[Prognostic value of the LRINEC score (Laboratory Risk Indicator for Necrotizing Fasciitis) in soft tissue infections: a prospective study at Clermont-Ferrand University hospital]

The performance of clinical risk scores in the diagnosis of necrotising fasciitis

OBJECTIVE

Necrotising fasciitis (NF) is a quickly progressing and potentially life-threatening infection, involving the fascia and subcutaneous tissues. The diagnosis of this disease is challenging, especially due to a lack of specific clinical signs. In order to ensure a better and quicker identification of NF patients, a laboratory risk indicator score has been developed for NF (LRINEC). A variant has widened this score by adding clinical parameters (modified LRINEC). This study shows current outcomes of NF and compares the two scoring systems.

METHODS

This study was conducted between 2011 and 2018, and included patient demographics, clinical presentations, sites of infection, comorbidities, microbiological and laboratory findings, antibiotic therapies and LRINEC as well as modified LRINEC scores. The primary outcome was in-hospital mortality.

RESULTS

A cohort of 36 patients, diagnosed with NF, were included in this study. The mean hospital stay was 56 days (±38.2 days). The mortality rate in the cohort was 25%. The sensitivity of the LRINEC score was 86%. Calculation of the modified LRINEC score showed an improvement of the sensitivity to 97%. The average LRINEC score and modified LRINEC score for patients who died and who survived were equal (7.4 versus 7.9 and 10.4 versus 10.0, respectively).

CONCLUSION

The mortality rate of NF remains high. The modified LRINEC score increased the sensitivity in our cohort to 97%, and this scoring system could be supportive in the diagnosis of NF for early surgical debridement.

Diagnostic and Prognostic Value of Laboratory Risk Indicator for Necrotizing Fasciitis Score

BACKGROUND

Necrotizing fasciitis (NF) is a lethal soft tissue infection involving skin and subcutaneous tissue with significant morbidity and mortality.

AIM

To validate the diagnostic and prognostic role of the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) scoring system for NF in patients who present with soft tissue infections.

METHODS

The study was conducted on 100 patients who presented with soft tissue infections. Based on the histopathological findings, they were divided into NF and non-necrotizing soft tissue infection groups. Patients were clinically assessed. The lab parameters were assessed and the LRINEC score was calculated. Patients were stratified based on score and grouped into low, intermediate, and high risk. For patients who went into sepsis, the death rate and length of hospital stay, including ICU, were noted based on the scoring system.

RESULTS

In our study, the diagnostic role of LRINEC score ≥ 6 had a sensitivity of 85.7% and specificity of 62.7%, and score ≥ 8 had a sensitivity of 67.3% and specificity of 82.3% with a positive predictive value (PPV) of 78.5 and negative predictive value (NPV) of 72.4, of which 8 is a better cut-off as a diagnostic criterion. The area under the curve was found to be 0.835. To predict the prognostic role, a cut-off value was calculated from the receiver operating characteristic curves of both mortality and sepsis patients in relation to the LRINEC score of 9. With the LRINEC score cut-off as 9, with mortality and sepsis as variables, the sensitivity was 50% and 53.3%, specificity was 94.2% and 91.4%, PPV was 78.9% and 72.7%, and NPV was 81.4% and 82%, respectively.

CONCLUSION

The LRINEC score is quick, safe, reproducible, noninvasive, cost-effective, and easily calculated, and has high sensitivity and specificity to predict early diagnosis, and it could be used for risk stratification and prognosis of necrotizing soft tissue infections.

Necrotizing Fasciitis: Evaluation of 85 Cases and Usage of LRINEC Score

Objective

The present study aims to define the characteristics of the necrotizing fasciitis (NF) cases followed at our hospital and to compare our results with the literature.

Materials and Methods

In this study, NF cases followed and treated at our hospital from January 2005 to April 2019 were evaluated retrospectively.

