report a case of necrotizing fasciitis occurring in the knee of a 65-year-old woman following an uneventful primary total knee arthroplasty and resulting in above-the-knee amputation. Having in mind severe infections like necrotising fasciitis, one should be aware of the possibility of such postoperative complications especially in patients with risk factors even in routine procedures like a total knee arthroplasty.
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73
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Necrotizing fasciitis of the extremities: a prospective study. Strategies Trauma Limb Reconstr 2011; 6:121-5. [PMID: 21863299 PMCID: PMC3225576 DOI: 10.1007/s11751-011-0116-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2010] [Accepted: 07/09/2011] [Indexed: 12/02/2022] Open
Abstract
Necrotizing fasciitis is a rapidly progressive infection and is a necrosis of the fascia and surrounding tissues. Despite recent advances in its management, outcomes have not improved and mortality rate is still high. Between September 2007 and August 2009, we prospectively studied twenty-four histopathologically proven necrotizing fasciitis patients to assess the prognostic factors that indicate the outcome. Mortality rate was 20.8%. Twelve patients (50%) improved, while seven patients (29.2%) were complicated by limb loss. Mortality rates related to upper and lower limb involvement were similar (20% vs. 22.2%). The rates of gangrene and amputation in patients with diabetes mellitus were significantly higher than other comorbidities. Patients with gram-positive infections had significantly lower rates of amputation (15.4% vs. 54.5%, P = 0.04). Mean band cell count and serum potassium level were significantly higher in the nonsurvivors same as leukocyte count in the patients with gangrene, while serum sodium level was significantly lower in nonsurvivors. We conclude that hyponatremia, hyperkalemia, and increased band cells in the peripheral blood of patients may be useful parameters in distinguishing life-threatening necrotizing fasciitis; hence, we recommended lower threshold to amputation during surgery for this group of patients.
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74
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Chen IC, Li WC, Hong YC, Shie SS, Fann WC, Hsiao CT. The microbiological profile and presence of bloodstream infection influence mortality rates in necrotizing fasciitis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R152. [PMID: 21693053 PMCID: PMC3219026 DOI: 10.1186/cc10278] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Revised: 05/27/2011] [Accepted: 06/21/2011] [Indexed: 11/23/2022]
Abstract
Introduction Necrotizing fasciitis (NF) is a life threatening infectious disease with a high mortality rate. We carried out a microbiological characterization of the causative pathogens. We investigated the correlation of mortality in NF with bloodstream infection and with the presence of co-morbidities. Methods In this retrospective study, we analyzed 323 patients who presented with necrotizing fasciitis at two different institutions. Bloodstream infection (BSI) was defined as a positive blood culture result. The patients were categorized as survivors and non-survivors. Eleven clinically important variables which were statistically significant by univariate analysis were selected for multivariate regression analysis and a stepwise logistic regression model was developed to determine the association between BSI and mortality. Results Univariate logistic regression analysis showed that patients with hypotension, heart disease, liver disease, presence of Vibrio spp. in wound cultures, presence of fungus in wound cultures, and presence of Streptococcus group A, Aeromonas spp. or Vibrio spp. in blood cultures, had a significantly higher risk of in-hospital mortality. Our multivariate logistic regression analysis showed a higher risk of mortality in patients with pre-existing conditions like hypotension, heart disease, and liver disease. Multivariate logistic regression analysis also showed that presence of Vibrio spp in wound cultures, and presence of Streptococcus Group A in blood cultures were associated with a high risk of mortality while debridement > = 3 was associated with improved survival. Conclusions Mortality in patients with necrotizing fasciitis was significantly associated with the presence of Vibrio in wound cultures and Streptococcus group A in blood cultures.
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Affiliation(s)
- I-Chuan Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No,6, W, Sec,, Jiapu Rd,, Puzih City, Chiayi County 613, Taiwan
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75
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Abstract
Complex wounds present a challenge to both the surgeon and patient in operative management, long-term care, cosmetic outcome, and effects on lifestyle, self-image, and general health. Each patient with complex wounds usually manifests multiple risk factors for their development. This article focuses on complex wounds involved with traumatic and orthopedic blunt or penetrating injuries, particularly in the extremities, as well as massive soft tissue infections including necrotizing fasciitis, gas gangrene, and Fournier gangrene. The principles of management of complex wounds involve assessing the patient's clinical status and the wound itself, appropriate timing of intervention, providing antibiotic therapy when necessary, and planning and executing surgical therapy, including the establishment of a clean wound bed and closure/reconstructive strategies.
