Predictors of mortality in patients with necrotizing fasciitis

Can The Systemic Immune-Inflammation Index (SII) and Charlson Comorbidity Index (CCI) be used to predict mortality in patients with necrotizing fasciitis?

PURPOSE

This study aimed to determine the impact of mortality and morbidity indices on the diagnosis and prognosis of patients suffering from necrotizing fasciitis.

METHODS

A retrospective analysis was performed on 41 patients (26 females, 15 males) with necrotizing fasciitis (NF). The SII (Systemic Immune-Inflammation Index) was computed using the formula SII = (P × N)/L, where P, N, and L measure the counts of peripheral platelets, neutrophils, and lymphocytes, respectively. This study evaluated the clinicopathological characteristics and follow-up information to assess the comparative effectiveness of SII, CCI (Charlson Comorbidity Index), and LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) scores as mortality and morbidity indices for patients with NF.

RESULTS

The optimal cut-off for SII was determined to be 455. The SII value in the group with mortality was significantly higher compared to the group without mortality (p < 0.05). The CCI value in the group with mortality was significantly higher than the group without mortality (p < 0.05). The SII and CCI values were found to be effective in distinguishing between patients who suffered mortality and those who did not.

CONCLUSION

SII is a powerful tool for predicting mortality in patients with necrotizing fasciitis (NF). The SII index provides a novel, easily accessible, and inexpensive indicator for monitoring the progress and predicting the survival of patients with NF.

Severe skin and soft tissue infection in cohort patients admitted in a teaching hospital in Belgium: identification of risk factors for surgery

BACKGROUND

Necrotizing soft tissue infections (NSTIs) are associated with significant mortality if not promptly diagnosed and surgically treated.

AIM

This study aims to compare patients with severe skin and soft tissue infection treated with or without a surgical intervention and to identify risk factors that can predict the need for early surgery.

METHODS

Demographics, clinical, laboratory, Risk Indicator for Necrotizing Fasciitis (LRINEC) and imaging results were retrospectively collected.

RESULTS

There were 91 non-NSTI (group 1), 26 NSTI who were operated (group 2) and eight suspected NSTI who were not operated (group 3). In the multivariate analysis, skin necrosis, tachycardia, CRP value and hyperglycemia were predictive for surgery. A performance analysis revealed AUC of 0.65 (95%CI: 0.52-0.78) as to the LRINEC score for the use of surgery. The AUC for a predictive model associating four variables (heart rate, skin necrosis, CRP and glycemia at admission) was 0.71 (95%CI: 0.59-0.84). In terms of outcome, the median length of stay (LOS) was statistically higher in group 2 vs. group 1 (seven days (5-15) vs. 34 days (20-42), p < .001) and in group 2 vs. group 3 (34 days (20-42) vs. 14 days (11-19), p = .005). The overall in-hospital mortality at 30 days was 3.2% and did not statistically differ between the three groups.

CONCLUSIONS

Although the LRINEC score performed well in predicting surgery, the AUC of a model combining four predictive variables (glycemia, skin necrosis, CRP and heart rate) was superior. Further research is needed to validate this model.

IDENTIFICATION OF POTENTIALLY MODIFIABLE FACTORS TO IMPROVE RECOGNITION AND OUTCOME OF NECROTIZING SOFT-TISSUE INFECTIONS

ABSTRACT

Background : Necrotizing soft-tissue infections (NSTIs) present a surgical emergency of increasing incidence, which is often misdiagnosed and associated with substantial mortality and morbidity. A retrospective multicenter (11 hospitals) cohort study was initiated to identify the early predictors of misdiagnosis, mortality, and morbidity (skin defect size and amputation). Methods : Patients of all ages who presented with symptoms and were admitted for acute treatment of NSTIs between January 2013 and December 2017 were included. Generalized estimating equation analysis was used to identify early predictors (available before or during the first debridement surgery), with a significance level of P < 0.05. Results : The median age of the cohort (N = 216) was 59.5 (interquartile range = 23.6) years, of which 138 patients (63.9%) were male. Necrotizing soft-tissue infections most frequently originated in the legs (31.0%) and anogenital area (30.5%). More than half of the patients (n = 114, 54.3%) were initially misdiagnosed. Thirty-day mortality was 22.9%. Amputation of an extremity was performed in 26 patients (12.5%). Misdiagnosis was more likely in patients with a higher Charlson Comorbidity Index (β = 0.20, P = 0.001), and less likely when symptoms started in the anogenital area (β = -1.20, P = 0.003). Besides the established risk factors for mortality (septic shock and age), misdiagnosis was identified as an independent predictor of 30-day mortality (β = 1.03, P = 0.01). The strongest predictors of the final skin defect size were septic shock (β = 2.88, P < 0.001) and a skin-sparing approach to debridement (β = -1.79, P = 0.002). Conclusion : Recognition of the disease is essential for the survival of patients affected by NSTI, as is adequate treatment of septic shock. The application of a skin-sparing approach to surgical debridement may decrease morbidity.

Severe necrotizing soft tissue infections-Is wound microbiology a prognostic factor for clinical outcome?

Necrotizing soft tissue infections (NSTIs) represent similar pathophysiological features, but the clinical course might range from subacute to a rapidly progressive, fulminant sepsis. Initial wound microbiology is the base for the Guiliano classification. The timeline of microbiological colonization has not been described during the clinical course. The role of the different microbiological pathogens on the outcome and mortality is unclear. One hundred eighty patients were included with septic inflammation response syndrome on admission. Initial wound microbiology and the changes in wound microbiology were analysed during the clinical course and correlated with outcome and risk indicators. Overall mortality was 35%. Higher age, a high Charlson Comorbidity Index or ASA score and truncal infections were highly prognostic for a lethal outcome. Microbiological findings revealed significant differences in the persistence of bacteria during the course of disease. Streptococci were only detectable within the first 5 days, whereas other bacteria persisted over a longer period of time. Initial microbiological findings correlated with better prognosis when no causative agent was identified and for gram-negative rods. Varying survival rates were observed for different Streptococci, Staphylococci, Enterococci and other bacteria. The highest odds ratio for a lethal outcome was observed for Enterococci and fungi. Microbiological colonization changes during the clinical course of NSTIs and some microbiologic pathogens are predictive for worsening the outcome and survival. Streptococcus pyogenes is only detectable in the very early phase of NSTI and after 6 days not anymore detectable. Later Enterococci and fungi showed the highest odds ratios for a lethal outcome. Enterococci bacteria and fungi have yet not been considered of clinical relevance in NSTI or even as indicator for worsening the outcome.

Initial skin necrosis presentation at emergency room was associated with fulminant clinical course and mortality in patients with Vibrio necrotizing fasciitis

Necrotizing fasciitis (NF) is a life-threatening infection. Skin necrosis is an important skin sign of NF. The purposes of this study was to investigate the initial skin conditions of Vibrio NF patients between emergency room (ER) to preoperative status, to compare the clinical and laboratory risk indicators of the skin necrosis group and non-skin necrosis group when they arrived at ER, and to evaluate whether initial cutaneous necrosis related to fulminant course and higher fatalities. From 2015 to 2019, seventy-two Vibrio NF patients with surgical confirmation were enrolled. We identified 25 patients for inclusion in the skin necrosis group and 47 patients for inclusion in the non-skin necrosis group due to the appearance of skin lesion at ER. Seven patients died, resulting in a mortality rate of 9.7%. Six patients of skin necrosis group and one patient of non-skin necrosis group died, which revealed the skin necrosis group had a significantly higher mortality rate than the non-skin necrosis group. All the patients in the skin necrosis group and 30 patients of non-skin necrosis group developed serous or hemorrhagic bullous lesions before operation (p = 0.0003). The skin necrosis group had a significantly higher incidence of APACHE score, postoperative intubation, Intensive care unit stay, septic shock, leukopenia, higher counts of banded leukocytes, elevated C-reactive protein (CRP), and lower serum albumin level. Vibrio NF patients presenting skin necrosis at ER were significantly associated with fulminant clinical courses and higher mortality. Physicians should alert the appearance of skin necrosis at ER to early suspect NF and treat aggressively by those clinical and laboratory risk indicators, such as elevated APACHE score, shock, leukopenia, higher banded leukocytes, elevated CRP, and hypoalbuminia.

Predictors of Mortality in Patients With Necrotizing Fasciitis: A Literature Review and Multivariate Analysis

Background

Necrotizing fasciitis (NF) is a life-threatening infectious disease that can result in significant morbidity and mortality. Previously identified factors have not been verified in a large population. The objective of this study is to further examine the relationship of patient factors in NF mortality.

Methods

This study is a retrospective review on patients ≥18 years old diagnosed with NF at the provincial referral centres from 2004 to 2016. The following data were examined: demographics, comorbidities, laboratory values, length of stay, and inhospital mortality.

Results

Three hundred forty patients satisfied the inclusion criteria: 297 survived and were discharged, 43 died in hospital. In multivariate analysis, a prognostic model for NF mortality identified age >60 years, elevated creatinine, abnormal blood platelets, and group A β-hemolytic Streptococcus (GABS) infection.