Results

A total of 85 cases of NF were included in the study. Of the cases, 33 (39%) were female and the median age was 59.8±13.1 years (range: 26-92 years). Diabetes mellitus (DM) (56%) was the most prevalent comorbid condition. Extremities were the most frequently involved field found in 41 (48%) of the cases followed by Fournier's gangrene found in 34 (40%) of the cases. All of the cases had undergone surgical intervention (debridement and/or amputation) and received broad-spectrum antibiotic therapy. Laboratory risk indicator for necrotizing fasciitis (LRINEC) score was calculated for 60 cases, and it was 6 or higher in 78% of them. Nineteen (22%) of 85 cases had died.

Conclusion

Necrotizing fasciitis affects generally older male patients with DM. In NF cases to avoid the higher risk of mortality, the removal of necrotic tissue via surgical procedure together with antimicrobial therapy is required urgently; therefore, it is very important to differentiate NF from soft tissue infections as soon as possible. As the LRINEC score predicted NF among nearly 80% of our patients, this score could be used as an early diagnostic tool of NF.

Level of Evidence

Level IV, case series.

Precritical abnormalities in routine blood parameters in necrotizing fasciitis

Necrotizing fasciitis is a rare and severe infectious disease that is often fatal and is characterized by the extensive necrosis of subcutaneous tissue and fascial planes. A number of clinical parameters have been intensively investigated to diagnose and assess the severity and prognosis of necrotizing fasciitis. Since it currently remains unclear whether these parameters are also abnormal before disease onset, the present study investigated this issue. We retrospectively recruited 38 patients, including 12 and 26 patients with necrotizing fasciitis and cellulitis, respectively. The results of routine blood examinations were collected at disease onset and also at baseline, which was defined as the time point before disease onset. No significant differences were observed in age or sex between the necrotizing fasciitis and cellulitis groups. However, significant differences were noted in the levels of hemoglobin, lymphocyte count, platelet count, neutrophil-to-lymphocyte ratio, sodium, creatinine, albumin, D-dimer, and Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score at disease onset. Significant differences were also observed in the levels of hemoglobin, lymphocyte count, monocyte count, platelet count, creatinine, D-dimer, and LRINEC score at baseline. Hemoglobin, platelet count, C-reactive protein, creatinine, albumin, and D-dimer levels were already abnormal at baseline in the necrotizing fasciitis group. In conclusion, the present results revealed precritical abnormalities in routine blood parameters in patients with necrotizing fasciitis. Therefore, individuals predisposed to necrotizing soft tissue infection may be identified prior to disease onset.

Necrotizing fasciitis in Indonesian adult with diabetes mellitus: Two case and review article

Background

Necrotizing fasciitis (NF) is a rare and life-threatening form of infection involving rapidly spreading inflammation and extensive necrosis of the skin, subcutaneous tissue, and superficial fascia.

Case presentation

This study reported two cases of NF in a 56-year-old female and a 38-year-old male who demonstrated typical signs and symptoms of NF. Both presented to the hospital with skin necrosis in the lower extremity, sepsis shock, and multiorgan failure. Based on the clinical presentation, physical examination, and additional examination, a diagnosis of NF was made. The LRINEC score was used to distinguish NF from other soft tissue infections. Both patients were treated with empirical antibiotics, surgical debridement and planned to be amputated, but the patients were hemodynamically unstable and passed away before the amputation proceeded.

Discussion

Delay in the diagnosis of NF increases the risk of mortality and the use of the LRINEC score is very helpful in decision making for health workers.

Conclusion

The key to the management of NF is early diagnosis, debridement, removal of necrotic tissue, amputation, and use of empirical antibiotics.

•

Early diagnosis of necrotizing fasciitis (NF) is key in the management of the disease.

•

The diagnosis of NF is established using the LRINEC score.

•

Debridement and amputation play an important role in preventing the spread of microorganisms in NF.

WSES/GAIS/WSIS/SIS-E/AAST global clinical pathways for patients with skin and soft tissue infections

Skin and soft-tissue infections (SSTIs) encompass a variety of pathological conditions that involve the skin and underlying subcutaneous tissue, fascia, or muscle, ranging from simple superficial infections to severe necrotizing infections.

