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Costa-Pattison D, Rush N, Gillespie S, Danford CA, Siedlecki SL. Importance of a thorough history and physical examination: Case report of atypical necrotizing fasciitis. J Am Assoc Nurse Pract 2024:01741002-990000000-00251. [PMID: 39356535 DOI: 10.1097/jxx.0000000000001061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 07/13/2024] [Indexed: 10/03/2024]
Abstract
ABSTRACT This case report presents a 34-year-old Middle Eastern woman with atypical symptoms of Type II Necrotizing Soft Tissue Infection (NSTI). Due to the difficulty in diagnosing Type II NSTI, the patient experienced protracted illness. Once diagnosed, the patient underwent multiple surgical debridement procedures requiring antibiotic and pain management therapy before being successfully discharged home. Initial diagnosis of Type II NSTI is challenging to the provider due to vague symptoms and late occurrence of cutaneous changes. When cutaneous lesions are identified, rapid surgical evaluation is imperative to minimize morbidity and mortality. This paper emphasizes the complexity of diagnosing Type II NSTI and the need for a comprehensive history and frequent physical examinations.
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Affiliation(s)
| | - Nicole Rush
- Pediatric Cardiology Cleveland Clinic, Cleveland, Ohio
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2
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Nagayama J, Sato T, Takanori I, Kouji K, Mitsunobu N. Necrotising fasciitis with extensive necrosis caused by Lactobacillus: a case report. BMC Infect Dis 2024; 24:425. [PMID: 38649870 PMCID: PMC11034093 DOI: 10.1186/s12879-024-09291-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 04/04/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Necrotising fasciitis (NF) is a life-threatening soft-tissue infection that rapidly destroys the epidermis, subcutaneous tissue, and fascia. Despite their low virulence, Lactobacillus spp. can cause NF, and because of its rare incidence, there is limited information about its molecular and clinicopathological characteristics. We report a rare case of NF in a patient with type 2 diabetes mellitus diagnosed on admission and severe obesity due to infection with two types of Lactobacillus spp. that manifested in extensive necrosis. CASE PRESENTATION A 48-year-old woman was referred to our hospital with a complaint of difficulty walking due to severe bilateral thigh pain. She presented with mild erythema, swelling, and severe skin pain extending from the pubic region to the groin. The patient was morbidly obese, had renal dysfunction, and had diabetes mellitus diagnosed on admission.; her LRINEC (Laboratory Risk Indicator for Necrotising Fasciitis) score was 9, indicating a high risk of NF. An exploratory surgical incision was made, and NF was diagnosed based on fascial necrosis. Emergent surgical debridement was performed, and cultures of the tissue culture and aspirated fluid/pus revealed two types of Lactobacillus spp.: Lactobacillus salivarius and L. iners. The patient was admitted to the intensive care unit (ICU), where antibiotics were administered and respiratory and circulatory management was performed. Diabetic ketoacidosis was detected, which was treated by controlling the blood glucose level stringently via intravenous insulin infusion. The patient underwent a second debridement on day 11 and a skin suture and skin grafting on day 36. The patient progressed well, was transferred from the ICU to the general ward on day 41, and was discharged unassisted on day 73. CONCLUSIONS Lactobacillus spp. are rarely pathogenic to healthy individuals and can scarcely trigger NF. However, these bacteria can cause rare infections such as NF in immunocompromised individuals, such as those with diabetes and obesity, and an early diagnosis of NF is imperative; surgical intervention may be required for the prevention of extensive necrosis. The LRINEC score may be useful for the early diagnosis of NF, even for less pathogenic bacteria such as Lactobacillus.
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Affiliation(s)
- Jun Nagayama
- Advanced Medical Emergency Department and Critical Care Center, Japanese Red Cross Maebashi Hospital, 389-1, Asakura-machi, 371-0811, Maebashi, Gunma, Japan.