Conclusions

Multiple factors were associated with mortality in NF. The strongest univariate association with mortality was age >60 years. In addition, a history of hypertension and/or dyslipidemia, renal disease, and the presence of GABS contributed to a predictive model for inhospital NF mortality.

Head and Neck Necrotizing Fasciitis: Abbreviated SOFA Score Associated With Death and Infection Spread

Objective

Describe features unique to head and neck (H&N) necrotizing fasciitis (NF) compared to other anatomic regions and specify a prognostic score associated with death and descending necrotizing mediastinitis (DNM).

Study Design

Retrospective cohort.

Setting

Tertiary care, level 1 trauma center.

Methods

A single-institution database identified 399 confirmed cases of NF between 2006 and 2021, 33 of which involved the H&N. Patients with confirmed H&N NF were sorted into cohorts based on clinical outcomes, with the "poor" outcomes group defined by death and/or DNM.

Results

Thirty-three patients with H&N NF were included. Compared to NF of other regions, patients with H&N NF had a significantly lower mortality rate (6.06% vs 20.8%, p = .041) and significantly lower rates of obesity (27.3% vs 63.7%, p < .001) and hypertension (42.4% vs 60.9%, p = .038). Within the H&N group, there were 2 deaths (6.06%) and 8 cases of DNM (24.2%). Diabetes was associated with poor outcomes (p = .047), as was an abbreviated sequential organ failure assessment score for necrotizing fasciitis (nfSOFA) of 2 or greater (p = .015).

Conclusion

H&N NF is unique among other forms of NF, with a lower mortality rate and lower rates of obesity and hypertension in affected patients. Within the H&N cohort, worse outcomes were associated with diabetes as well as a nfSOFA score of 2 or greater. Timely surgical debridement alongside broad-spectrum antibiotics remains the mainstay of treatment for NF; however, this simple prognostic score may play a role during the early stages of care for patients with H&N NF.

Fournier's Gangrene: Microbiological Profile and Risk Factors for Mortality: Review of 97 Cases

Objective

Fournier's gangrene (FG) is a rare necrotizing fasciitis affecting genital and perianal areas. This study aimed to provide data on predicting factors, mortality rates, and factors affecting mortality in comparison of survivors and non-survivors in patients with FG.

Materials and Methods

This study included a retrospective analysis of patients diagnosed with FG between 2008 and 2018.

Results

A total of 97 patients with FG were included in this study. Of the patients, 72 (74%) were male. The mean age was 56.03±13.92 years, and the median was 57 (21-90). The mortality rate was 21.6%. The most frequently isolated microorganism from tissue and blood cultures was Escherichia coli (43%-42%). The median Fournier's Gangrene Severity Index (FGSI) and Uludağ FGSI (UFGSI) scores were 4 (0-20) and 5 (1-22), respectively. In the univariate model, mortality risk increases 7.18 times (p=0.001) in patients with two or more comorbidities, 1.31 times as the FGSI score increases (p<0.001), 1.28 times as the UFGSI score increases (p<0.001). When the cut-off value was set as 8 for the FGSI score, the sensitivity was 71.43%, and the specificity was 73.68%. The sensitivity was 73.43%, and the specificity was 75% when the cut-off value was set as 6 for the UFGSI score. In the univariate model, the mortality risk of those with hypotension was 6.07 times higher (p=0.003); as the platelet count increased, mortality risk decreased (odds ratio [OR]=0.99; p=0.02). The mortality risk of those hospitalized in the intensive care unit (ICU) was 16.5 times higher than those followed in the ward (p<0.001). In the multivariate model, this ratio was 6.49.

Conclusion

We concluded that FGSI and UFGSI scores could be used to predict mortality. Management of FG requires a multidisciplinary approach. Empiric treatment should include carbapenems and be de-escalated once getting the culture results. Authors from different centers should report their experiences to help reveal the ideal treatment and evaluate the consequences.

Causative Micro-Organisms in Necrotizing Fasciitis and their Influence on Inflammatory Parameters and Clinical Outcome

Background: Necrotizing fasciitis (NF) is a potentially fatal soft tissue infection. Four types of pathogens can be distinguished in the pathogen spectrum, although there are strong regional differences with regard to the most common pathogens. Patients and Methods: All cases of NF between 2003 and 2021 with an identified causative agent were analyzed retrospectively. The cases were divided into three groups: polymicrobial, gram-positive and gram-negative. Demographic factors, localization of infection, inflammatory parameters, and clinical outcome were compared between the three groups. Results: A total of 95 cases were analyzed, 41% of which were caused by multiple pathogens. A gram-positive pathogen was reported in 40% of cases and a gram-negative pathogen in 19%. There were significant differences between the three groups with respect to age (with patients in the gram-negative group being on average the oldest) and intensive care unit admissions (which was most frequent in the polymicrobial group). Conclusions: The pathogen spectrum of NF has rarely been studied in a large patient population. Gram-positive pathogens account for the majority of monomicrobial infections in our study. Nevertheless, we recommend calculated broad-spectrum antibiotic therapy given the high number of polymicrobial infections and gram-negative infections. Gram-negative infections may be associated with increased mortality, elevated procalcitonin levels, and are relatively frequent in NF of the lower extremities.

MRSA Causing Necrotizing Fasciitis in 18-Month-Old Boy

Necrotizing fasciitis is a rare and fulminant infection of the superficial fascia and subcutaneous cellular tissue. It is commonly polymicrobial, with the combination of aerobic and anaerobic bacteria, which contributes to the rapid progression and severity of the disease. The microbes commonly involved include group A streptococcus, Enterobacteriaceae, anaerobes, and Staphylococcus aureus. Over the past few years, skin and soft tissue infections, including necrotizing fasciitis, due to methicillin-resistant Staphylococcus aureus are increasing.

Rational Use of Antibiotics and Education Improved Aeromonas Necrotizing Fasciitis Outcomes in Taiwan: A 19-Year Experience

BACKGROUND

Aeromonas necrotizing fasciitis (NF) causes high rates of amputation and mortality, even after aggressive surgical debridement and antibacterial therapy. This study investigated the effects of rational use of antibiotics and education by infectious disease (ID) physicians on Aeromonas NF treatment outcomes.

METHODS

Retrospective review for conducted for four years (period I, without an ID physician, December 2001 to December 2005) and 15 years (period II, with an ID physician, January 2006 to March 2021). In period II, the hospital-wide computerized antimicrobial approval system (HCAAS) was also implemented. A pretest-posttest time series analysis compared the two periods. Differences in clinical outcomes, demographics, comorbidities, signs and symptoms, laboratory findings, Aeromonas antibiotic susceptibility, and antibiotic regimens were compared between the two periods.

RESULTS

There were 19 patients in period I and 53 patients in period II. Patients had a lower rate of amputation or mortality in period II (35.8%) compared with period I (63.2%). Forty-four patients (61.1%) had polymicrobial infections. In the emergency room, the rate of misdiagnosis decreased from 47.4% in period I to 28.3% in period II, while effective empiric antibiotic usage increased from 21.1% in period I to 66.0% in period II. After the ID physician's adjustment, 69.4% received monotherapy in period II compared to 33.3% in period I.

CONCLUSIONS

Because Aeromonas NF had a high mortality rate and was often polymicrobial, choosing an antibiotic regimen was difficult. Using the HCAAS by an experienced ID physician can improve rational antibiotic usage and clinical outcomes in Aeromonas NF.

Rational Use of Ceftriaxone in Necrotizing Fasciitis and Mortality Associated with Bloodstream Infection and Hemorrhagic Bullous Lesions

Necrotizing fasciitis (NF) is an uncommon life-threatening necrotizing skin and soft tissue infection. The formation of hemorrhagic bullae is a special skin sign of NF. The purposes of this study were to investigate the incidence of hemorrhagic bullae formation and bacteremia associated with different organisms, to appraise the appropriate use of ceftriaxone, and to compare the clinical and laboratory risk indicators of NF patients with Gram-positive and Gram-negative infections on the initial examination. Methods: From March 2018 to December 2020, there were seventy-four NF patients with positive monomicrobial bacterial cultures enrolled based on surgical confirmation, and were categorized into two groups: the Gram-positive group and the Gram-negative group. Ceftriaxone susceptibility tests were carried out using the standard disk diffusion technique. Data, such as demographics, clinical outcomes, microbiological results, presentations of hemorrhagic bullae, and laboratory findings, were compared among these two groups. Results: The Gram-negative group included 52 patients, of whom 6 patients died, resulting in a mortality rate of 11.5%. The Gram-positive group included 22 patients and none died. Patients with bacteremia, hemorrhagic bullae, shock, fever, higher segmented forms and banded forms, and lower platelet counts constituted higher proportions in the Gram-negative group than in the Gram-positive group. The multivariate analysis identified six variables for the differentiation of Gram-negative and Gram-positive NF: the presentation of bacteremia, hemorrhagic bullae, shock at first consultation, fever with body temperature > 38.5 °C, band forms > 0%, and segmented forms ≦ 74%. A total of 66 isolates (89.2%) was susceptible to ceftriaxone. Conclusions: Gram-negative NF patients were significantly associated with hemorrhagic bullae presentation, blood stream infection, and mortality. Physicians should be alert to NF patients with the appearance of bacteremia, shock, fever, higher WBC banded and segmented forms, and lower platelet counts at the emergency department, with patients revealed to more likely have Gram-negative infections. Ceftriaxone with/without other appropriate antibiotics under the supervision of infectious doctors appeared to be clinically effective for the treatment of NF and blood stream infections.

