Determinants of mortality for necrotizing soft-tissue infections

Epidemiology of upper limb necrotising fasciitis in England: A national study (1998-2018)

BACKGROUND

Necrotising fasciitis (NF) is a surgical emergency characterised by rapidly progressive infection of the subcutaneous tissues and fascial planes, leading to widespread fascial necrosis and systemic toxicity. Although NF can affect any part of the body, the upper limbs are a notable site, accounting for 27% of cases. Antibiotics and surgical debridement form the basis of treatment.

METHODOLOGY

We conducted a retrospective study on NF of the upper limb requiring surgical intervention from 1998-2018 using data from Hospital Episode Statistics. Age, sex, deprivation index, length of stay (LOS) and complications were analysed.

RESULTS

We identified 728 patients, comprising 468 males and 260 females, with a mean age of 54.97 years (95% CI: 53.76-56.17 years). The incidence of NF in the upper limb increased from 0.0035 per 100,000 in 1998 to 0.01 per 100,000 in 2018. Lower index of multiple deprivation scores correlated with higher NF prevalence, with 67.32% (n=474) presenting scores between 0 and 5. The average LOS was 27.55 days (95% CI: 25.08-30.02 days). Complications within 30 days of surgery included 8 (1.10%) cases of renal failure, 8 (1.10%) urinary tract infections (UTIs), and 103 (14%) deaths. Meanwhile, 90-day complications included 23 (3.15%) cases of renal failure, 6 (0.82%) pulmonary embolisms, 22 (3.02%) UTI, and 113 (16%) deaths.

CONCLUSION

This study highlights the impact of upper limb NF and provides crucial insights into its incidence, demographic correlations, and clinical outcomes, which can inform clinical management.

Necrotizing Soft Tissue Infections

Necrotizing soft tissue infections are a diverse group of severe infections of the skin, fascia, and musculature. These infections are characterized by the rapid and progressive destruction of soft tissue, as well as high incidence of morbidity and mortality. Prompt diagnosis, appropriate antimicrobial choice, and aggressive surgical interventions are essential in effecting a clinical cure and optimal outcomes for patients. Despite advances in medical care since necrotizing soft tissue infections were first described, the morbidity and mortality associated with them remains high. The etiology, pathophysiology, clinical presentation, diagnostic options, and treatment approach will be reviewed in this article.

Time to diagnose and time to surgery in patients presenting with necrotizing fasciitis: a retrospective analysis

BACKGROUND

Necrotizing Fasciitis (NF) is a life-threatening infection characterized by rapid tissue destruction and high mortality. The role of timely diagnosis and surgical intervention in improving patient outcomes remains debated. This study investigates the impact of "time to diagnosis" (TTD) and "time to surgical treatment" (TTS) on the outcomes of NF patients, with a specific focus on the first six hours of critical diagnosis.

METHODS

A retrospective analysis was conducted for patients hospitalized with NF between June 2016 and June 2023. Demographic data, comorbidities, clinical features, treatment, and outcomes were analyzed. The study stratified patients based on TTD (early (≤ 6 h) vs. delayed (> 6 h) and TTS (≤ 6 vs. > 6 h). Outcomes included severity scores, intensive care unit admission, length of stay (LOS), and mortality.

RESULTS

One hundred and twenty-one patients were diagnosed with NF with a mortality rate of 10%. Early diagnosis (≤ 6 h) was associated with lower mortality (5.7% vs. 13.2%) and shorter LOS (17 vs. 27 days) compared to delayed diagnosis. Early diagnosis was associated with a lower Sequential Organ Failure Assessment (SOFA) score compared to delayed diagnosis (p = 0.02). A combined analysis of TTD and TTS revealed that the group with early diagnosis and early treatment (TTD and TTS were ≤ 6 h) had a 3% mortality rate, and 7% of them had a SOFA score > 9. In contrast, delayed diagnosis (TTD > 6 h) was significantly associated with increased mortality, regardless of the TTS.