| | - Takeo Sato
- Center for Community Clinical Education, Jichi Medical University, 3311-1 Yakushiji, 329-0498, Shimotsuke-shi, Tochigi-ken, Japan
| | - Ishida Takanori
- Advanced Medical Emergency Department and Critical Care Center, Japanese Red Cross Maebashi Hospital, 389-1, Asakura-machi, 371-0811, Maebashi, Gunma, Japan
| | - Koga Kouji
- Advanced Medical Emergency Department and Critical Care Center, Japanese Red Cross Maebashi Hospital, 389-1, Asakura-machi, 371-0811, Maebashi, Gunma, Japan
| | - Nakamura Mitsunobu
- Advanced Medical Emergency Department and Critical Care Center, Japanese Red Cross Maebashi Hospital, 389-1, Asakura-machi, 371-0811, Maebashi, Gunma, Japan
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3
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Senneville É, Albalawi Z, van Asten SA, Abbas ZG, Allison G, Aragón-Sánchez J, Embil JM, Lavery LA, Alhasan M, Oz O, Uçkay I, Urbančič-Rovan V, Xu ZR, Peters EJG. Diagnosis of infection in the foot of patients with diabetes: A systematic review. Diabetes Metab Res Rev 2024; 40:e3723. [PMID: 37715722 DOI: 10.1002/dmrr.3723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 08/29/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND Securing an early accurate diagnosis of diabetic foot infections and assessment of their severity are of paramount importance since these infections can cause great morbidity and potential mortality and present formidable challenges in surgical and antimicrobial treatment. METHODS In June 2022, we searched the literature using PubMed and EMBASE for published studies on the diagnosis of diabetic foot infection (DFI). On the basis of pre-determined criteria, we reviewed prospective controlled, as well as non-controlled, studies in English. We then developed evidence statements based on the included papers. RESULTS We selected a total of 64 papers that met our inclusion criteria. The certainty of the majority of the evidence statements was low because of the weak methodology of nearly all of the studies. The available data suggest that diagnosing diabetic foot infections on the basis of clinical signs and symptoms and classified according to the International Working Group of the Diabetic Foot/Infectious Diseases Society of America scheme correlates with the patient's likelihood of the need for hospitalisation, lower extremity amputation, and risk of death. Elevated levels of selected serum inflammatory markers such as erythrocyte sedimentation rate (ESR), C-reactive protein and procalcitonin are supportive, but not diagnostic, of soft tissue infection. Culturing tissue samples of soft tissues or bone, when care is taken to avoid contamination, provides more accurate microbiological information than culturing superficial (swab) samples. Although non-culture techniques, especially next-generation sequencing, are likely to identify more bacteria from tissue samples including bone than standard cultures, no studies have established a significant impact on the management of patients with DFIs. In patients with suspected diabetic foot osteomyelitis, the combination of a positive probe-to-bone test and elevated ESR supports this diagnosis. Plain X-ray remains the first-line imaging examination when there is suspicion of diabetic foot osteomyelitis (DFO), but advanced imaging methods including magnetic resonance imaging (MRI) and nuclear imaging when MRI is not feasible help in cases when either the diagnosis or the localisation of infection is uncertain. Intra-operative or non-per-wound percutaneous biopsy is the best method to accurately identify bone pathogens in case of a suspicion of a DFO. Bedside percutaneous biopsies are effective and safe and are an option to obtain bone culture data when conventional (i.e. surgical or radiological) procedures are not feasible. CONCLUSIONS The results of this systematic review of the diagnosis of diabetic foot infections provide some guidance for clinicians, but there is still a need for more prospective controlled studies of high quality.
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Affiliation(s)
- Éric Senneville
- Department of Infectious Diseases, Gustave Dron Hospital, Tourcoing, France
- Univ-Lille, Lille, France
| | - Zaina Albalawi
- Department of Medicine, Division of Endocrinology, Memorial University, St. John's, Newfoundland, Canada
| | - Suzanne A van Asten
- Department of Medical Microbiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Zulfiqarali G Abbas
- Abbas Medical Centre, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Geneve Allison
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - John M Embil
- Alberta Public Laboratories, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Lawrence A Lavery
- Department of Plastic Surgery, Southwestern Medical Center, Dallas, Texas, USA
| | - Majdi Alhasan
- Department of Medicine, Prisma Health-Midlands, Columbia, South Carolina, USA
| | - Orhan Oz
- Department of Plastic Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Ilker Uçkay
- Department of Infectious Diseases, Balgrist University Hospital, Zurich, Switzerland
| | - Vilma Urbančič-Rovan
- Faculty of Medicine, University Medical Centre, University of Ljubljana, Ljubljana, Slovenia
| | - Zhang-Rong Xu
- Diabetes Centre, The 306th Hospital of PLA, Beijing, China
| | - Edgar J G Peters
- Section of Infectious Diseases, Department of Internal Medicine, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, The Netherlands
- Amsterdam Infection & Immunity, Infectious Diseases, Amsterdam, The Netherlands
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Senneville É, Albalawi Z, van Asten SA, Abbas ZG, Allison G, Aragón-Sánchez J, Embil JM, Lavery LA, Alhasan M, Oz O, Uçkay I, Urbančič-Rovan V, Xu ZR, Peters EJG. IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes-related foot infections (IWGDF/IDSA 2023). Diabetes Metab Res Rev 2024; 40:e3687. [PMID: 37779323 DOI: 10.1002/dmrr.3687] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 06/23/2023] [Indexed: 10/03/2023]
Abstract