Necrotizing fasciitis of the extremities in high and low Charlson Comorbidity Index: A multi-center retrospective cohort study

BACKGROUND

Necrotizing fasciitis (NF) is a life-threatening and acute progressive soft tissue infection and needs early surgical intervention, that is, debridement or amputation. Surgical strategy or prognosis is influenced by the speed of progression and patients' general condition, which can be calculated by the Charlson Comorbidity Index (CCI). The purpose of this study was to investigate the association between the CCI scores and prognosis of patients with NF of the upper/lower extremities.

METHODS

In the retrospective cohort study, we analyzed patients with NF of the upper/lower extremities who were determined to undergo surgery by orthopedic surgeons at four tertiary hospitals between August 2003 and April 2016. We divided the patients into two groups, Group L (low CCI scores of 0-2) and Group H (high CCI scores of ≥3). The primary event of this study was defined as death or amputation. Mortality cases were included when amputation was informed with documented certification but patients died while waiting for surgery. We compared the patients' background, laboratory data on admission, the laboratory risk indicator for necrotizing fasciitis (LRINEC) score, and primary outcome between the two groups.

RESULTS

Of the 56 patients, 28 patients were classified into Group L and the other 28 patients into Group H. The data in this study showed that patients in Group H had lower white blood cell counts and hemoglobin and higher creatinine than Group L, but there was no difference in LRINEC scores between the two groups. Streptococcus pyogenes was the most common infectious agent in Group L (54%) but not in Group H (11%). Poorer outcome was observed in Group H compared with Group L (4 mortality and 16 amputation vs. no mortality and 9 amputation, P = 0.007).

CONCLUSIONS

Laboratory data and causative microorganisms were different between high CCI and low CCI patients with NF. High CCI scores were associated with limb amputation or death caused by NF of the upper/lower extremities; whereas, low CCI scores were more likely associated with S. pyogenes monoinfection.

In-hospital mortality associated with necrotizing soft tissue infection due to Vibrio vulnificus: a matched-pair cohort study

Background

It remains unclear whether Vibrio vulnificus necrotizing soft tissue infection (NSTI) is associated with higher mortality compared with non-Vibrio NSTI. This study’s objective was to compare outcomes including in-hospital mortality and prognosis between patients with V. vulnificus NSTI and those with non-Vibrio NSTI.

Method

A retrospective 1:2 matched-pair cohort study of hospitalized patients with NSTI diagnosed by surgical finding was conducted in two tertiary hospitals in southern Taiwan between January 2015 and January 2020. In-hospital outcomes (mortality, length of stay) were compared between patients with and without V. vulnificus infection. We performed multiple imputation using chained equations followed by multivariable regression analyses fitted with generalized estimating equations to account for clustering within matched pairs. All-cause in-hospital mortality and length of stay during hospitalization were compared for NSTI patients with and without V. vulnificus.

Result

A total of 135 patients were included, 45 in V. vulnificus NSTI group and 90 in non-Vibrio group. The V. vulnificus NSTI patients had higher mortality and longer hospital stays. Multivariable logistic regression analysis revealed that V. vulnificus NSTI was significantly associated with higher in-hospital mortality compared with non-Vibrio NSTI (adjusted odds ratio = 1.52; 95% confidence interval 1.36–1.70; p < 0.01).

Conclusion

Vibrio vulnificus NSTI was associated with higher in-hospital mortality and longer hospital stay which may increase health care costs, suggesting that preventing V. vulnificus infection is essential.

Necrotizing Skin and Soft Tissue Infection Due to Syncephalastrum Species and Fusarium solani Species Complex Following Open Tibia Fracture

Fungal necrotizing skin and soft tissue infection (NSSTI) represents a rare clinical entity. An extremely rare case of NSSTI, following an open tibia fracture in a 36-year-old male caused by both Syncephalastrum spp. and Fusarium solani species complex (SC) is presented. The infection was diagnosed through direct microscopy, cultures and histology. The disease had a long course. The patient underwent a total of seven consecutive surgical debridements, while proper and timely antifungal treatment was initiated and included liposomal amphotericin B and voriconazole. He gradually recovered and 4 years later he is completely functioning and healthy. Invasive fungal infections are well-documented causes of high morbidity and mortality in immunocompromised individuals, whereas in immunocompetent hosts, trauma-related fungal infections have also been reported. It is of note that Syncephalastrum spp. has very rarely been identified to cause infection in immunocompromised or immunocompetent hosts, whereas Fusarium spp. has rarely been involved in skin necrotic lesions in non-immunocompromised individuals. A high suspicion index, especially in necrotic lesions in trauma patients, is pivotal for early diagnosis, which may lead to lower mortality as well as lower amputation rates. Definite diagnosis through microscopy, histology and/or cultures are of paramount importance, whereas PCR testing may also be extremely useful.

Necrotizing Fasciitis of the Upper Limb: Optimizing Management to Reduce Complications

Background: Necrotizing fasciitis (NF) is a severe, potentially life-threatening condition. The aim of this study is to identify strategies aimed at reducing complications in patients with NF of the upper limb. Methods: We conducted a retrospective study on patients admitted to our Unit for suspected NF of the upper limb. The analyzed data included patient characteristics, delay before primary care, clinical and biological signs upon arrival, pathogens involved, and the rate of amputations and mortality. Results: A total of 21 patients presented with confirmed necrotizing bacterial dermohypodermitis-NBDH with NF (NBDH-NF) affecting the upper limb. The mean delay between the onset of symptoms and the clinical examination in the Emergency Dermatology Unit was 48 h (range: 6 to 72 h). The mean delay between admission and primary surgery was 150 min (range: 60 min to 280 min). No amputations were performed. All patients were alive one year after the first surgical procedure. Conclusions: Our study demonstrated that it is possible to reduce mortality and morbidity rates in NF of the upper limb. Timely diagnosis and early treatment and a multidisciplinary medico-surgical dedicated team providing care can significantly modify the outcomes. Early surgical debridement is the most important factor affecting the prognosis of these infections.

Comparison of LRINEC Scoring System with Finger Test and Histopathological Examination for Necrotizing Fasciitis

Background  Necrotizing fasciitis (NF) is a life-threatening condition requiring urgent attention. It is clinically difficult to diagnose, linked to severe systemic toxicity, and has poor prognosis. In 2001, Andreasen and coworkers described the "Finger test" for the diagnosis of NF. Subsequent studies have suggested early recognition and management of NF. In this study, we compare the LRINEC-Laboratory Risk Indicator for Necrotizing Fasciitis-scoring system with the "Finger test" and histopathological examination for diagnosis of NF. Results  In our study, LRINEC scoring system and Finger test are statistically significant in the diagnosis of NF. Males are more frequently affected, and the most common organism causing NF is Staphylococcus . Histopathology remained the gold standard for diagnosis of NF, while LRINEC score and Finger test were good diagnostic tools for early diagnosis, with sensitivities of 83.33 and 86.11%, respectively. Conclusion  LRINEC laboratory-based scoring system is easy and reliable diagnostic tool though histopathology remains the gold standard. There is statistically significant correlation between histopathology and laboratory criteria. LRINEC test is independently better than bedside Finger test alone or combined LRINEC and bedside Finger test.

Novel clinical risk scoring model for predicting mortality in patients with necrotizing fasciitis: The MNF scoring system

Necrotizing fasciitis (NF) is a life-threatening soft tissue infection that rapidly progresses and requires urgent surgery and medical therapy. If treatment is delayed, the likelihood of an unfavorable outcome, including death, is significantly increased. The goal of this study was to develop and validate a novel scoring model for predicting mortality in patients with NF. The proposed system is hereafter referred to as the Mortality in Necrotizing Fasciitis (MNF) scoring system. A total of 1503 patients with NF were recruited from 3 provincial hospitals in Thailand during January 2009 to December 2012. Patients were randomly allocated into either the derivation cohort (n = 1192) or the validation cohort (n = 311). Clinical risk factors used to develop the MNF scoring system were determined by logistic regression. Regression coefficients were transformed into item scores, the sum of which reflected the total MNF score. The following 6 clinical predictors were included: female gender; age > 60 years; white blood cell (WBC) ≤5000/mm3; WBC ≥ 35,000/mm3; creatinine ≥ 1.6 mg/dL, and pulse rate > 130/min. Area under the receiver operating characteristic curve (AuROC) analysis showed the MNF scoring system to have moderate power for predicting mortality in patients with NF (AuROC: 76.18%) with good calibration (Hosmer-Lemeshow χ2: 1.01; P = .798). The positive likelihood ratios of mortality in patients with low-risk scores (≤2.5) and high-risk scores (≥7) were 11.30 (95% confidence interval [CI]: 6.16-20.71) and 14.71 (95%CI: 7.39-29.28), sequentially. When used to the validation cohort, the MNF scoring system presented good performance with an AuROC of 74.25%. The proposed MNF scoring system, which includes 6 commonly available and easy-to-use parameters, was shown to be an effective tool for predicting mortality in patients with NF. This validated instrument will help clinicians identify at-risk patients so that early investigations and interventions can be performed that will reduce the mortality rate among patients with NF.