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Affiliation(s)
- Habeeba Park
- Department of Surgery, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215, USA
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76
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Abstract
We report an exceptional case of life-threatening Escherichia coli-induced necrotizing fasciitis. A combined host-pathogen genetic analysis explained the phenotype: the host displayed a susceptibility to intravascular coagulation, and the strain was capable of producing a necrotic toxin (cytotoxic necrotizing factor 1), showing how E. coli can be a dermonecrotic pathogen.
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77
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Tsai YH, Hsu RWW, Huang KC, Huang TJ. Laboratory indicators for early detection and surgical treatment of vibrio necrotizing fasciitis. Clin Orthop Relat Res 2010; 468:2230-7. [PMID: 20232179 PMCID: PMC2895833 DOI: 10.1007/s11999-010-1311-y] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2009] [Accepted: 03/03/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Vibrio necrotizing fasciitis is a rare and life-threatening soft tissue infection, with fulminant clinical courses and high mortality rates. However, the lack of specific disease characteristics and diagnostic tools during the initial examination may delay diagnosis. QUESTIONS/PURPOSES We (1) asked whether the clinical indicators could predict laboratory findings during the initial stage of Vibrio necrotizing fasciitis and (2) determined the relationships between the laboratory risk indicator for necrotizing fasciitis (LRINEC) score and the diagnosis of Vibrio infection. METHODS We retrospectively reviewed 70 patients with 71 episodes of Vibrio necrotizing fasciitis and sepsis. Of the 70 patients, 68 had a history of contact with seawater or raw seafood; 66 had underlying chronic diseases. RESULTS Eighteen patients (25.7%) died a mean 18.7 days after admission, and 52 patients survived. A systolic blood pressure of 90 mm Hg or less at the time of admission to the emergency room was associated with mortality. Patients who died had lower leukocyte counts, segmented leukocyte counts, platelet counts, and serum albumin levels compared with the patients who survived and higher counts of band forms of leukocytes. Only eight patients (11%) who survived had a LRINEC score of 6 or greater. CONCLUSIONS The LRINEC scoring system is not applicable when treating such a highly lethal disease. We propose that severe hypoalbuminemia, severe thrombocytopenia, and increased banded forms of leukocytes are laboratory risk indicators of necrotizing fasciitis that aid in pointing toward initiation of early surgery and predict a higher risk of death. LEVEL OF EVIDENCE Level III Prognostic study. See the Guidelines for Authors for complete descriptions of levels of evidence.
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Affiliation(s)
- Yao-Hung Tsai
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital at Chia-Yi, 6, West Sec, Chia-Pu Rd, Putz City, Chia-Yi, 613, Taiwan, Republic of China ,College of Medicine, Chang Gung University at Taoyuan, Taiwan, Republic of China
| | - Robert Wen-Wei Hsu
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital at Chia-Yi, 6, West Sec, Chia-Pu Rd, Putz City, Chia-Yi, 613, Taiwan, Republic of China ,College of Medicine, Chang Gung University at Taoyuan, Taiwan, Republic of China
| | - Kuo-Chin Huang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital at Chia-Yi, 6, West Sec, Chia-Pu Rd, Putz City, Chia-Yi, 613, Taiwan, Republic of China ,College of Medicine, Chang Gung University at Taoyuan, Taiwan, Republic of China
| | - Tsung-Jen Huang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital at Chia-Yi, 6, West Sec, Chia-Pu Rd, Putz City, Chia-Yi, 613, Taiwan, Republic of China ,College of Medicine, Chang Gung University at Taoyuan, Taiwan, Republic of China ,Department of Orthopedic Surgery, Xiamen Chang Gung Hospital, Xiamen, Fu-Jian, China
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78
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Phanzu MD, Bafende AE, Imposo BBD, Meyers WM, Portaels F. Under treated necrotizing fasciitis masquerading as ulcerated edematous Mycobacterium ulcerans infection (Buruli ulcer). Am J Trop Med Hyg 2010; 82:478-81. [PMID: 20207877 DOI: 10.4269/ajtmh.2010.09-0256] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
We report a case of under treated necrotizing fasciitis (NF) in a 65-year-old woman with diabetes misdiagnosed as Mycobacterium ulcerans infection. She came to the Institut Médical Evangélique (IME) with an extensive painful edematous ulcerated lesion on the dorsum of the right foot and ankle. The diagnosis of Buruli ulcer (BU) was based initially on clinical findings and place of residence (Songololo Territory, the largest known focus of BU in Bas-Congo province). Tissue specimens gave negative results for acid-fast bacilli (AFB), culture, and polymerase chain reaction (PCR) for M. ulcerans. Histopathologic analysis revealed marked necrosis of the lower dermis and subcutaneous tissue. No AFB was found. Later, scattered foci of intracellular gram-positive cocci typical of streptococci were seen. Clinicopathologic correlation of these findings strongly supported the diagnosis of NF. This patient shows the difficulties that may be encountered even in known endemic areas in recognizing BU cases purely on clinical findings.