The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the management and prevention of diabetes-related foot diseases since 1999. The present guideline is an update of the 2019 IWGDF guideline on the diagnosis and management of foot infections in persons with diabetes mellitus. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was used for the development of this guideline. This was structured around identifying clinically relevant questions in the P(A)ICO format, determining patient-important outcomes, systematically reviewing the evidence, assessing the certainty of the evidence, and finally moving from evidence to the recommendation. This guideline was developed for healthcare professionals involved in diabetes-related foot care to inform clinical care around patient-important outcomes. Two systematic reviews from 2019 were updated to inform this guideline, and a total of 149 studies (62 new) meeting inclusion criteria were identified from the updated search and incorporated in this guideline. Updated recommendations are derived from these systematic reviews, and best practice statements made where evidence was not available. Evidence was weighed in light of benefits and harms to arrive at a recommendation. The certainty of the evidence for some recommendations was modified in this update with a more refined application of the GRADE framework centred around patient important outcomes. This is highlighted in the rationale section of this update. A note is also made where the newly identified evidence did not alter the strength or certainty of evidence for previous recommendations. The recommendations presented here continue to cover various aspects of diagnosing soft tissue and bone infections, including the classification scheme for diagnosing infection and its severity. Guidance on how to collect microbiological samples, and how to process them to identify causative pathogens, is also outlined. Finally, we present the approach to treating foot infections in persons with diabetes, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and bone infections; when and how to approach surgical treatment; and which adjunctive treatments may or may not affect the infectious outcomes of diabetes-related foot problems. We believe that following these recommendations will help healthcare professionals provide better care for persons with diabetes and foot infections, prevent the number of foot and limb amputations, and reduce the patient and healthcare burden of diabetes-related foot disease.
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Affiliation(s)
- Éric Senneville
- Gustave Dron Hospital, Tourcoing, France
- Univ-Lille France, Lille, France
| | - Zaina Albalawi
- Department of Medicine, Division of Endocrinology, Memorial University, St. John's, Newfoundland and Labrador, Canada
| | - Suzanne A van Asten
- Department of Medical Microbiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Zulfiqarali G Abbas
- Abbas Medical Centre, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Geneve Allison
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - John M Embil
- Department of Medicine, Section of Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lawrence A Lavery
- Department of Plastic Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Majdi Alhasan
- Department of Medicine, Prisma Health-Midlands, Columbia, South Carolina, USA
| | - Orhan Oz
- UT Southwestern Medical Center, Dallas, Texas, USA
| | - Ilker Uçkay
- Balgrist University Hospital, Zurich, Switzerland
| | - Vilma Urbančič-Rovan
- Faculty of Medicine, University Medical Centre, University of Ljubljana, Ljubljana, Slovenia
| | | | - Edgar J G Peters
- Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Section of Infectious Diseases, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, the Netherlands
- Amsterdam Infection & Immunity, Infectious Diseases, Amsterdam, the Netherlands
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5
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Ge X, Sun Y, Lin J, Zhou F, Yao G, Luo B, Su X. Diagnostic Key Points and Surgical Management of Necrotizing Fasciitis: A Retrospective Study. INT J LOW EXTR WOUND 2024; 23:153-160. [PMID: 34612747 PMCID: PMC10949409 DOI: 10.1177/15347346211045282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Necrotizing fasciitis (NF) is a fatal disease with a high mortality rate that can be easily misdiagnosed. The aim of this study was to improve the diagnostic rate of NF and overall survival. We conducted a single-center, retrospective, noncontrolled study involving 36 patients who were admitted to our department between December 2017 and October 2019, and summarized the diagnostic key points and timing of surgical treatment. All patients were diagnosed at our department and underwent multiple courses of treatment. The records included information regarding underlying diseases, bacterial culture results, laboratory risk indicator for necrotizing fasciitis (LRINEC) score, number of procedures, and type of antibiotics. All 36 cases of NF were cured and showed good patient condition on follow-up; the mean number of surgeries was three, and the mean duration of hospitalization was 37 days (range, 21-83 days). The LRINEC scores of 16 patients were ≥8 points. Seventeen patients with underlying diabetic disease had higher inflammatory index scores than those without diabetes. The LRINEC scores of patients with (n = 17) and without (n = 19) DM were 7.40 ± 2.99 and 3.80 ± 2.39, respectively (P < .01). Cases of NF that were treated with early incision and surgical abscess drainage required fewer surgeries and a shorter length of hospitalization. Thus, surgeons should be more aware of NF and aim to make an early and accurate diagnosis using various approaches. Complete surgical debridement plays an essential role in NF treatment, and diabetes mellitus is a significant adverse factor that exacerbates the severity of NF. Negative-pressure techniques are useful in cases involving nonanaerobic infections and cause minimal complications.