Utility of the Lactate/Albumin Ratio as a Predictor for Mortality in Necrotizing Fasciitis Patients

Background

The lactate/albumin (L/A) ratio has been proposed as a prognostic marker because the ratio is associated with multiple organ failure and mortality in critically ill patients. We aimed to investigate the clinical utility of the L/A ratio as a good prognostic indicator of mortality in a cohort of necrotizing fasciitis patients.

Method

This retrospective study was conducted in two tertiary hospitals in Taiwan between 2015 and 2020. We reviewed adult patients with measured serum lactate and albumin on the emergency department (ED) arrival to evaluate the prognostic performance of the lactate and lactate/albumin (L/A) ratio for outcome prediction.

Result

Of the 262 NF patients, 20 (7.63%) died in the hospital. The area under the receiver operating characteristic curve (AUROC) value of the L/A ratio (0.76, 95% confidence interval [CI] 0.69–0.81, P < 0.01) was higher than lactate alone (0.71, 95% CI 0.65–0.74 P < 0.01) for predicting in-hospital mortality. The optimal cutoff of the L/A ratio was 1.61. The AUROC value of the L/A ratio was better than lactate alone regardless of normal lactate level. The cutoff of L/A ratio and hypoalbuminemia showed further discriminative value for in-hospital mortality even in patients with normal lactate levels.

Conclusion

The prognostic performance of the L/A ratio was superior to a single measurement of lactate for predicting in-hospital mortality and intensive care unit (ICU) lengths in necrotizing fasciitis patients. Aggressive intervention and intensive care were necessary for high-risk NF patients upon ED arrival.

Bacteriology and mortality of necrotizing fasciitis in a tertiary coastal hospital with comparing risk indicators of methicillin-resistant Staphylococcus aureus and Vibrio vulnificus infections: a prospective study

BACKGROUND

Vibrio vulnificus has been reported as the leading causative pathogen of necrotizing fasciitis (NF) and related fatality in the coastal area. Necrotizing fasciitis caused by methicillin-resistant Staphylococcus aureus (MRSA) and V. vulnificus have high mortality rates. The purpose of this prospective study was to clarify the clinical characteristics between death and survival NF patients, to investigate bacteriologic profile and mortality of NF patients, and to compare risk indicators of MRSA and V. vulnificus NF patients.

METHODS

This prospective study was conducted in 184 consecutive NF patients over a period of three years in a tertiary coastal hospital. Differences in mortality, laboratory findings, microbiology and clinical outcomes were compared between the death and survival groups, and the V. vulnificus and MRSA subgroups.

RESULTS

Twenty patients died, resulting in a mortality rate of 10.9%, and there were 108 patients with a monomicrobial infection (58.7%). The death group had a significantly higher incidence of shock at emergency room and bacteremia than did the survival group. Vibrio species (40 cases) and S. aureus (31 cases) were the two major pathogens. Significant differences with respect to hepatic dysfunction, shock, the event with seawater or seafood contact, bacteremia, C-reactive protein, mean platelet counts, and the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score were observes between V. vulnificus and MRSA groups.

CONCLUSIONS

NF patients with both hepatic dysfunction and diabetes mellitus, bacteremia and shock have significantly higher mortality. We should be aware of the increasing incidence of monomicrobial NF and higher mortality rates of Gram-negative pathogens in the warm coastal area. LRINEC score is not a suitable diagnostic indicator for V. vulnificus NF, which is more rapidly progressive and fulminant than MRSA NF. NF needed team works by early suspicion, immediate surgical intervention and aggressive care, which can successfully decrease mortality.

Aeromonas sobria necrotizing fasciitis complicating neonatal sclerosing cholangitis

Aeromonas species can cause gastroenteritis, soft tissue infections, hepatobiliary tract and other infections. While most reported soft tissue infections have been attributed to Aeromonas hydrophila, we report a case of necrotizing fasciitis caused by Aeromonas veronii biovar sobria. Prompt and accurate diagnosis cum treatment could help save children with Aeromonas soft tissue infections from developing a bacteremia with extended morbidity and mortality.

Utility of the Laboratory Risk Indicator for Necrotizing Fasciitis Score: Comorbid Conditions Do Matter

Background: The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) has been proposed as a diagnostic tool for necrotizing soft tissue infection (NSTI). However, its utility remains underreported, particularly in patients with comorbid conditions. The purpose of this study was to identify the test characteristics of LRINEC for patients with various comorbid conditions. Patients and Methods: We conducted a retrospective study including patients with suspected NSTI. Our study patients were then relegated into the subgroups; intravenous drug use (IVDU), end-stage liver disease (ESLD), and diabetes mellitus (DM). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a positive LRINEC score (≥ 6 or 8) were calculated in reference to intra-operative findings or results of the pathologic examination. Area under the curve (AUC) using receiver operating characteristic (ROC) plots were compared between each subgroup and the overall study population using DeLong test. Results: A total of 220 patients were included for the analysis. Overall, the sensitivity was 76%, specificity of 52%, PPV of 32%, and NPV of 88%. The subgroup analysis showed low PPVs in all subgroups. The DM and ESLD groups had a high NPV (90.5% and 88.0%, respectively), whereas NPV in the IVDU group was 70.6%. The AUC and DeLong test for the subgroups were 0.649 (p = 0.902) for ESLD, 0.699 (p = 0.683) for DM, and 0.565 (p = 0.034) for IVDU. Conclusions: The LRINEC can be a useful adjunct to rule out the diagnosis of NSTI with exception of IVDU. In contrast, further diagnostic workup might be still required in those patients with positive LRINEC.

Different types of bullae of limbs with necrotizing fasciitis predict different outcome: a prospective study

Study objective

Necrotizing fasciitis (NF) is an uncommon life-threatening necrotizing skin and soft tissue infection. Bullae are special skin manifestations of NF. This study was conducted to analyze the differences between different types of bullae of limbs with NF for providing the information to emergency treatment.

Methods

From April 2015 to August 2018, patients were initially enrolled based on surgical confirmation of limbs with NF. According to the presence of different bullae types, patients were divided into no bullae group (Group N), serous-filled bullae group (Group S), and hemorrhagic bullae group (Group H). Data such as demographics, clinical outcomes, microbiological results, presenting symptoms/signs, and laboratory findings were compared among these groups.

Results

In total, 187 patients were collected, with 111 (59.4%) patients in Group N, 35 (18.7%) in Group S, and 41 (21.9%) in Group H. Group H had the highest incidence of amputation, required intensive care unit care, and most patients infected with Vibrio species. In Group N, more patients were infected with Staphylococcus spp. than Group H. In Group S, more patients were infected with β-hemolytic Streptococcus than Group H. Patients with bacteremia, shock, skin necrosis, anemia, and longer prothrombin time constituted higher proportions in Group H and S than in Group N.

Conclusions

In southern Taiwan, patients with NF accompanied by hemorrhagic bullae appear to have more bacteremia, Vibrio infection, septic shock, and risk for amputation. If the physicians at the emergency department can detect for the early signs of NF as soon as possible, and more patient’s life and limbs may be saved.

Cervical necrotizing fasciitis affects only immunocompromized patients? Diagnostic challenges, treatment outcomes and clinical management of eleven immunocompetent adult patients with a still fatal disease

PURPOSE

Cervical Necrotizing fasciitis (CNF) has been reported as an unusual rapidly progressive, life-threatening, inflammatory disease that is known to affect predominately immunocompromised patients. Few case reports have been sporadically published involving immunocompetent adults. This is the first study presents a series of immunocompetent CNF patients.

MATERIALS AND METHODS

A retrospective chart review study was performed on immunocompetent adults with CNF from January 2003 to December 2019. The diagnosis was histologically confirmed. We analyzed epidemiological, clinical, laboratory and imaging findings and discussed them along with the treatment plan.

RESULTS

A total of eleven adult patients were included in the study. The average age was 43 years, ranging from 17 to 62 years. The average hospitalization time was 28 days, ranging from 10 to 129 days. All patients presented with cervical erythema and odynophagia. The causative factors are known in nine patients. Tissue cultures demonstrated mixed flora in six patients. Seven underwent a temporary tracheostomy. Wide neck exploration incisions were performed in all patients as the diagnosis was established after imaging findings. In nine cases the anterior-upper mediastinum was affected but only in two patients extension of the surgical planes to the mediastinum was performed. Four patients developed polyserositis. Nine patients survived and two developed multiorgan failure and died.

CONCLUSION

There seem to be no differences between immunocompetent and immunocompromised CNF patients, in regards to clinical, imaging and laboratory findings as well as their treatment plan.

Non-necrotizing and necrotizing soft tissue infections in South America: A retrospective cohort study

BACKGROUND

This study analyzed and described factors related to necrotizing or non-necrotizing soft tissue infections (SSTIs) in a hospitalized patient population in Northeastern South America.

MATERIALS AND METHODS

This retrospective study included patients hospitalized with SSTIs between January 2011 and December 2016. The main factors related to necrotizing SSTIs (NSTIs) or non-necrotizing SSTIs were analyzed together or separately.