CONCLUSION

Timely diagnosis within 6 h is crucial for improving outcomes in NF. While early surgical intervention is vital, our findings suggest that the time to diagnosis and subsequent resuscitation efforts may significantly impact survival. This study highlights the importance of optimizing early recognition and diagnosis in the emergency room to reduce delays and improve patient prognosis in NF. Further multicenter studies are needed to validate these findings and refine clinical protocols.

The burden of group A Streptococcus (GAS) infections: The challenge continues in the twenty-first century

Streptococcus pyogenes is a Gram-positive bacterium, also known as Group A Streptococcus (GAS), that has become a significant threat to the healthcare system, infecting more than 18 million people and resulting in more than 500,000 deaths annually worldwide. GAS infection rates decreased gradually during the 20th century in Western countries, largely due to improved living conditions and access to antibiotics. However, post-COVID-19, the situation has led to a steep increase in GAS infection rates in Europe, the United States, Australia, and New Zealand, which triggers a global concern. GAS infections are normally moderate, with symptoms of fever, pharyngitis, and pyoderma; nevertheless, if left untreated or with continued exposure to GAS or with recurring infections it can result in fatal outcomes. GAS produces a variety of virulence factors and exotoxins that can lead to deadly infections such as necrotizing fasciitis, impetigo, cellulitis, pneumonia, empyema, streptococcal toxic shock syndrome, bacteremia, and puerperal sepsis. In addition, post-immune mediated disorders such as post-streptococcal glomerulonephritis, acute rheumatic fever, and rheumatic heart disease contribute to extremely high death rates in developing nations. Despite substantial research on GAS infections, it is still unclear what molecular pathways are responsible for their emergence and how to best manage them. This review thus provides insights into the most recent research on the pathogenesis, virulence, resistance, and host interaction mechanisms of GAS, as well as novel management options to assist scientific communities in combating GAS infections.

Case report: A case of severe lower limb necrotizing fasciitis caused by an insulin injection has been reported

Necrotizing fasciitis (NF) is a rare but life-threatening soft tissue infection, often accompanied by severe systemic toxicity. Early detection and prompt treatment are critical for survival. We report a case of NF in a 53-year-old diabetic woman following a subcutaneous insulin injection in the thigh. The patient presented with severe local pain as the initial symptom, and Escherichia coli was the sole isolated pathogen, which is seldom reported in the current literature. We combined with existing literature and clinical manifestations observed in NF patients at our hospital, offer valuable guidance for clinicians in recognizing and responding to NF.

Hypermucoviscous Klebsiella pneumoniae presenting as sternocleidomastoid pyomyositis with subsequent lower extremity necrotising fasciitis

Necrotising fasciitis (NF) is a severe, rapidly progressing infection of the muscular fascia and subcutaneous tissue. Monomicrobial NF from hypermucoviscous Klebsiella pneumoniae (hvKP-NF) is rare but highly virulent, most common in East Asia. This report reviews a unique case of hvKP-NF in a US male in his 40s with undiagnosed diabetes mellitus, presenting with severe sepsis, neck swelling and calf pain. Imaging revealed pyomyositis in the sternocleidomastoid, and debridement cultures confirmed hvKP. Despite unremarkable examination findings, persistent pain led to a diagnosis of necrotising fasciitis after initial imaging misinterpretations. The patient was treated with multiple surgical debridements and tailored antibiotics. This case underscores the importance of maintaining a high index of suspicion for necrotising fasciitis despite atypical risk factors and symptomatology, awareness of hvKP in the Western Hemisphere, prompt consideration of advanced imaging modalities when initial evaluations are inconclusive and the critical role of multidisciplinary care in managing severe infections.