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Affiliation(s)
- Xiaojing Ge
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yute Sun
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jing Lin
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Fang Zhou
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Gang Yao
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Binlin Luo
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xin Su
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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6
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Castater C, Bishop E, Santos A, Freedberg M, Kim P, Sciarretta C. Diabetic Soft Tissue Infections. Surg Clin North Am 2023; 103:1191-1216. [PMID: 37838463 DOI: 10.1016/j.suc.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
Diabetes is a systemic illness that can cause a broad range of physiologic effects. Infection rates and wound healing are both affected through multiple mechanisms. Other physiologic changes increase risk for wounds as well as complex soft tissue infections ranging from simple cellulitis to necrotizing soft tissue infections. Clinicians and surgeons need to have a low index of suspicion for severe infection in a patient presenting with diabetes, and even more so in patients with uncontrolled diabetes.
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Affiliation(s)
- Christine Castater
- Morehouse School of Medicine, Grady Memorial Hospital 1C-144, 80 Jesse Hill Jr Drive Southeast, Atlanta, GA 30303, USA.
| | - Elliot Bishop
- Emory University, Grady Memorial Hospital Glenn Building 69 Jesse Hill Jr Drive Southeast, Atlanta, GA 30303, USA
| | - Adora Santos
- Emory University, Grady Memorial Hospital Glenn Building 69 Jesse Hill Jr Drive Southeast, Atlanta, GA 30303, USA
| | - Mari Freedberg
- Emory University, Grady Memorial Hospital Glenn Building 69 Jesse Hill Jr Drive Southeast, Atlanta, GA 30303, USA
| | - Phillip Kim
- Emory University, Grady Memorial Hospital Glenn Building 69 Jesse Hill Jr Drive Southeast, Atlanta, GA 30303, USA
| | - Christopher Sciarretta
- University of Tennessee, University of Tennessee College of Medicine, 975 3rd Avenue, Chattanooga, TN 37403, USA
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7
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Senneville É, Albalawi Z, van Asten SA, Abbas ZG, Allison G, Aragón-Sánchez J, Embil JM, Lavery LA, Alhasan M, Oz O, Uçkay I, Urbančič-Rovan V, Xu ZR, Peters EJG. IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-related Foot Infections (IWGDF/IDSA 2023). Clin Infect Dis 2023:ciad527. [PMID: 37779457 DOI: 10.1093/cid/ciad527] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 06/23/2023] [Indexed: 10/03/2023] Open
Abstract
The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the management and prevention of diabetes-related foot diseases since 1999. The present guideline is an update of the 2019 IWGDF guideline on the diagnosis and management of foot infections in persons with diabetes mellitus. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was used for the development of this guideline. This was structured around identifying clinically relevant questions in the P(A)ICO format, determining patient-important outcomes, systematically reviewing the evidence, assessing the certainty of the evidence, and finally moving from evidence to the recommendation. This guideline was developed for healthcare professionals involved in diabetes-related foot care to inform clinical care around patient-important outcomes. Two systematic reviews from 2019 were updated to inform this guideline, and a total of 149 studies (62 new) meeting inclusion criteria were identified from the updated search and incorporated in this guideline. Updated recommendations are derived from these systematic reviews, and best practice statements made where evidence was not available. Evidence was weighed in light of benefits and harms to arrive at a recommendation. The certainty of the evidence for some recommendations was modified in this update with a more refined application of the GRADE framework centred around patient important outcomes. This is highlighted in the rationale section of this update. A note is also made where the newly identified evidence did not alter the strength or certainty of evidence for previous recommendations. The recommendations presented here continue to cover various aspects of diagnosing soft tissue and bone infections, including the classification scheme for diagnosing infection and its severity. Guidance on how to collect microbiological samples, and how to process them to identify causative pathogens, is also outlined. Finally, we present the approach to treating foot infections in persons with diabetes, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and bone infections; when and how to approach surgical treatment; and which adjunctive treatments may or may not affect the infectious outcomes of diabetes-related foot problems. We believe that following these recommendations will help healthcare professionals provide better care for persons with diabetes and foot infections, prevent the number of foot and limb amputations, and reduce the patient and healthcare burden of diabetes-related foot disease.