RESULTS

Of 344 SSTI patients (161 [46.8%] non-necrotizing, 183 [53.2%] necrotizing), NSTI patients had a higher incidence of heart disease (P = 0.0081) and peripheral arterial disease (PAD; p < 0.001), more antibiotic use, and longer hospital stay (P < 0.001). NSTI was associated with a 9.58, 33.28, 2.34, and 2.27 times higher risk of PAD (confidence interval [CI] 3.69-24.87), amputation (7.97-139), complications (1.45-3.79), and death (1.2-4.26), respectively, than non-necrotizing SSTI. The risk factors associated with amputation were PAD (P < 0.001) and poor glycemic control during hospitalization (P = 0.0011). Factors associated with higher mortality were heart disease (P < 0.001), smoking (P = 0.0135), PAD (P = 0.001), chronic renal failure (P = 0.0039), poor glycemic control (P = 0.0005), and evolution to limb irreversibility (P < 0.001).

CONCLUSION

Patients with NSTI have greater illness severity, with a greater association with PAD and amputation. Patients with poor glycemic control more frequently underwent amputation and died.

Mortality Risk in Necrotizing Fasciitis: National Prevalence, Trend, and Burden

Background: Necrotizing fasciitis (NF) is a fulminant, life-threating infection of fascia and subcutaneous tissue. Because of the low incidence, previous studies were statistically underpowered to assess factors associated with the risk of mortality. The aim of this study is to identify the risk factors associated with mortality in this select group of patients. Methods: A retrospective cross-sectional study was performed utilizing the Nationwide Readmissions Database, 2010-2014. The database captures 56.6% of all U.S. annual hospitalizations. Study population included inpatients admitted emergently with NF. Results: A total of 4,178 cases were included, of which 2,061(48.9%) patients had a history of diabetes mellitus (DM). The most common presentation was septicemia (39.5%) and 9.2% were admitted initially as cellulitis/abscess. Overall mortality risk was 12.6% with no substantial change in the annual trend. Mortality in patients with diabetes was substantially lower (8.5% vs. 16.5%, odds ratio [OR]: 0.44, 95% confidence interval [CI] = [0.34, 0.56], p < 0.001). Factors associated with a higher mortality risk included: older age, chronic liver diseases, disseminated intravascular coagulopathy, septic shock, pulmonary complications, acute renal failure, and not undergoing surgical intervention (p < 0.05 each). Patients who did not undergo surgical debridement were more likely to be ≥65 years of age and have multiple comorbidities. Hyperbaric oxygen therapy and intravenous immunoglobulin were used in 1.3% and 0.3% of the sample, respectively, with no reported use among patients who died. Conclusions: This study provides a new and updated perspective on the prevalence, trend, and outcomes of NF in the United States. Necrotizing fasciitis is associated with septicemia and lack of surgical intervention is associated with a higher mortality.

Prospective Validation of the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) Score for Necrotizing Fasciitis of the Extremities

OBJECTIVES

The Laboratory Risk Indicator for Necrotizing Fasciitis score was developed as a clinical decision tool for distinguishing necrotizing fasciitis from other soft tissue infections. We prospectively evaluated the performance of the Laboratory Risk Indicator for Necrotizing Fasciitis score for the diagnosis of patients with necrotizing fasciitis in the extremities.

METHODS

We conducted a prospective and observational cohort study of emergency department patients with necrotizing fasciitis or severe cellulitis in the extremities between April 2015 and December 2016. The Laboratory Risk Indicator for Necrotizing Fasciitis score was calculated for every enrolled patient. The sensitivity, specificity, positive predictive value, and negative predictive value of cut-off scores of 6 and 8 were evaluated. The accuracy of the Laboratory Risk Indicator for Necrotizing Fasciitis score was expressed as the area under the receiver operating characteristic curve.

RESULTS

A total of 106 patients with necrotizing fasciitis and 825 patients with cellulitis were included. With an Laboratory Risk Indicator for Necrotizing Fasciitis cut-off score ≥6, the sensitivity was 43% (95% confidence interval 34% to 53%), specificity was 83% (95% confidence interval 80% to 86%), positive predictive value was 25% (95% confidence interval 20% to 30%), and negative predictive value was 92% (95% confidence interval 91% to 93%); with an Laboratory Risk Indicator for Necrotizing Fasciitis cut-off score ≥8, the sensitivity was 27% (95% confidence interval 19% to 37%), specificity was 93% (95% confidence interval 91% to 94%), positive predictive value was 33% (95% confidence interval 25% to 42%), and negative predictive value was 91% (95% confidence interval 90% to 92%). The area under the receiver operating characteristic curve for accuracy of the Laboratory Risk Indicator for Necrotizing Fasciitis score was 0.696 (95% CI 0.640 to 0.751).

CONCLUSION

The Laboratory Risk Indicator for Necrotizing Fasciitis score may not be an accurate tool for necrotizing fasciitis risk stratification and differentiation between severe cellulitis and necrotizing fasciitis in the emergency department setting based on our study.

Predictors for gram-negative monomicrobial necrotizing fasciitis in southern Taiwan

BACKGROUND

Necrotizing fasciitis (NF) is a rare and life-threatening necrotizing skin and soft-tissue infection. Infectious pathogens of NF must be detected early and treated rapidly to prevent loss of limb or a fatal outcome. This study aimed to detect more reliable predictors between gram-negative and gram-positive monomicrobial NF of limbs.

METHODS

A total of 100 patients with limb monomicrobial NF were diagnosed prospectively from April 2015 to July 2018. These monomicrobial NF pathogens can be divided into gram-negative and gram-positive groups according to the result of Gram staining and final bacterial reports. Data such as demographics, seawater or seafood contact history, infectious location, comorbidities, presenting signs and symptoms, and laboratory findings were recorded and compared.

RESULTS

A total of 55 patients were infected with gram-negative organisms and 45 patients with gram-positive organisms. Among the 55 cases of monomicrobial gram-negative NF, 48 (87.3%) were caused mainly by Vibrio spp. (38, 69.1%) and Aeromonas spp. (10, 18.2%). A higher incidence of chronic kidney disease, cerebrovascular accident, tachypnea, and septic shock; a higher rate of band forms of leukocytes of more than 3%, serum lactate of more than 20 mg/dL, and C-reactive protein level of less than 150 mg/dL; prolonged prothrombin time; and a lower fibrinogen level were observed in patients with gram-negative infection. In a multivariate analysis, a higher incidence of seawater or seafood contact history (odds ratio [OR]: 66.301; 95% confidence interval [CI]: 7.467-588.702), a higher rate of hyperlactatemia (OR: 7.904; 95% CI: 1.231-50.744), and a low fibrinogen level (OR: 1.013; 95% CI: 1.004-1.023) indicated gram-negative infection.

CONCLUSIONS

In southern Taiwan, NF of limbs mainly affected the lower limbs, exhibited monomicrobial infection, and was predominated by gram-negative bacteria. Gram-negative monomicrobial NF of limbs often occurred in individuals with the more seawater or seafood contact history, hyperlactatemia, and low fibrinogen levels.

Wound Culture Utility in Negative Surgical Exploration for Necrotizing Soft Tissue Infection

Early surgical intervention decreases mortality in necrotizing soft tissue infections (NSTIs). Yet, a subset of patients will not have NSTIs (non-NSTIs) at the time of exploration. We hypothesized that NSTI and non-NSTI patients had similar causative organisms and that intraoperative wound cultures could help guide management. Culture results and outcomes were compared for all patients undergoing surgery for suspected NSTIs over a seven-year-period. Of 295 patients, 240 (81.4%) had NSTIs. Of the 55 non-NSTI patients (18.6%), 50 had cellulitis and 5 had abscesses. NSTI and non-NSTI patients had similar rates of bacteremia (20.4% vs 17.6%, P = 0.66), septic shock (15.9% vs 12.7%, P = 0.68), and mortality (10.4% vs 7.2%, P = 0.62). Wound cultures were collected more often in NSTI patients (229/240, 95.4%) than in non-NSTI patients (42/55, 76.4%, P < 0.01). Non-NSTI patients had positive deep wound cultures more than half of the time (23/42, 54.8%). The microbiologic profile was similar between groups, with Methicillin Resistant Staphylococcus aureus and Group A Streptococcus occurring with the same frequency. We advocate for deep wound cultures in all patients being evaluated operatively for NSTIs even if the exploration is considered negative because these patients have similar clinical characteristics and virulent microbiology, and culture results can help guide antimicrobial therapy.

Necrotizing skin and soft-tissue infections in the intensive care unit

BACKGROUND

Necrotizing skin and soft-tissue infections (NSTI) are rare but potentially life-threatening and disabling infections that often require intensive care unit admission.

OBJECTIVES

To review all aspects of care for a critically ill individual with NSTI.

SOURCES

Literature search using Medline and Cochrane library, multidisciplinary panel of experts.

CONTENT

The initial presentation of a patient with NSTI can be misleading, as features of severe systemic toxicity can obscure sometimes less impressive skin findings. The infection can spread rapidly, and delayed surgery worsens prognosis, hence there is a limited role for additional imaging in the critically ill patient. Also, the utility of clinical scores is contested. Prompt surgery with aggressive debridement of necrotic tissue is required for source control and allows for microbiological sampling. Also, prompt administration of broad-spectrum antimicrobial therapy is warranted, with the addition of clindamycin for its effect on toxin production, both in empirical therapy, and in targeted therapy for monomicrobial group A streptococcal and clostridial NSTI. The role of immunoglobulins and hyperbaric oxygen therapy remains controversial.