A Rare Case of Necrotizing Fasciitis Presenting As Tarsal Tunnel Syndrome in a Patient With Uncontrolled Diabetes

Necrotizing fasciitis is a severe and rapidly progressing soft tissue infection that requires immediate intervention. However, its manifestation as tarsal tunnel syndrome in a diabetic patient is an extremely rare occurrence, with no previous reports found in the existing literature. We present a case report of a patient in their late 50s with uncontrolled diabetes who had necrotizing fasciitis and presented initially to the emergency department with hypotension. The patient complained of symptoms consistent with acute tarsal tunnel syndrome and displayed systemic signs of infection, necessitating urgent surgical intervention. Intraoperatively, the necrotic fascia involved the flexor retinaculum and its septa. A complete release of the tarsal tunnel and subsequent fasciectomy were performed. The patient experienced a successful postoperative recovery. This case emphasizes the importance of early recognition and intervention due to the aggressive nature of necrotizing fasciitis. Moreover, it highlights a unique presentation not previously reported in the literature, thereby contributing to increased awareness of this rare phenomenon in diabetic patients.

Skin, Soft Tissue, and Musculoskeletal Ultrasound

Point-of-care ultrasound may be used to assist in the diagnosis of skin, soft tissue, and musculoskeletal concerns in the emergency department. Frequently, linear or curvilinear probes are used to perform these studies and ultrasound may be used to assist in common emergency department procedures related to these conditions.

Clostridial gas gangrene involving the brain, gallbladder, heart, and soft tissue: A case report and literature review

Clostridial gas gangrene (CGG) is among the most rapidly spreading infections in humans, with mortality rates approaching 100 % if not treated promptly. Most cases follow traumatic inoculation, although spontaneous infections occur in a minority of patients with immunodeficiency. Spontaneous CGG is primarily caused by Clostridium septicum, whereas traumatic infection is associated with Clostridium perfringens. Patients with CGG present abruptly with rapidly progressive symptoms, underscoring the importance of early recognition, prompt surgical intervention, and appropriate antimicrobial therapy. We describe an illustrative case of spontaneous CGG caused by C. perfringens in a polymorbid 73-year-old female patient. Despite aggressive medical and surgical management, she succumbed to metastatic infection within 48 h of presentation.

Necrotizing Fasciitis Mimicking Interstitial Cystitis: An Atypical Clinical Presentation

Necrotizing fasciitis is a severe, life-threatening disease with a nonspecific clinical presentation, making it a challenging diagnosis. Early treatment with broad-spectrum antibiotics and surgical debridement is crucial to prevent rapid disease progression and poor outcomes. Given its high mortality rate and ambiguous presentation, maintaining a high index of suspicion for necrotizing fasciitis is essential. In this case, a 60-year-old woman presented to her gynecologist with urinary tract infection symptoms of frequency, hematuria, and suprapubic pain, with a year-long history of night sweats, hematuria, dysuria, and incomplete voiding. Although initially treated with outpatient antibiotics, she returned to the emergency department one day later with severe lower abdominal pain, overlying erythema, and a high fever. Abdominal imaging revealed extensive cellulitis. Upon the development of rapidly expanding erythema and crepitus, there was concern for necrotizing fasciitis. The patient received immediate treatment with broad-spectrum antibiotics and underwent urgent surgical debridement. While she showed clinical improvement in the following days, laboratory studies revealed profound hypercalcemia, anemia, and persistent leukocytosis. Additional testing ultimately led to the diagnosis of advanced bladder cancer. This case underscores the importance of prompt recognition and treatment of necrotizing fasciitis. It also highlights the influence of confirmation and availability biases, which can lead to overlooking symptoms that may indicate more serious underlying conditions. As medical professionals, it is crucial to remain vigilant and not disregard seemingly insignificant symptoms, as they could be indicative of life-threatening diagnoses.

Real-time identification of life-threatening necrotizing soft-tissue infections using indocyanine green fluorescence imaging

Significance

Necrotizing soft-tissue infections (NSTIs) are life-threatening infections with a cumulative case fatality rate of 21%. The initial presentation of an NSTI is non-specific, frequently leading to misdiagnosis and delays in care. No current strategies yield an accurate, real-time diagnosis of an NSTI.

