Unusual cases of necrotizing fasciitis: a clinical experience from Turkey

Gender and Racial Differences in the Provision of Palliative Care Services Among Critically ill Necrotizing Fasciitis and Septic Shock Geriatric Patients: Analysis of a Nationwide Database in the United States

Introduction: Necrotizing fasciitis (NF) and sepsis shock (SS) are both severe and life-threatening conditions requiring specialized care, including palliative care (PC), to optimize comfort. However, data on the utilization of PC in this population, including racial and gender differences, are limited. Methods: We used the National Inpatient Sample (NIS) database from 2016 to 2020 to extract data on patients with NF and SS as well as PC utilization. Chi-squared tests and multivariate linear regression models were utilized to analyze relationships between categorical and continuous variables, respectively. Multivariable logistic regression was used to determine adjusted odds ratios (aORs) and 95% confidence intervals (CI) for various outcomes among various gender and racial groups. Mann-Kendall trend test was used to assess mortality trends over time. Results: Among the 11,260 patients with NF and SS, 2,645 received PC whereas 8,615 did not. Female patients had significantly higher odds of receiving PC versus males (aOR: 1.42, 95% CI 1.27-1.58). No significant racial differences in PC utilization were observed. Patients receiving PC had higher odds of in-hospital mortality (aOR: 1.18, 95% CI 1.03-1.35). No significant trend in in-hospital deaths was observed over the study period. PC was associated with significantly shorter length-of-stay and lower costs. Conclusion: Our study provides comprehensive insights, and identifies gender differences in PC utilization in NF and SS patients. Further research must aim to refine delivery strategies and address potential differences in PC.

Meleney's Gangrene of the Abdomen Managed With Serial Debridement and Negative Pressure Wound Therapy: A Case Report

Meleney's gangrene (necrotizing fasciitis (NF)), also known as progressive bacterial synergistic gangrene, is a potentially fatal subcutaneous tissue infection with abdominal wall necrosis that progresses rapidly and systematically. It has been observed to exhibit the cultural characteristics of a symbiotic organism. Due to its rarity and high mortality rate, this infection needs to be diagnosed promptly and treated aggressively with antibiotics and rigorous debridement. There are several approaches to management, which include intravenous antibiotics, aggressive debridement, and dressings, along with the application of negative pressure wound therapy (NPWT). Herein, we report the case of a 45-year-old male patient with type 2 diabetes mellitus who presented to our facility after being bitten by an insect and exhibiting symptoms of Meleney's gangrene of the abdomen.

Meleney's gangrene managed with a single extensive debridement and resultant defect closure with abdominoplasty technique - a case report

Introduction

Meleney's gangrene, or progressive bacterial synergistic gangrene, is a life-threatening subcutaneous tissue infection and skin necrosis of the abdomen that is persistent and quickly progressing and has documented cultural characteristics of a symbiotic organism. The nobility of this case lies in the use of the modern technique, abdominoplasty, used to close the wound post-radical debridement for Meleney's gangrene. This uncommon illness has a high fatality rate and requires immediate diagnosis, aggressive antibiotic treatment, and extensive debridement.

Case presentation

We report the case of a 55-year-old female with no known comorbidities, who presented to our center with features of Meleney's gangrene and pleural effusion. Radical debridement was performed and empirical intravenous antibiotics were administered. The wound was closed using the abdominoplasty approach.

Clinical discussion

Meleney's gangrene should be identified quickly and treated with wide-spectrum antibiotics and rigorous surgical debridement. It is difficult to diagnose the illness early, and skepticism is strong during this process. An increased risk of death may follow a postponed diagnosis of Meleney's gangrene. A long-term hospital stay can result from extensive debridement. Furthermore, skin transplants may be required to close wounds in certain instances.

Conclusion

This case is presented to show how early intervention and radical debridement can improve the outcome in cases of Meleney's gangrene, which is rare and clinically significant. Additionally, this suggests that a cosmetic procedure known as abdominoplasty could be a viable option for wound closure.