Together, the World Society of Emergency Surgery, the Global Alliance for Infections in Surgery, the Surgical Infection Society-Europe, The World Surgical Infection Society, and the American Association for the Surgery of Trauma have jointly completed an international multi-society document to promote global standards of care in SSTIs guiding clinicians by describing reasonable approaches to the management of SSTIs.

An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting evidence was shared by an international task force with different clinical backgrounds.

Prognostic factors for mortality in 123 severe cases of necrotizing fasciitis in 5 hospitals in the Netherlands between 2003 and 2017

Purpose

Necrotizing fasciitis (NF) is a severe soft tissue infection with a high morbidity and mortality. With early diagnosis and treatment this could be reduced. Unfortunately, the diagnosis of necrotizing fasciitis can be very difficult. In recent years many risk factors have been identified. In 2004, the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was developed. A tool that could help diagnosing NF. In this study, we search for prognostic factors for mortality in necrotizing fasciitis.

Methods

All adult patients with histopathological or surgical confirmed NF needed to be admitted to the intensive care unit for at least 24 h between January 2003 and December 2017 in five hospitals from the Nijmegen teaching region were included. We excluded patients with other forms of soft tissue infections or patients with an intensive care unit (ICU) stay of < 24 h because we exclusively wanted to include patients with a fulminant course of necrotizing fasciitis.

Results

We have included 123 cases. The overall mortality was 31.7% (N = 39). The overall mean LRINEC score was 7.4 ± 2.7. Patients who died as the result of NF had a significantly higher median LRINEC score (8 vs. 7, p = 0.034). Other parameters found to be associated with mortality are age ≥ 60 years, cardiovascular disease in the medical history, ≥ 2 comorbidities, and lactate level greater than 1.7 mmol/L.

Conclusion

LRINEC score should be calculated in all patients presenting with NF to provide an additional source for clinical outcome. A high LRINEC score could implicate a higher risk of mortality. Especially in elderly patients, with a cardiac history, more than two comorbidities or a lactate level greater than 1.7 mmol/L.

Higher LRINEC Scores and Escalation of Anesthesia Care in Necrotizing Soft Tissue Infection

BACKGROUND

The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score may distinguish necrotizing soft tissue infection (NSTI) from non-NSTI. The association of higher preoperative LRINEC scores with escalations of intraoperative anesthesia care in NSTI is unknown and may be useful in communicating illness severity during patient handoffs.

MATERIALS AND METHODS

We conducted a retrospective cohort study of first operative debridement for suspected NSTI in a single referral center from 2013 to 2016. We assessed the association between LRINEC score and vasopressors, blood products, crystalloid, invasive monitoring, and minutes of operative and anesthesia care.

RESULTS

We captured 332 patients undergoing their first operative debridement for suspected NSTI. For every 1-point higher LRINEC score, there was a higher risk of norepinephrine and vasopressin use (relative risk [RR] = 18%, 95% confidence interval [CI] [10%, 26%] and [10%, 27%], respectively), packed red blood cell use (RR = 28% [95% CI 13%, 45%]), and additional crystalloid (17.57 mL/h [95% CI 0.37, 34.76]). Each additional LRINEC point was associated with longer anesthesia (3.42 min, 95% CI 0.94, 5.91) and operative times (2.35 min, 95% CI 0.29, 4.40) and a higher risk of receiving invasive arterial monitoring (RR 1.11, 95% CI 1.05, 1.18). The negative predictive value for an LRINEC score < 6 was > 90% for use of vasopressors and packed red blood cells.

CONCLUSIONS

Preoperative LRINEC scores were associated with escalations in intraoperative care in patients with NSTI. A low score may predict patients unlikely to require vasopressors or blood and may be useful in standardized handoff tools for patients with NSTI.