Aim

A first-in-kind, observational, clinical pilot study tested the hypothesis that measurable fluorescence signal voids occur in NSTI-affected tissues following intravenous administration and imaging of perfusion-based indocyanine green (ICG) fluorescence. This hypothesis is based on the established knowledge that NSTI is associated with local microvascular thrombosis.

Approach

Adult patients presenting to the Emergency Department of a tertiary care medical center at high risk for NSTI were prospectively enrolled and imaged with a commercial fluorescence imager. Single-frame fluorescence snapshot and first-pass perfusion kinetic parameters-ingress slope (IS), time-to-peak (TTP) intensity, and maximum fluorescence intensity (IMAX)-were quantified using a dynamic contrast-enhanced fluorescence imaging technique. Clinical variables (comorbidities, blood laboratory values), fluorescence parameters, and fluorescence signal-to-background ratios (SBRs) were compared to final infection diagnosis.

Results

Fourteen patients were enrolled and imaged (six NSTI, six cellulitis, one diabetes mellitus-associated gangrene, and one osteomyelitis). Clinical variables demonstrated no statistically significant differences between NSTI and non-NSTI patient groups (p -value ≥ 0.22 ). All NSTI cases exhibited prominent fluorescence signal voids in affected tissues, including tissue features not visible to the naked eye. All cellulitis cases exhibited a hyperemic response with increased fluorescence and no distinct signal voids. Median lesion-to-background tissue SBRs based on snapshot, IS, TTP, and IMAX parameter maps ranged from 3.2 to 9.1, 2.2 to 33.8, 1.0 to 7.5, and 1.5 to 12.7, respectively, for the NSTI patient group. All fluorescence parameters except TTP demonstrated statistically significant differences between NSTI and cellulitis patient groups (p -value < 0.05 ).

Conclusions

Real-time, accurate discrimination of NSTIs compared with non-necrotizing infections may be possible with perfusion-based ICG fluorescence imaging.

Necrotizing soft-tissue infection of the upper limb: A single-center study of 24 cases

OBJECTIVES

Necrotizing soft-tissue infection and necrotizing fasciitis of the upper limb are infrequent. Studies are rare, and often include other anatomical regions. The specificities and particularities of this pathology are not well known. The aim of this study was to report diagnosis and treatment aspects.

METHODS

A retrospective study was conducted over 10 years on every patient treated for necrotizing fasciitis of the upper limb with clinical, bacteriological and histological confirmation. One hundred ninety-eight items were extracted for each patient concerning clinical, biological, radiological and therapeutic data.

RESULTS

During 10 years, 24 patients were diagnosed with necrotizing fasciitis of the upper limb: 18 males, 6 females; mean age, 59.9 years; mean body mass index, 25. Local erythema, pain and fever were the most frequent symptoms. Skin necrosis was present in fewer than 40% of patients. Sixteen cases (66.6%) had prior skin lesions and/or an entry point on the limb. Ten had non-steroidal anti-inflammatory drug prescription before acute symptom onset (42%), requiring intensive care unit admission. Treatment comprised surgical resection, resuscitative measures, antibiotic therapy and reconstructive surgery. Seven patients (30.4%) had 1 session of cutaneous excision, and the others had more than 2. Microbiological analysis found mono-microbial beta-hemolytic group A streptococci (BHGAS) infection in 14 patients (58.4%). Antibiotics were prescribed in 91% of cases before surgery, and in 100% after. The most frequently prescribed substance was clindamycin (18 patients, 75%). Ten patients (42%) stayed in the intensive care unit during treatment. Seventeen patients (70.8%) had thin skin graft reconstruction, including 50% with dermal substitute. Five patients (20.8%) had partial upper limb amputation. Two patients (8.3%) died in the 30 days following diagnosis.