IMPLICATIONS

Close collaboration between intensive care, surgery, microbiology and infectious diseases, and centralization of care is fundamental in the approach to the severely ill patient with NSTI. As many aspects of management of these rare infections are supported by low-quality data only, multicentre trials are urgently needed.

Obligate anaerobes are abundant in human necrotizing soft tissue infection samples - a metagenomics analysis

Necrotizing soft tissue infections (NSTIs) are associated with high morbidity and mortality and are increasing in incidence. Proper identification of the microbial causes of NSTIs is a crucial step in diagnosis and treatment, but the majority of data collected are culture based, which is biased against fastidious organisms, including obligate anaerobes. The goal of this study was to address this gap in knowledge by characterizing NSTI microbial communities through molecular diagnostics. We performed 16S rRNA sequencing on human NSTI samples and identified five genera most commonly found in NSTIs (Prevotella, Bacteroides, Peptoniphilus, Porphyromonas, and Enterococcus). We found that a >70% contribution of obligate anaerobes to the bacterial population distribution was associated with NSTI mortality, and that NSTI samples, from both survivors and non-survivors, had an increased relative abundance of gram negative bacteria compared to those of abscess patients. Based on our data, we conclude that obligate anaerobes are abundant in NSTIs and a high relative abundance of anaerobes is associated with a worse outcome. We recommend increasing anaerobe antibiotic coverage during the treatment of NSTIs even when anaerobes are not found by traditional clinical microbiology methods, and especially when there is a clinical suspicion for anaerobe involvement.

A Systematic Review of the Laboratory Risk Indicator for Necrotizing Fasciitis Score and Its Utility in Orthopedics for Diagnosing Necrotizing Fasciitis in Adults

Given its association with trauma and surgery, necrotizing fasciitis is a disease orthopedists are likely to encounter. The laboratory risk indicator for necrotizing fasciitis score is an adjunct diagnostic test designed to help diagnose early necrotizing fasciitis infections, but studies evaluating the scoring system have reported conflicting results. The purpose of this systematic review was to provide clarity on the laboratory risk indicator for necrotizing fasciitis score's capabilities and when it is best used. [Orthopedics. 2019; 42(3):e288-e294.].

Chance to cut: defining a negative exploration rate in patients with suspected necrotizing soft tissue infection

Background

Necrotizing soft tissue infections (NSTI) are aggressive infections associated with significant morbidity and mortality. Despite multiple predictive models for the identification of NSTI, a subset of patients will not have an NSTI at the time of surgical exploration. We hypothesized there is a subset of patients without NSTI who are clinically indistinguishable from those with NSTI. We aimed to characterize the differences between NSTI and non-NSTI patients and describe a negative exploration rate for this disease process.

Methods

We conducted a retrospective review of adult patients undergoing surgical exploration for suspected NSTI at our county-funded, academic-affiliated medical center between 2008 and 2015. Patients were identified as having NSTI or not (non-NSTI) based on surgical findings at the initial operation. Pathology reports were reviewed to confirm diagnosis. The NSTI and non-NSTI patients were compared using χ² test, Fisher's exact test, and Wilcoxon rank-sum test as appropriate. A p value <0.05 was considered significant.

Results

Of 295 patients undergoing operation for suspected NSTI, 232 (79%) were diagnosed with NSTI at the initial operation and 63 (21%) were not. Of these 63 patients, 5 (7.9%) had an abscess and 58 (92%) had cellulitis resulting in a total of 237 patients (80%) with a surgical disease process. Patients with NSTI had higher white cell counts (18.5 vs. 14.9 k/mm³, p=0.02) and glucose levels (244 vs. 114 mg/dL, p<0.0001), but lower sodium values (130 vs. 134 mmol/L, p≤0.0001) and less violaceous skin changes (9.2% vs. 23.8%, p=0.004). Eight patients (14%) initially diagnosed with cellulitis had an NSTI diagnosed on return to the operating room for failure to improve.

Conclusions

Clinical differences between NSTI and non-NSTI patients are subtle. We found a 20% negative exploration rate for suspected NSTI. Close postoperative attention to this cohort is warranted as a small subset may progress.

Level of evidence

Retrospective cohort study, level III.

Necrotizing Soft Tissue Infections in the Vasculopathic Patient: Review of Literature

Background:

Necrotizing soft tissue infection is a surgical emergency associated with high mortality. Its presence in patients with risk factors for peripheral arterial disease such as diabetes mellitus is consistently associated with significantly poorer outcomes. Though it has been over a century since it was initially described in the literature, mortality rates remain high and treatment regimens are not standardized.

Materials and methods:

PubMed and Cochrane databases were searched for articles pertaining to necrotizing soft tissue infections. Articles were screened for relevance with the intent to compare outcomes in prospective studies of patients with diabetes mellitus or peripheral arterial disease. Patient demographics, clinical findings, mortality, rates of amputation, and morbidity were intended to be compared.

Results:

857 articles were identified, 165 duplicates were removed, and 6 prospective trials were identified for inclusion. Due to significant paucity of data, patient heterogeneity, and lack of standardization for surgical management, a descriptive review of the literature in relation to necrotizing soft tissue infections was pursued, with a focus on high-risk patients with peripheral arterial disease or diabetes mellitus.

Conclusions:

Early aggressive surgical intervention or major amputation may reduce mortality at the cost of increased disability and poorer quality of life in the long term, and may be appropriate in vasculopaths with poorly controlled diabetes and rapidly progressive fulminant infection. However, there is a deficiency in high-level evidence supporting surgical decision-making in this setting, with no standardized protocols for amputation. Future research will be needed to clarify the patient population who would benefit from radical amputation versus intention for limb salvage.

Factors Affecting Mortality Following Necrotizing Soft-Tissue Infections: Randomized Prospective Study

Background and Aim:

Necrotizing soft-tissue infections (NSTIs) are common in the Indian subcontinent and are associated with high morbidity and mortality. The aim of this paper was to correlate clinical factors and Acute Physiology Health and Chronic Health Evaluation (APACHE) II score with mortality following NSTI.

Methodology:

Patients presenting to our tertiary-care center between November 1, 2014, and December 1, 2016, with NSTI and between the age of 15 and 90 years were included and entered into a prospectively maintained database. Fifty random patients were selected from the database and were divided according to the survival outcome into two groups: Group 1-survivors and Group 2-nonsurvivors. The two groups were compared for clinical factors and APACHE II score to identify the variable which correlated with the survival.

Results:

Mean age of the study cohort (n = 50, 44 males) was 50.8 ± 17.1 years. Fournier's gangrene was the most common manifestation (64%), followed by lower limb (14%). Infection was leading cause (34%) followed by trauma (16%) and prior surgery (14%). There were 16 in-hospital deaths (32%). Two groups were similar regarding age and sex. At presentation, nonsurvival group had significantly higher body surface area involvement (P = 0.001), anemia (P = 0.023), metabolic acidosis (P < 0.0001), serum creatinine (P = 0.007), and mean APACHE II score (P < 0.001). There was no difference between time from presentation to the first debridement.

Conclusions:

We found that APACHE II is a significant predictor of mortality. Early diagnosis and prompt aggressive treatment is the only way to improve outcome. Further studies with larger sample size are warranted.

Diagnostic Performance of Initial Serum Albumin Level for Predicting In-Hospital Mortality among Necrotizing Fasciitis Patients

Background: Hypoalbuminemia is known to be associated with adverse outcomes in critical illness. In this study, we attempted to identify whether hypoalbuminemia on emergency department (ED) arrival is a reliable predictor for in-hospital mortality in necrotizing fasciitis (NF). patients. Method: A retrospective cohort study of hospitalized adult patients with NF was conducted in a tertiary teaching hospital in Taiwan between March 2010 and March 2018. Blood samples were collected in the ED upon arrival, and serum albumin levels were determined. We evaluated the predictive value of serum albumin level at ED presentation for in-hospital mortality. All collected data were statistically analyzed. Result: Of the 707 NF patients, 40 (5.66%) died in the hospital. The mean serum albumin level was 3.1 ± 0.9 g/dL and serum albumin levels were significantly lower in the non-survivor group than in the survivor group (2.8 ± 0.7 g/dL vs. 3.5 ± 0.8 g/dL). In the multivariable logistic regression model, albumin was significantly associated with in-hospital mortality (odds ratio (OR) 0.92, 95% confidence interval (CI) 0.88–0.96, p < 0.001). The area under-the-receiver-operating-characteristic curve (AUC) for in-hospital survival was 0.77 (95% CI 0.72–0.82) and corresponding sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratio were 66%, 74%, 33%, 88%, 2.25, and 0.48, respectively. High sensitivity (96%) for survival was shown at albumin level of 4.0 g/dL and high specificity (91%) for mortality was shown at a level of 2.5 g/dL. Conclusion: Initial serum albumin levels strongly predicted in-hospital mortality among patients with necrotizing fasciitis. NF patients with hypoalbuminemia on ED arrival should be closely monitored for signs of deterioration and early and aggressive intervention should be considered to prevent mortality.