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Affiliation(s)
- Éric Senneville
- Gustave Dron Hospital, Tourcoing, France
- Univ-Lille France, Lille, France
| | - Zaina Albalawi
- Department of Medicine, Division of Endocrinology, Memorial University, St. John's, Newfoundland and Labrador, Canada
| | - Suzanne A van Asten
- Department of Medical Microbiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Zulfiqarali G Abbas
- Abbas Medical Centre, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Geneve Allison
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - John M Embil
- Department of Medicine, Section of Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lawrence A Lavery
- Department of Plastic Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Majdi Alhasan
- Department of Medicine, Prisma Health-Midlands, Columbia, South Carolina, USA
| | - Orhan Oz
- UT Southwestern Medical Center, Dallas, Texas, USA
| | - Ilker Uçkay
- Balgrist University Hospital, Zurich, Switzerland
| | - Vilma Urbančič-Rovan
- Faculty of Medicine, University Medical Centre, University of Ljubljana, Ljubljana, Slovenia
| | | | - Edgar J G Peters
- Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Section of Infectious Diseases, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, The Netherlands
- Amsterdam Infection & Immunity, Infectious Diseases, Amsterdam, The Netherlands
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Zhang KF, Shi CX, Chen SY, Wei W. Progress in Multidisciplinary Treatment of Fournier's Gangrene. Infect Drug Resist 2022; 15:6869-6880. [PMID: 36465810 PMCID: PMC9717591 DOI: 10.2147/idr.s390008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/10/2022] [Indexed: 07/27/2023] Open
Abstract
Fournier's gangrene (FG) is a life-threatening and special form of necrotizing fasciitis, characterized by occult onset, rapid progress and high mortality, occurring mainly in men over 50 years of age. Risk factors of FG include diabetes, HIV infection, chronic alcoholism and other immunosuppressive state. FG was previously considered as an idiopathic disease, but in fact, three quarters of the infections originated from the skin, urethra and gastrointestinal tract. Initial symptoms of FG are often inconsistent with severity and can progress promptly to fatal infection. Although the treatment measures of FG have been improved in recent years, the mortality does not seem to have decreased significantly and remains at 20% - 30%. The time to identify FG and the waiting period before surgical debridement are directly related to the prognosis. Therefore, in addition to the combination of intensive fluid resuscitation and broad-spectrum antibiotics, treatment of FG should particularly emphasize the importance of early surgical debridement assisted with fecal diversion and skin reconstruction when necessary. This paper is to briefly summarize the progress in the definition, epidemiology, clinical manifestations, diagnosis, treatment and prognosis of Fournier's gangrene in recent years, more importantly, illustrates the importance of multidisciplinary cooperation in the management of FG.
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Affiliation(s)
- Ke-Fan Zhang
- Department of General Surgery, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, People’s Republic of China
| | - Chuan-Xin Shi
- Department of General Surgery, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, People’s Republic of China
| | - Si-Yu Chen
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, People’s Republic of China
| | - Wei Wei
- Department of General Surgery, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, People’s Republic of China
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9
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Kim J, Yoo G, Lee T, Kim JH, Seo DM, Kim J. Classification Model for Diabetic Foot, Necrotizing Fasciitis, and Osteomyelitis. BIOLOGY 2022; 11:biology11091310. [PMID: 36138789 PMCID: PMC9495746 DOI: 10.3390/biology11091310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/31/2022] [Accepted: 09/01/2022] [Indexed: 11/21/2022]
Abstract
Simple Summary Necrotizing fasciitis (NF) and osteomyelitis (OM) are severe complications in patients with diabetic foot ulcers (DFUs). Although NF and OM often cause results including limb amputation and death, definite diagnoses of these are challenging. To aid the prompt and proper diagnosis of NF and OM in patients with DFU, we developed and evaluated a novel prediction model based on machine learning technology. In summary, our prediction model appropriately discriminated the NF and OM from diabetic foot. Moreover, this prediction model has advantages in that it is based on the demographic data and routine laboratory results, which requires no additional examinations which are complicated or expensive. Abstract Diabetic foot ulcers (DFUs) and their life-threatening complications, such as necrotizing fasciitis (NF) and osteomyelitis (OM), increase the healthcare cost, morbidity and mortality in patients with diabetes mellitus. While the early recognition of these complications could improve the clinical outcome of diabetic patients, it is not straightforward to achieve in the usual clinical settings. In this study, we proposed a classification model for diabetic foot, NF and OM. To select features for the classification model, multidisciplinary teams were organized and data were collected based on a literature search and automatic platform. A dataset of 1581 patients (728 diabetic foot, 76 NF, and 777 OM) was divided into training and validation datasets at a ratio of 7:3 to be analyzed. The final prediction models based on training dataset exhibited areas under the receiver operating curve (AUC) of the 0.80 and 0.73 for NF model and OM model, respectively, in validation sets. In conclusion, our classification models for NF and OM showed remarkable discriminatory power and easy applicability in patients with DFU.