Necrotizing fasciitis - two case reports and literature review

<b><br>Introduction:</b> Necrotizing fasciitis (NF) is a rare, rapidly progressing infection of the skin and subcutaneous tissue. NF can lead to massive tissue necrosis, resulting in sepsis, septic shock and death. In this disease, it is important to quickly diagnose and implement appropriate treatment.</br> <b><br>Aim:</b> Analysis of the diagnostic and therapeutic process in two clinical cases and a review of the literature on the methods of diagnosis and treatment of necrotizing fasciitis.</br> <b><br>Material and methods:</b> The medical data of two patients hospitalized in the St Alexander Hospital in Kielce from December 2022 to June 2023 due to necrotizing fasciitis were analyzed. Also literature search across PubMed, Medline and Research Gate databases from 2000 up to 2023 was performed. We reviewed English literature according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. The following keywords were used: necrotizing fasciitis, etiopathogenesis, pathophysiology, management.</br> <b><br>Results:</b> The research group consisted of two male patients with NF after trauma, in different parts of the body. Based on the clinical examination, the results of laboratory and imaging tests, a diagnosis was made and appropriate treatment was initiated. Despite the applied treatment, one patient died as a result of progressive multiple organ failure.</br> <b><br>Conclusions:</b> Despite advances in diagnosis and treatment, including universal access to antibiotics, necrotizing fasciitis still cause high mortality. The microbiological complexity of the majority of cases and non-specific symptoms make the diagnostic and therapeutic process difficult. Taking into account necrotizing fasciitis each time in the differential diagnosis of inflammation of the skin and subcutaneous tissue, especially based on trauma, will allow to reduce morbidity and mortality in this disease.</br>.

Necrotizing Fasciitis of the Upper Extremity - A Review

Necrotizing fasciitis is a soft tissue infection that habitually originates from the fascial sheaths, expands at a volant pace, leads to extensive necrosis of the subcutaneous tissues, and eventually ends up in a life-threatening condition with notably elevated amputation and mortality rates. Factors that induce interruption of skin integrity, such as trauma or intravenous drug use, are the most common inciting events. Specific clinical signs heralding its presence are usually absent in the early stages, often resulting in misdiagnosis. Early recognition, prompt and aggressive surgical debridement, antibiotic use, and supportive care constitute the fundamental principles to lean on for a better prognosis. Necrotizing fasciitis of the upper extremity is relatively rare and consequently holds a limited place in the literature. Only a few studies assess it as a separate entity, with most of them being case reports or small case series. We, therefore, performed a review of the current literature, to assemble the dispersed results of different studies and clarify the various aspects of upper limb necrotizing fasciitis. In this systematic review, we present the epidemiological data, the causative events, the most frequent underlying diseases, the risk factors, the amputation and mortality rates, the pathogenic microorganisms, the clinical characteristics, the diagnostic tools, the medical and surgical management concerning necrotizing fasciitis of the upper limb. Finally, the results indicating its differentiation compared to necrotizing fasciitis of other anatomic sites are remarkably highlighted.

Necrotizing fasciitis a review

Necrotizing fasciitis is an uncommon, rapidly progressive, often aggressive bacterial infection that causes extensive necrosis of the subcutaneous tissue and fascia, relatively sparing the muscle and skin tissues. Rapid diagnosis of the disease is mandatory because the delay in initiation of aggressive treatment negatively influences the outcome. Specific clinical signs may not be always present, which makes an accurate and timely diagnosis difficult. Based on the literature, this article presents a review of the historical background, etiology, pathophysiology, clinical findings, diagnostic strategies, treatment and prognosis of the disease.

Flap coverage for necrotising soft tissue infections: A systematic review

BACKGROUND

Necrotising soft tissue infections (NSTI) are destructive and often life-threatening infections of the skin and soft tissue, necessitating prompt recognition and aggressive medical and surgical treatment. After debridement, the aim of surgical closure and reconstruction is to minimize disability and optimize appearance. Although skin grafting may fulfil this role, techniques higher on the reconstructive ladder, including local, regional and free flaps, are sometimes undertaken. This systematic review sought to determine the circumstances when this is true, which flaps were most commonly employed, and for which anatomical areas.

METHODS

A systematic review of the literature was conducted utilising electronic databases (Medline, Embase, Cochrane Library). Full text studies of flaps used for the management of NSTI's (including Necrotising Fasciitis and Fournier Gangrene) were included. The web-based program 'Covidence' facilitated storage of references and data management. Data obtained in the search included reference details (journal, date and title), the study design, the purpose of the study, the study findings, number of patients with NSTI included, the anatomical areas of NSTI involved, the types of flaps used, and the complication rate.

RESULTS

After screening 4555 references, 501 full text manuscripts were assessed for eligibility after duplicates and irrelevant studies were excluded. 230 full text manuscripts discussed the use of 888 flap closures in the context of NSTI in 733 patients; the majority of these were case series published in the last 20 years in a large variety of journals. Reconstruction of the perineum following Fournier's gangrene accounted for the majority of the reported flaps (58.6%). Free flaps were used infrequently (8%), whereas loco-regional muscle flaps (18%) and loco-regional fasciocutaneous flaps (71%) were employed more often. The reported rate of partial or complete flap loss was 3.3%.

CONCLUSION

Complex skin and soft tissue defects from NSTIs, not amenable to skin grafting, can be more effectively and durably covered using a spectrum of flaps. This systematic review highlights the important contribution that the plastic surgeon makes as an integral member of multidisciplinary teams managing these patients.