Risk factors for mortality in the late amputation of necrotizing fasciitis: a retrospective study

Background

Necrotizing fasciitis (NF) is a rapidly progressive infectious disease that primarily involves the fascia and subcutaneous tissue. If not promptly treated, it can lead to morbidity as well as mortality. It can affect any part of the body, most commonly the extremities. Early and aggressive surgical treatment is the proper way of management. The purpose of this study was to identify the risk factors for mortality in late amputation among NF patients that may be used in routine clinical practice to prevent mortality.

Methods

A retrospective cohort study of hospitalized patients with NF was conducted in a tertiary teaching hospital in Taiwan between March 2015 and March 2018. All collected data were statistically analyzed.

Results

A total of 582 patients with NF were included; 35 of them had undergone amputation (7 primary and 28 late amputations), with a 6% amputation rate. Thirteen amputated patients still died eventually (all in the late amputation group). Significant risk factors for mortality identified in the late amputation group included hemorrhagic bullae (p = 0.001, OR 4.7, 95% confidence interval (CI) 2.68–8.69), peripheral vascular disease (p < 0.001, OR 3.2, 95% CI 1.12–10.58), bacteremia (p = 0.021, OR 2.87, 95% CI 2.07–5.96), and Laboratory Risk Indicator of Necrotizing Fasciitis (LRINEC) score > 8 (p < 0.001, OR 1.97, 95% CI 1.28–4.61). Vibrio vulnificus was the main causative organism based on our study, but the microbiology results showed no significant correlation.

Conclusion

NF patients with hemorrhagic bullae, comorbidity with peripheral vascular disease, presence of bacteremia, or LRINEC score > 8 should receive early and primary amputation in order to prevent mortality.

Healthcare Resource Utilization Associated with Burns and Necrotizing Fasciitis: A Single-Center Comparative Analysis

Necrotizing fasciitis (NF) patients are increasingly managed in burn units. Although treated similarly to burns, the healthcare resource utilization (HRU) in NF appears to be greater. Accurate knowledge of the HRU is important to better allocate resources and to compare outcomes between units. The goal of this study is to provide better understanding of the HRU for NF compared with burns. A retrospective chart review of patients ≥18 years admitted to two regional tertiary referral centers with either NF or burns requiring surgery. The authors examined age, sex, %TBSA, geographic region, anatomical location, length of stay (LOS) in hospital, LOS in intensive care unit, number of operative procedures, number of packed red blood cells transfused, amputation, death, and use of free tissue transfer or skin graft. There were 210 NF and 209 burn patients. The NF cohort had a smaller TBSA (3.3 vs 10.0%), longer LOS (20 vs 14 days), and consequently a longer LOS/%TBSA (6.0 vs 1.5 days). This difference persisted after adjusting for age. More of the NF cohort (44.8%) spent ≥1 day in the intensive care unit. The NF cohort also had more procedures (median 2 vs 1), required blood (46.2 vs 16.7%), died in hospital (13.3 vs 4.3%), had an amputation (12.4 vs 4.8%), or required free tissue transfer (7.6 vs 2.9%). This study shows that NF requires substantially more HRU compared with burns. This information is important in recognizing the impact of these patients on burn units and planning for allocation of appropriate resources.

Interventions for necrotizing soft tissue infections in adults

BACKGROUND

Necrotizing soft tissue infections (NSTIs) are severe and rapidly spreading soft tissue infections of the subcutaneous tissue, fascia, or muscle, which are mostly caused by bacteria. Associated rates of mortality and morbidity are high, with the former estimated at around 23%, and disability, sequelae, and limb loss occurring in 15% of patients. Standard management includes intravenous empiric antimicrobial therapy, early surgical debridement of necrotic tissues, intensive care support, and adjuvant therapies such as intravenous immunoglobulin (IVIG).

OBJECTIVES

To assess the effects of medical and surgical treatments for necrotizing soft tissue infections (NSTIs) in adults in hospital settings.

SEARCH METHODS

We searched the following databases up to April 2018: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers, pharmaceutical company trial results databases, and the US Food and Drug Administration and the European Medicines Agency websites. We checked the reference lists of included studies and reviews for further references to relevant randomised controlled trials (RCTs).

SELECTION CRITERIA

RCTs conducted in hospital settings, that evaluated any medical or surgical treatment for adults with NSTI were eligible for inclusion. Eligible medical treatments included 1) comparisons between different antimicrobials or with placebo; 2) adjuvant therapies such as intravenous immunoglobulin (IGIV) therapy compared with placebo; no treatment; or other adjuvant therapies. Eligible surgical treatments included surgical debridement compared with amputation, immediate versus delayed intervention, or comparisons of number of interventions.RCTs of hyperbaric oxygen (HBO) therapy for NSTI were ineligible because HBO is the focus of another Cochrane Review.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. The primary outcome measures were 1) mortality within 30 days, and 2) proportion of participants who experience a serious adverse event. Secondary outcomes were 1) survival time, and 2) assessment of long-term morbidity. We used GRADE to assess the quality of the evidence for each outcome.

MAIN RESULTS

We included three trials randomising 197 participants (62% men) who had a mean age of 55 years. One trial compared two antibiotic treatments, and two trials compared adjuvant therapies with placebo. In all trials, participants concomitantly received standard interventions, such as intravenous empiric antimicrobial therapy, surgical debridement of necrotic tissues, intensive care support, and adjuvant therapies. All trials were at risk of attrition bias and one trial was not blinded.Moxifloxacin versus amoxicillin-clavulanate One trial included 54 participants who had a NSTI; it compared a third-generation quinolone, moxifloxacin, at a dose of 400 mg given once daily, against a penicillin, amoxicillin-clavulanate, at a dose of 3 g given three times daily for at least three days, followed by 1.5 g three times daily. Duration of treatment varied from 7 to 21 days. We are uncertain of the effects of these treatments on mortality within 30 days (risk ratio (RR) 3.00, 95% confidence interval (CI) 0.39 to 23.07) and serious adverse events at 28 days (RR 0.63, 95% CI 0.30 to 1.31) because the quality of the evidence is very low.AB103 versus placebo One trial of 43 randomised participants compared two doses, 0.5 mg/kg and 0.25 mg/kg, of an adjuvant drug, a CD28 antagonist receptor (AB103), with placebo. Treatment was given via infusion pump for 10 minutes before, after, or during surgery within six hours after the diagnosis of NSTI. We are uncertain of the effects of AB103 on mortality rate within 30 days (RR of 0.34, 95% CI 0.05 to 2.16) and serious adverse events measured at 28 days (RR 1.49, 95% CI 0.52 to 4.27) because the quality of the evidence is very low.Intravenous immunoglobulin (IVIG) versus placebo One trial of 100 randomised participants assessed IVIG as an adjuvant drug, given at a dose of 25 g/day, compared with placebo, given for three consecutive days. There may be no clear difference between IVIG and placebo in terms of mortality within 30 days (RR 1.17, 95% CI 0.42 to 3.23) (low-certainty evidence), nor serious adverse events experienced in the intensive care unit (ICU) (RR 0.73 CI 95% 0.32 to 1.65) (low-certainty evidence).Serious adverse events were only described in one RCT (the IVIG versus placebo trial) and included acute kidney injury, allergic reactions, aseptic meningitis syndrome, haemolytic anaemia, thrombi, and transmissible agents.Only one trial reported assessment of long-term morbidity, but the outcome was not defined in the way we prespecified in our protocol. The trial used the Short Form Health Survey (SF36). Data on survival time were provided upon request for the trials comparing amoxicillin-clavulanate versus moxifloxacin and IVIG versus placebo. However, even with data provided, it was not possible to perform survival analysis.

AUTHORS' CONCLUSIONS

We found very little evidence on the effects of medical and surgical treatments for NSTI. We cannot draw conclusions regarding the relative effects of any of the interventions on 30-day mortality or serious adverse events due to the very low quality of the evidence.The quality of the evidence is limited by the very small number of trials, the small sample sizes, and the risks of bias in the included trials. It is important for future trials to clearly define their inclusion criteria, which will help with the applicability of future trial results to a real-life population.Management of NSTI participants (critically-ill participants) is complex, involving multiple interventions; thus, observational studies and prospective registries might be a better foundation for future research, which should assess empiric antimicrobial therapy, as well as surgical debridement, along with the placebo-controlled comparison of adjuvant therapy. Key outcomes to assess include mortality (in the acute phase of the condition) and long-term functional outcomes, e.g. quality of life (in the chronic phase).

[Postoperative quality of life of patients with a bacterial necrotizing dermis-hypodermitis or necrotizing fasciitis, a ten-year study]

INTRODUCTION

Bacterial necrotizing dermis-hypodermitis and necrotizing fasciitis (BNDH-NF) are serious life-threatening soft-tissue infections. The object is to evaluate the quality of life (QOL) of patients who have been operated in our plastic surgery departement.

PATIENTS AND METHODS

This is a retrospective study of cases who have been treated at Nancy University Hospital between 2005 and 2014. We analyzed the perioperative data (demographic, clinical, bacteriological), the surgical data (excision, reconstruction) and the follow up data (consequences, mortality). The quality of life was assessed by the Short-Form 36 score, and the patients' satisfaction was assessed by a four-level scale.