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Affiliation(s)
- Jiye Kim
- Department of Plastic Surgery, Yonsei University Wonju College of Medicine, Wonju 26411, Korea
| | - Gilsung Yoo
- Department of Laboratory Medicine, Yonsei University Wonju College of Medicine, Wonju 26411, Korea
| | - Taesic Lee
- Division of Data Mining and Computational Biology, Institute of Global Health Care and Development, Wonju Severance Christian Hospital, Wonju 26411, Korea
- Department of Family Medicine, Yonsei University Wonju College of Medicine, Wonju 26411, Korea
- Center for Precision Medicine and Genomics, Wonju Severance Christian Hospital, Wonju 26411, Korea
| | - Jeong Ho Kim
- Department of Plastic Surgery, Yonsei University Wonju College of Medicine, Wonju 26411, Korea
| | - Dong Min Seo
- Department of Medical Information, Yonsei University Wonju College of Medicine, Wonju 26411, Korea
| | - Juwon Kim
- Department of Laboratory Medicine, Yonsei University Wonju College of Medicine, Wonju 26411, Korea
- Center for Precision Medicine and Genomics, Wonju Severance Christian Hospital, Wonju 26411, Korea
- Correspondence: ; Tel.: +82-33-741-1596; Fax: +82-33-741-1780
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10
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Meng Z, Wang Y, Chao J, Ji Y, Sun Y, Zhu J, Gao T, Chen S, Wang S. Extensive necrotizing fasciitis of scrotum and abdominal wall: Report of two cases and a review of the literature. Front Surg 2022; 9:952042. [PMID: 35928030 PMCID: PMC9343677 DOI: 10.3389/fsurg.2022.952042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 07/04/2022] [Indexed: 11/13/2022] Open
Abstract
The incidence rate of necrotizing fasciitis(NF) is low, but it has a high mortality rate. At present, it lacks experience in clinical treatment in municipal and county-level hospitals, insufficient awareness of disease risk, lack of experience in disease surgical intervention, and lack of a set of mature treatment norms and standards. Most patients have no time to transfer to a higher hospital for treatment. In January and April 2022, two cases of large-scale necrotizing fasciitis of the scrotum and abdominal wall were treated in the Department of Urology of Weifang people's Hospital respectively and were clinically cured after active surgical debridement combined with broad-spectrum antibiotics. Through the retrospective analysis of the diagnosis and treatment of two cases of necrotizing fasciitis, this paper analyzes and summarizes the scope of surgical debridement of NF, postoperative dressing changing skills, timing of multiple debridements, application and timing of vacuum sealing drainage(VSD), and the combined use of antibiotics. To provide experience for clinical diagnosis and treatment of necrotizing fasciitis.
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Affiliation(s)
- Zhe Meng
- Yuhe Campus of Weifang Medical College, Weifang, China
- Department of Urology, Weifang people’s Hospital, Weifang, China
| | - Yanchen Wang
- Yuhe Campus of Weifang Medical College, Weifang, China
- Department of Urology, Weifang people’s Hospital, Weifang, China
| | - Jun Chao
- Yuhe Campus of Weifang Medical College, Weifang, China
- Department of Urology, Weifang people’s Hospital, Weifang, China
| | - Yongjian Ji
- Yuhe Campus of Weifang Medical College, Weifang, China
- Department of Urology, Weifang people’s Hospital, Weifang, China
| | - Yaofei Sun
- Yuhe Campus of Weifang Medical College, Weifang, China
- Department of Urology, Weifang people’s Hospital, Weifang, China
| | - Jiang Zhu
- Yuhe Campus of Weifang Medical College, Weifang, China
- Department of Urology, Weifang people’s Hospital, Weifang, China
| | - Tongbin Gao
- Yuhe Campus of Weifang Medical College, Weifang, China
- Department of Urology, Weifang people’s Hospital, Weifang, China
| | - Si Chen
- Yuhe Campus of Weifang Medical College, Weifang, China
- Department of Urology, Weifang people’s Hospital, Weifang, China
| | - Shenyang Wang
- Yuhe Campus of Weifang Medical College, Weifang, China
- Department of Urology, Weifang people’s Hospital, Weifang, China
- Correspondence: Wang Shenyang
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He X, Xiang X, Zou Y, Liu B, Liu L, Bi Y, Kan D. Distinctions between Fournier's gangrene and lower extremity necrotising fasciitis: microbiology and factors affecting mortality. Int J Infect Dis 2022; 122:222-229. [PMID: 35598736 DOI: 10.1016/j.ijid.2022.05.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 05/03/2022] [Accepted: 05/17/2022] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES In this study, we aimed to illustrate distinctions between Fournier's gangrene (FG) and lower extremity necrotising fasciitis (NF) and screen out possible risk factors of poor prognosis for each cohort. METHODS The medical records of qualified patients with NF admitted to the Second People's Hospital of Yibin from January 2016 to June 2021 were retrospectively reviewed. All participants were anatomically categorised into FG and lower extremity NF groups, and their baseline data and microbiological results were compared. Further comparisons of critical parameters were conducted between survivors and nonsurvivors within each group. RESULTS A total of 49 patients were included in the study with a median age of 58 years, and overall mortality was 20.4%. There were 18 patients with FG and 31 patients with lower extremity NF. A microbiology distinction was found-the predominance of gram-negative infection in FG and gram-positive infection in lower extremity NF. High Fournier's gangrene severity index scores (greater than 7), advanced age, procalcitonin and D-dimer value were identified as risk factors for FG, and the presentation of sepsis was an alarming indicator for lower extremity NF. CONCLUSIONS The distinction of microbiology might provide advice for appropriate antibacterial administrations. In addition, with practical prognostic predicting tools, clinicians might be able to identify patients at increased risk and intervene promptly to avoid unfavourable outcomes.