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Affiliation(s)
- Mavinga D Phanzu
- Institut Médical Evangélique, Kimpese, Bas-Congo, Democratic Republic of Congo.
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79
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Raffoul T, Fournier B, Lecomte C. Dermohypodermite bactérienne nécrosante avec fasciite nécrosante après un traumatisme fermé. ANN CHIR PLAST ESTH 2010; 55:78-81. [DOI: 10.1016/j.anplas.2008.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2008] [Accepted: 12/05/2008] [Indexed: 11/16/2022]
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80
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Sunderland IR, Friedrich JB. Predictors of mortality and limb loss in necrotizing soft tissue infections of the upper extremity. J Hand Surg Am 2009; 34:1900-1. [PMID: 19969198 DOI: 10.1016/j.jhsa.2009.08.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2009] [Accepted: 08/30/2009] [Indexed: 02/02/2023]
Affiliation(s)
- Ian R Sunderland
- Division of Plastic Surgery, University of Washington, Seattle, WA, USA
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81
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Khanna AK, Tiwary SK, Kumar P, Khanna R, Khanna A. A case series describing 118 patients with lower limb necrotizing fasciitis. INT J LOW EXTR WOUND 2009; 8:112-6. [PMID: 19443900 DOI: 10.1177/1534734609334809] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Necrotizing fasciitis of the lower limb is not uncommon, with poor outcome. This study reviewed 118 cases (78 males and 40 females) with mean age of 45 + 16.5 years (range 12-95 years) of lower limb necrotizing fasciitis admitted to the Department of Surgery, BHU in India between 1995 and 2007. Most patients (n = 97) presented with fever. Other presenting symptoms included painful swelling, bullae, erythema, ulcer, and necrosis. Comorbid conditions such as diabetes, tuberculosis, malignancy, and immunosuppressive therapy were associated in 72 (61%) cases. Amputations were done in 24 patients. Thirty one patients developed septic shock. Renal dialysis was done in 16 patients and ventilatory support was needed in 12 patients. The most common organism identified was beta-hemolytic streptococci (n = 42). Eighteen patients died, a mortality of 15%. The authors consider early diagnosis and aggressive surgical intervention to be crucial for the successful treatment of disease.
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Affiliation(s)
- A K Khanna
- Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India.
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82
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Naqvi GA, Malik SA, Jan W. Necrotizing fasciitis of the lower extremity: a case report and current concept of diagnosis and management. Scand J Trauma Resusc Emerg Med 2009; 17:28. [PMID: 19527519 PMCID: PMC2704167 DOI: 10.1186/1757-7241-17-28] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2009] [Accepted: 06/15/2009] [Indexed: 11/24/2022] Open
Abstract
Necrotizing fasciitis is a severe soft tissue infection characterized by rapidly progressing necrosis, involving subcutaneous tissues. This rare condition carries high mortality rate and require prompt diagnosis and urgent treatment with radical debridement and antibiotics. We describe a case of 21-year old man who presented with the history of trivial injury to the knee. Initially he was admitted and treated for septic arthritis but later was diagnosed as necrotizing fasciitis which was successfully treated with no ill effects what so ever from this devastating condition. This rare condition has been reported in literature but still early diagnosis, which is a key for successful treatment, remains a challenge.
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Affiliation(s)
- GA Naqvi
- Department of Orthopaedics, Our Lady of Lourdes Hospital, Drogheda, Republic of Ireland
| | - SA Malik
- Department of Orthopaedics, Our Lady of Lourdes Hospital, Drogheda, Republic of Ireland
| | - W Jan
- Department of Orthopaedics, Our Lady of Lourdes Hospital, Drogheda, Republic of Ireland
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