2018 WSES/SIS-E consensus conference: recommendations for the management of skin and soft-tissue infections

Skin and soft-tissue infections (SSTIs) encompass a variety of pathological conditions that involve the skin and underlying subcutaneous tissue, fascia, or muscle, ranging from simple superficial infections to severe necrotizing infections. SSTIs are a frequent clinical problem in surgical departments. In order to clarify key issues in the management of SSTIs, a task force of experts met in Bertinoro, Italy, on June 28, 2018, for a specialist multidisciplinary consensus conference under the auspices of the World Society of Emergency Surgery (WSES) and the Surgical Infection Society Europe (SIS-E). The multifaceted nature of these infections has led to a collaboration among general and emergency surgeons, intensivists, and infectious disease specialists, who have shared these clinical practice recommendations.

Procalcitonin: A Powerful Rescuer on Surgical Floors

Necrotizing fasciitis (NF) is a rare but life-threatening medical and surgical emergency. It is characterized by necrosis of the soft tissue leaving the overlying tissue unaffected, which delays the diagnosis and treatment. Delay in recognition of the severity of necrotizing fasciitis might lead to serious morbidity and mortality. Diagnosis of NF relies on strong clinical judgment, predictable by severe pain, erythema, and a presence of air under the skin, but all of them are not always present. Management of NF is prompt surgical intervention and antimicrobial therapy. The effectiveness depends on the timely diagnosis of NF because it rapidly spreads and may cause irreversible damage.

Various investigations for necrotizing fasciitis have been proposed. However, misdiagnosis is not infrequent and more work is needed to identify the different presentations across the spectrum. We consider changing it to discuss the role of procalcitonin in the diagnosis of necrotizing fasciitis.There is scarce literature about its clinical role in necrotizing fasciitis although it has evolved not only as a prognostic marker but also as a way of differentiating between cellulitis and necrotizing fasciitis. It can also predict the future consequences of septic shock.

The laboratory risk indicator for necrotizing fasciitis (LRINEC) scoring: the diagnostic and potential prognostic role

BACKGROUND

Necrotizing fasciitis (NF) is a devastating soft tissue infection associated with potentially poor outcomes. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score has been introduced as a diagnostic tool for NF. We aimed to evaluate the prognostic value of LRINEC scoring in NF patients.

METHODS

A retrospective analysis was conducted for patients who were admitted with NF between 2000 and 2013. Based on LRINEC points, patients were classified into (Group 1: LRINEC < 6 and Group 2: LRINEC ≥ 6). The 2 groups were analyzed and compared. Primary outcomes were hospital length of stay, septic shock and hospital death.

RESULTS

A total of 294 NF cases were identified with a mean age 50.9 ± 15 years. When compared to Group1, patients in Group 2 were 5 years older (p = 0.009), more likely to have diabetes mellitus (61 vs 41%, p < 0.001), Pseudomonas aeruginosa infection (p = 0.004), greater Sequential Organ Failure Assessment (SOFA) score (11.5 ± 3 vs 8 ± 2, p = 0.001), and prolonged intensive care (median 7 vs 5 days) and hospital length of stay (22 vs 11 days, p = 0.001). Septic shock (37 vs. 15%, p = 0.001) and mortality (28.8 vs. 15.0%, p = 0.005) were also significantly higher in Group 2 patients. Using Receiver operating curve, cutoff LRINEC point for mortality was 8.5 with area under the curve of 0.64. Pearson correlation analysis showed a significant correlation between LRINEC and SOFA scorings (r = 0.51, p < 0.002).

DISCUSSION

Early diagnosis, simplified risk stratification and on-time management are vital to achieve better outcomes in patients with NF.

CONCLUSIONS

Beside its diagnostic role, LRINEC scoring could predict worse hospital outcomes in patients with NF and simply identify the high-risk patients. However, further prospective studies are needed to support this finding.

Laboratory Risk Indicators for Necrotizing Fasciitis and Associations with Mortality

OBJECTIVES

Necrotizing fasciitis (NF) is rare but life threatening soft tissue infection characterized by a necrotizing process of the subcutaneous tissues and fascial planes. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score has been verified as a useful diagnostic tool for detecting necrotizing fasciitis. A certain LRINEC score might also be associated with mortality. The aims of this study are to determine risk factors affecting the prognosis and to evaluate the prognostic value of the LRINEC score in NF.