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Affiliation(s)
- Xuefeng He
- Department of Plastic and Burn Surgery, the Second People's Hospital of Yibin (the Yibin Hospital of West China Hospital, Sichuan University), Sichuan, China.
| | - Xin Xiang
- Department of Orthopaedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China.
| | - Yong Zou
- Department of Plastic and Burn Surgery, the Second People's Hospital of Yibin (the Yibin Hospital of West China Hospital, Sichuan University), Sichuan, China.
| | - Bing Liu
- Department of Plastic and Burn Surgery, the Second People's Hospital of Yibin (the Yibin Hospital of West China Hospital, Sichuan University), Sichuan, China
| | - Lili Liu
- Department of Plastic and Burn Surgery, the Second People's Hospital of Yibin (the Yibin Hospital of West China Hospital, Sichuan University), Sichuan, China
| | - Yaodan Bi
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Daohong Kan
- Department of Plastic and Burn Surgery, the Second People's Hospital of Yibin (the Yibin Hospital of West China Hospital, Sichuan University), Sichuan, China
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Wu KH, Chang CP. Differentiating Lower Extremity Necrotizing Soft Tissue Infection from Severe Cellulitis by Laboratory Parameters and Relevant History Points. Infect Drug Resist 2021; 14:3563-3569. [PMID: 34511947 PMCID: PMC8423024 DOI: 10.2147/idr.s327880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 08/24/2021] [Indexed: 11/23/2022] Open
Abstract
Background Necrotizing soft tissue infection (NSTI) of the lower extremity (LE) is a rapidly progressing infection that requires early diagnosis and prompt treatment to decrease risks of loss of limb or life. Clinical presentation, particularly of early NSTI, can appear similar to severe cellulitis. The purpose of this study is to identify factors that are associated with NSTI rather than severe cellulitis to differentiate patients with similar clinical presentation. Methods This retrospective cohort design study compares patients finally diagnosed with LE NSTI versus those diagnosed with severe cellulitis. Cohorts were matched using the modified Laboratory Risk Indicator for Necrotizing Fasciitis (m-LRINEC) score in the setting of LE soft tissue infection. Laboratory values, vital signs, subjective symptoms, and social factors including substance abuse were recorded. Univariate and multivariate analyses were performed. Results Multivariate statistical analysis and clinical interpretation of data identified four factors more associated with a diagnosis of NSTI than severe cellulitis: elevated lactate, a patient-reported history of fever, male gender, and intravenous substance user. Conclusion In patients with lower extremity infections, the clinical presentation of NSTI and severe cellulitis may appear similar. In this retrospective cohort of patients matched with m-LRINEC scores, elevated lactate, subjective fever, male gender, and intravenous substance abuser were significantly associated with NSTI rather than severe cellulitis. Further studies of these factors in the clinical setting can help tailor the differential diagnosis in the care of patients with severe lower extremity infections. Matched with m-LRINEC scores, elevated lactate, subjective fever, male gender, and intravenous substance abuser were significantly associated with NSTI rather than severe cellulitis. Further studies of these factors in the clinical setting can help tailor the differential diagnosis in the care of patients with severe lower extremity infections.