RESULTS

We analyzed 23 patients with an average age of 60 years (28-84 years). The main comorbidities were diabetes (43 %) and obesity (39 %). The average number of surgical excision was about 1.9 (1-5) and the average excised body surface area was about 5 % (1-16 %). The short-term mortality was about 17 %. The mortality rate has been statistically correlated with the surgically excised body surface area (short-term 95 days: P=0.02; and long-term: P=0.003). The statistical analysis has shown a strong relative linear relationship between number of surgical excision and the physical score of QOL (P<0.001), between number of surgical excision and mental score of QOL (P=0.032), and between age and physical score of QOL (P≤0.021). The statistical analysis has also shown a strong relative linear relationship between E. coli infections and physical score of QOL (P=0.01). The percentage of patients' satisfaction in our study was evaluated at 86 %.

CONCLUSION

We have found that multiple surgical excisions, an advanced age of patients and E. coli infections have been associated with poor QOL. The mortality rate increased in relation with the importance of excised body surface. In spite of the gravity of these infections, our patients were satisfied of their treatment.

Necrotizing soft tissue infection: clinical characteristics and outcomes at a reconstructive center in Jilin Province

BACKGROUND

To investigate the clinical characteristics and treatment outcomes in necrotizing fasciitis (NF) patients in a reconstructive unit in northeastern China.

METHODS

Medical records of patients diagnosed with and treated for NF in the extremities from November 2013 to December 2016 were retrospectively reviewed. Demographic data, clinical presentation, duration of signs and symptoms, location of infection, predisposing factors, causative microbiological organisms, laboratory risk indicator for necrotizing fasciitis (LRINEC) score, number of surgical debridements, length of hospital stay, treatments, and outcomes were recorded.

RESULTS

A total of 39 consecutive patients were treated for severe NF (32 male and 7 female). Diabetes mellitus and blunt trauma were the most common risk factors (13 and 9 cases, respectively). The positive predictive value of the LRINEC score in NF diagnosis was 46.2%. Mean duration of signs and symptoms was 4.6 days. Staphylococcus aureus was the most commonly isolated bacteria (20 cases). All patients underwent their first debridement within 12 h of presentation (mean, 4.6 h). Mean number of surgical treatments was 2.8 (range, 2-5) per patient, including debridements. All patients survived, and mean length of hospital stay was 30.81 (range, 21-43) days. Three patients underwent limb amputation.

CONCLUSIONS

In our clinical experience, early detection and aggressive debridement are the cornerstones of NF treatment. Antibiotic therapy and intensive care support is essential in severe cases of NF. Anaerobic tissue culture and frozen section biopsy could be adopted as routine tests for diagnosis and decision-making in NF. These findings should inform clinical decisions about the treatment of individual patients with NF.

Epidemiology and Outcomes of Hospitalized Children With Necrotizing Soft-Tissue Infections

OBJECTIVE

The purpose of this study was to evaluate the epidemiology and outcome of hospitalized children with a diagnosis of necrotizing soft-tissue infections (NSTIs).

METHODS

Demographic and outcome data of children 1 month to 18 years of age with a diagnosis of NSTI (International Classification of Diseases, 9th revision diagnosis codes 728.86 and 729.4) were extracted from the Kids' Inpatient Database 2009 and 2012. Univariate and multivariate analyses were done to determine the factors affecting mortality. The sample data were weighted to get national estimates.

RESULTS

A total of 446 children with NSTI (prevalence of 1.12/10,000 discharges) were included. Males comprised 54%. The median age was 10 (interquartile range 4-16) years. The mortality rate was 6%. In addition, 29.3% of children with NSTI were discharged to either skilled nursing facilities or to home health care compared with 4.5% of children without NSTI (odds ratio 8.9; 95% confidence interval 7.3-10.9; P < 0001). A bacterial infection was reported in 72.1% of children. An infection with Staphylococcus, Streptococcus, Gram-negative bacteria, anaerobic bacteria, methicillin-resistant Staphylococcus areus and polymicrobia was present in 34.5%, 21.8%, 8.6%, 3.9%, 18.7% and 13.6% of cases, respectively. A compartment syndrome, severe sepsis/septic shock and toxic shock were documented in 4.4%, 22.2% and 3.2% of the cases, respectively. Severe sepsis/septic shock, the need for mechanical ventilation and Hispanic race were associated with increased mortality, whereas skin/muscle surgery was associated with lower mortality.

CONCLUSIONS

NSTI in children is associated with high morbidity. The mortality is higher with the presence of severe sepsis/septic shock and among Hispanics and lower with surgical intervention.

Necrotizing fasciitis: treatment concepts and clinical results

BACKGROUND

Necrotizing fasciitis is a life-threatening soft tissue infection characterized by a rapid spreading infection of the subcutaneous tissue and in particular the fascia. The management of infected tissues requires a rapid diagnosis, immediate aggressive surgical management and an extended debridement. In some cases early amputations of the affected tissues and maximum intensive care treatment, in case of sepsis, are required. Due to a rising number of cases we aimed to evaluate our patients in a retrospective review.

METHOD

All patients diagnosed with necrotizing fasciitis from 2014 to 2016 (21 months) in our level one trauma center were identified. Their charts were reviewed and data were analyzed in terms of demographic and social information, microbiological results, therapeutic course, socio-economic outcome and mortality.

RESULTS

We found 15 patients with necrotizing fasciitis. None of these died in the observation period. The mean number of surgical interventions was seven. Two patients underwent limb amputation; diabetes mellitus was assigned with a significant higher risk for amputation. The mean hospitalization was 32 days, including 8 days on intensive care unit. Of the discovered bacteria 93% were sensitive to the initial antibiotic treatment with Ampicillin, Clindamycin and Clont.

CONCLUSION

Surgical therapy is indicated if necrotizing fasciitis is suspected. Diabetes mellitus was a clinical predictor of limb amputation in patients with necrotizing fasciitis in our cohort. Aminopenicillin ± sulbactam in combination with clindamycin and/or metronidazole is recommended as initial calculated antibiotic treatment.

Necrotizing Fasciitis: How Reliable are the Cutaneous Signs?

Necrotizing fasciitis (NF) is a surgical emergency. It is often aggressive and characterized by the rapidly progressive inflammatory infection of the fascia that causes extensive necrosis of the subcutaneous tissue and fascia, relatively sparing the muscle and skin tissue. As the disease progresses, thrombosis of the affected cutaneous perforators subsequently devascularizes the overlying skin. The course indeed can be a fulminant one. The diagnosis of NF, especially in the early stages, is extremely challenging, and it can be very close in presentation to other skin and subcutaneous tissue infections. The primary site of the pathology is the deep fascia. Necrosis of the tissues and fascia may manifest as erythema without sharp margins, swelling, warmth, shiny, and exquisitely tender areas. Pain out of proportion to physical examination findings may be observed. The subcutaneous tissue may be firm and indurated such that the underlying muscle groups cannot be distinctly palpated. Eventually, as the overlying skin is stripped of its blood supply, skin necrosis ensues and hemorrhagic bullae form. Bacteremia and sepsis invariably develop when the infection is well established. This paper discusses some of issues related to the cutaneous signs found in NF and also provides a review the current, available literature on the subject matter.

A comparison of necrotising fasciitis in diabetics and non-diabetics

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.

Pattern and predictors of mortality in necrotizing fasciitis patients in a single tertiary hospital

Background

Necrotizing fasciitis (NF) is a fatal aggressive infectious disease. We aimed to assess the major contributing factors of mortality in NF patients.

Methods

A retrospective study was conducted at a single surgical intensive care unit between 2000 and 2013. Patients were categorized into 2 groups based on their in-hospital outcome (survivors versus non-survivors).

Results

During a14-year period, 331 NF patients were admitted with a mean age of 50.8 ± 15.4 years and 74 % of them were males Non-survivors (26 %) were 14.5 years older (p = 0.001) and had lower frequency of pain (p = 0.01) and fever (p = 0.001) than survivors (74 %) at hospital presentation. Diabetes mellitus, hypertension, and coronary artery disease were more prevalent among non-survivors (p = 0.001). The 2 groups were comparable for the site of infection; except for sacral region that was more involved in non-survivors (p = 0.005). On admission, non-survivors had lower hemoglobin levels (p = 0.001), platelet count (p = 0.02), blood glucose levels (p = 0.07) and had higher serum creatinine (p = 0.001). Non-survivors had greater median LRINEC (Laboratory Risk Indicator for NECrotizing fasciitis score) and Sequential Organ Failure Assessment (SOFA) scores (p = 0.001). Polybacterial and monobacterial gram negative infections were more evident in non-survivors group. Monobacterial pseudomonas (p = 0.01) and proteus infections (p = 0.005) were reported more among non-survivors. The overall mortality was 26 % and the major causes of death were bacteremia, septic shock and multiorgan failure. Multivariate analysis showed that age and SOFA score were independent predictors of mortality in the entire study population.

Conclusion

The mortality rate is quite high as one quarter of NF patients died during hospitalization. The present study highlights the clinical and laboratory characteristics and predictors of mortality in NF patients.