METHODS

Twenty-five patients with necrotizing fasciitis treated in Samsun Education and Research Hospital between January 2008 and April 2013 were enrolled in the study. Surviving and non-surviving patient groups were compared regarding demographic data, co-morbidity, predisposing factors, causative agents, number of debridements and LRINEC score.

RESULTS

Mean age was 55.6±16.79 years (min: 17-max: 84), and the female/male ratio was 16/9. Mortality was observed in 6 (24%) patients. The most frequent comorbid diseases were diabetes mellitus (52) and peripheral circulatory disorders (24%), and the most frequent etiologies were cutaneous (32%) and perianal abscess (20%). Pseudomonas aeruginosa infection was higher in the non-surviving group (p=0.006). The mean number of debridements and LRINEC score were higher in the non-surviving group than in the surviving group (p=0.003 and p=0.003, respectively).

CONCLUSIONS

Pseudomans aeruginosa infection and multiple debridements are related with mortality. The LRINEC score might help predict mortality in NF.

The role of contrast enhanced computed tomography in the diagnosis of necrotizing fasciitis and comparison with the laboratory risk indicator for necrotizing fasciitis (LRINEC)

PURPOSE

To evaluate the diagnostic efficacy of contrast enhanced computed tomography (CECT) in emergency departments for diagnosis of necrotizing fasciitis (NF) and for differential diagnosis of other musculoskeletal infections; to correlate radiological findings with the laboratory risk indicator for necrotizing fasciitis (LRINEC).

MATERIALS AND METHODS

7 radiological parameters to be analysed on CECT scans were established, exams of 36 patients with proven diagnosis of NF (n 12) and other musculoskeletal infections (n 24) were retrospectively reviewed; LRINEC score was calculated. Fisher's test and Spearman's and Kendall's coefficients of rank correlations were performed.

RESULTS

Two parameters were found to be strongly associated with the diagnosis of NF: involvement of the fascia (Spearman's ρ of 0.888, p < 0.001) and lack of fascial enhancement (Spearman's ρ of 0.672, p < 0.001). LRINEC score did not show strong association with the presence of fasciitis NF (Spearman's ρ of 0.490, p = 0.0024).

CONCLUSION

Computed tomography (CT) parameters, which are significantly associated with the diagnosis of NF, are the involvement of the fascia and its lack of enhancement; LRINEC score could be high (>5) also in other musculoskeletal infections. Final diagnosis of necrosis among the fascia is surgical. Presence of gas is not a specific sign of necrotizing fasciitis being present in other musculoskeletal infections. CT could easily discriminate NF from other musculoskeletal infections, adds an important value to clinical and laboratory tests in diagnosis of NF in an emergency context when magnetic resonance imaging, which is superior to CT in this discernment, could not be performed.

Improvement of a Clinical Score for Necrotizing Fasciitis: 'Pain Out of Proportion' and High CRP Levels Aid the Diagnosis

Necrotizing fasciitis (NF) is a rare mono-/polymicrobial skin infection that spreads to underlying tissues. NF is quickly progressing and leads to life threatening situations. Immediate surgical debridement together with i.v. antibiotic administration is required to avoid fatal outcome. Early diagnosis is often delayed due to underestimation or confusion with cellulitis. We now compared the initial clinical and laboratory presentation of NF and cellulitis in detail to assess if a typical pattern can be identified that aids timely diagnosis of NF and avoidance of fatal outcome. 138 different clinical and laboratory features of 29 NF patients were compared to those of 59 age- and gender matched patients with severe erysipelas requiring a subsequent hospitalization time of ≥10 days. Differences in clinical presentation were not obvious; however, NF patients suffered significantly more often from strong pain. NF patients exhibited dramatically elevated CRP levels (5-fold, p>0.001). The overall laboratory risk indicator for necrotizing fasciitis (LRINEC) score was significantly higher in NF patients as compared to cellulitis. However, a modification of the score (alteration of laboratory parameters, addition of clinical parameters) led to a clear improvement of the score with a higher positive predictive value without losing specificity. In summary, clinical differentiation of NF from cellulitis appears to be hard. ‘Pain out of proportion’ may be an early sign for NF. An improvement of the LRINEC score emphasizing only relevant laboratory and clinical findings as suggested may aid the early diagnosis of NF in the future leading to improvement of disease outcome by enabling rapid adequate therapy.