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Affiliation(s)
- Kai-Hsiang Wu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Chia-Peng Chang
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
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13
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Wu H, Liu S, Li C, Song Z. Modified Laboratory Risk Indicator for Necrotizing Fasciitis (m-LRINEC) Score System in Diagnosing Necrotizing Fasciitis: A Nested Case-Control Study. Infect Drug Resist 2021; 14:2105-2112. [PMID: 34113137 PMCID: PMC8187035 DOI: 10.2147/idr.s313321] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 05/18/2021] [Indexed: 11/23/2022] Open
Abstract
Aim This study aims to present a modified Laboratory Risk Indicator for Necrotizing Fasciitis (m-LRINEC) scoring system and to evaluate its ability in discriminating necrotizing fasciitis (NF) from other severe soft-tissue infections. Methods Patients with NF diagnosed by surgical findings in our institution between January 2014 and December 2020 were included as the case group, matched by controls with severe soft-tissue infections other than NF in a ratio of 2:1, based on demographics, calendar time and immunosuppressant status. Patients’ demographics, comorbidities and laboratory test results were extracted from medical records. Logistic regression analyses were used to determine the association with NF after adjustment for confounders, whereby m-LRINEC was developed. Receiver operating characteristics (ROC) curves and the area under the curve (AUC) were used to evaluate its discriminating ability. Results There were 177 patients included, 59 in the NF group and 118 in the non-NF group. We added comorbid diabetes and kidney disease to the original LRINEC scoring system, used high-sensitivity C-reactive protein (HCRP) to replace the CRP and redefined the cut-off values for the other four variables, to develop the m-LRINEC system. The cut-off value for m-LRINEC was 17 points, with corresponding sensitivity of 93.2% and specificity of 86.9%, and the AUC was 0.935 (95% CI 0.892 to 0.977; p<0.001). Conclusion The m-LRINEC scoring system shows a high sensitivity and specificity in discriminating NF from other severe soft-tissue infections. Patients with an m-LRINEC score of >17 points should have a high index of suspicion for the presence of NF. The validity of the m-LRINEC needs to be confirmed in studies with larger samples and better design.
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Affiliation(s)
- Haotian Wu
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, People's Republic of China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Song Liu
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, People's Republic of China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Chunxia Li
- Department of Imaging Medicine, General Hospital of Inner Mongolia Autonomous Region, Hohhot, Inner Mongolia 010017, People's Republic of China
| | - Zhaohui Song
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, People's Republic of China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China
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Wu PH, Wu KH, Hsiao CT, Wu SR, Chang CP. Utility of modified Laboratory Risk Indicator for Necrotizing Fasciitis (MLRINEC) score in distinguishing necrotizing from non-necrotizing soft tissue infections. World J Emerg Surg 2021; 16:26. [PMID: 34039397 PMCID: PMC8157441 DOI: 10.1186/s13017-021-00373-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 05/18/2021] [Indexed: 11/25/2022] Open
Abstract
Background We conducted this study to promote a modified Laboratory Risk Indicator for Necrotizing Fasciitis (MLRINEC) score and evaluate the utility in distinguishing necrotizing fasciitis (NF) from other soft-tissue infections. Method A retrospective cohort study of hospitalized patients with NF diagnosed by surgical finding was conducted in two tertiary hospital in southern Taiwan between January 2015 and January 2020. Another group was matched by controls with non-necrotizing soft tissue infections based on time, demographics, and immune status. Data such as infectious location, comorbidities, and laboratory findings were recorded and compared. Logistics regression were used to determine the association with NF after adjustment for confounders and MLRINEC score was developed by then. Receiver operating curve (ROC) and the area under the curve (AUC) were used to evaluate its discriminating ability. Result A total of 303 patients were included; 101 in NF group and 202 in non-NF group. We added serum lactate and comorbid liver disease to the original LRINEC score and re-defined the cut-off values for 3 variables to develop the MLRINEC score. The cut-off value for MLRINEC score was 12 points with corresponding sensitivity of 91.8% and a specificity of 88.4%, and the area under ROC (AUC) was 0.893 (95% CI, 0.723 to 0.948; p < 0.01). Conclusion MLRINEC score shows a high sensitivity and specificity in distinguishing NF from non-necrotizing soft-tissue infections. Patients with a MLRINEC score > 12 points should be highly suspected of presence of necrotizing fasciitis.
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Affiliation(s)
- Po-Han Wu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No.6, Sec. W., Jiapu Rd., Puzi City, Chiayi County, 613, Taiwan (R.O.C.)
| | - Kai-Hsiang Wu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No.6, Sec. W., Jiapu Rd., Puzi City, Chiayi County, 613, Taiwan (R.O.C.)
| | - Cheng-Ting Hsiao
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No.6, Sec. W., Jiapu Rd., Puzi City, Chiayi County, 613, Taiwan (R.O.C.).,Department of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shu-Ruei Wu
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chia-Peng Chang
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No.6, Sec. W., Jiapu Rd., Puzi City, Chiayi County, 613, Taiwan (R.O.C.).
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