Extended negative pressure wound therapy-assisted dermatotraction for the closure of large open fasciotomy wounds in necrotizing fasciitis patients

Background

Necrotizing fasciitis (NF) is a rapid progressive infection of the subcutaneous tissue or fascia and may result in large open wounds. The surgical options to cover these wounds are often limited by the patient condition and result in suboptimal functional and cosmetic wound coverage. Dermatotraction can restore the function and appearance of the fasciotomy wound and is less invasive in patients with comorbidities. However, dermatotraction for scarred, stiff NF fasciotomy wounds is often ineffective, resulting in skin necrosis. The authors use extended negative pressure wound therapy (NPWT) as an assist in dermatotraction to close open NF fasciotomy wounds. The authors present the clinical results, followed by a discussion of the clinical basis of extended NPWT-assisted dermatotraction.

Methods

A retrospective case series of eight patients with NF who underwent open fasciotomy was approved for the study. After serial wound preparation, dermatotraction was applied in a shoelace manner using elastic vessel loops. Next, the extended NPWT was applied over the wound. The sponge was three times wider than the wound width, and the transparent covering drape almost encircled the anatomical wound area. The negative pressure of the NPWT was set at a continuous 100 mmHg by suction barometer. The clinical outcome was assessed based on wound area reduction after treatment and by the achievement of direct wound closure.

Results

After the first set of extended NPWT-assisted dermatotraction procedures, the mean wound area was significantly decreased (658.12 cm² to 29.37 cm²; p = 0.002), as five out of eight patients achieved direct wound closure. One patient with a chest wall defect underwent latissimus dorsi musculocutaneous flap coverage, with primary closure of the donor site. Two Fournier’s gangrene patients underwent multiple sets of treatment and finally achieved secondary wound closure with skin grafts. The patients were followed up for 18.3 months on average and showed satisfactory results without wound recurrence.

Conclusions

Extended NPWT-assisted dermatotraction advances scarred, stiff fasciotomy wound margins synergistically in NF and allows direct closure of the wound without complications. This method can be another good treatment option for the NF patient with large open wounds whose general condition is unsuitable for extensive reconstructive surgery.

Extensive subcutaneous emphysema resembling necrotizing fasciitis

Necrotizing fasciitis is an aggressive, invasive soft tissue infection. Because it can rapidly progress to patient instability, prompt diagnosis followed by urgent debridement is critical to decreasing mortality. Despite the importance of early diagnosis, necrotizing fasciitis remains a clinical diagnosis, with little evidence in the literature regarding the effectiveness of diagnostic tools or criteria. Common clinical findings are nonspecific, including pain, blistering, crepitus, and swelling with or without fever and a known infection source.This article describes a patient who was transferred to the authors' institution from another hospital, where she had been taken following seizure activity and was treated with antibiotics for suspected cellulitis at the intravenous catheter placement site on her left dorsal hand. On admission to the current authors' institution, she presented with pain and swelling in the setting of significant left upper-extremity emphysema. She had undergone a left shoulder arthroscopy 4 weeks previously. Vital signs were within normal limits, and a preoperative chest radiograph was read as normal. The patient underwent an emergent fasciotomy, irrigation and debridement of the left upper extremity, and intravenous antibiotics for suspected necrotizing fasciitis. Intraoperative findings indicative of infection were absent, and a left apical pneumothorax was later found on postoperative chest imaging.In a stable patient with a normal chest radiograph on presentation who demonstrates upper-extremity crepitus suspicious for necrotizing fasciitis, a chest computed tomography scan may be indicated to rule out an intrathoracic source.