CONCLUSIONS

The death rate in necrotizing fasciitis of the upper limb was rather low but the amputation rate was higher than in other locations. This study shows the specific clinical, biological and treatment features of this rare but serious pathology of the upper limb.

Necrotizing Fasciitis Masquerading as Stroke: A Diagnostic Dilemma

Necrotizing fasciitis (NF) poses a diagnostic challenge due to its rarity and similarity in presentation with other critical conditions. We report a case of a 79-year-old male who initially presented with altered mental status and stroke-like symptoms; he was ultimately diagnosed with abdominal wall NF spreading to the lower extremity. Despite a history of cecal mass perforation noted in prior imaging, the patient had been discharged from an outside emergency room on antibiotics, highlighting a missed opportunity for early intervention. Subsequent deterioration led to sepsis, organ failure, and ultimately, the detection of NF. Prompt recognition of subtle skin changes and laboratory abnormalities, along with a detailed physical examination, is essential for a timely and accurate diagnosis. Surgical debridement, coupled with broad-spectrum antibiotics, remains the cornerstone of treatment. Delays in surgical management significantly increase mortality, emphasizing the importance of prompt diagnosis and intervention. This case underscores the necessity for heightened awareness among healthcare providers to recognize NF promptly, especially when its clinical presentation overlaps with other critical conditions. Multidisciplinary collaboration and continued education are imperative to improve outcomes and prevent delays in the diagnosis and treatment of NF.

Assessing Second Debridement Timing and Mortality in Necrotizing Soft Tissue Infections

BACKGROUND

Patients with necrotizing soft tissue infection undergo an average of 4-5 debridements per hospital admission. Optimal timing for initial debridement is emergent. Second debridement is universally recommended to occur within 24 hours of the first, but no studies have successfully evaluated this time frame. Prior work has suggested that delays in second debridement are associated with increased mortality, and that few patients receive second debridement within 24 hours.

METHODS

We performed a retrospective cohort study at a single center from 01/01/08 to 09/01/2021. The explanatory variable was whether the subject received second debridement within 24 hours of initial debridement. The primary outcome was in-hospital mortality. Baseline characteristics were collected. Subjects were stratified into 2 groups by time between first and second debridement: <24 and ≥24 hours. Variables were compared using Fisher's exact and Wilcoxon rank-sum tests.

RESULTS

77 patients met inclusion criteria. The median overall time to second debridement was 40 hours. 12 subjects received second debridement within 24 hours (15.6%). There was no difference in in-hospital mortality between the <24 (n = 3, 25.0%) and ≥24-hour second debridement groups (n = 4, 6.2%; P = .07). The 2 groups did not differ by secondary outcomes, including total number of debridements, ICU LOS, or wound closure.

CONCLUSION

No difference in mortality was observed between subjects undergoing second debridement within 24 vs after 24 hours. Only 16% of subjects received second debridement within the recommended 24-hour time interval. Further study is required to identify the optimal timing of second debridement.

Bacterial Skin and Soft Tissue Infections in Older Adults

This article focuses on bacterial infections that commonly affect geriatric patients. The elderly population is at a higher risk of contracting bacterial infections due to weakened immune systems and comorbidities. The article explores the cause, pathogenesis, clinical manifestations, and treatment options of these infections. Additionally, antibiotic resistance is a growing concern in the treatment of bacterial infections. The article highlights the importance of preventing these infections through proper hygiene and wound care. This article aims to provide an understanding of bacterial infections in geriatric patients and inform health-care providers on the most effective ways to manage and prevent these infections.

Necrotizing fasciitis and fatal septic shock associated with Streptococcus constellatus

Streptococcus constellatus is usually a benign, commensal bacteria but has increased incidence in blood cultures and abscesses. This pathogenic involvement is most prevalent in individuals with underlying medical conditions, such as solid tumors and type 2 diabetes mellitus, as well as in cases of community-acquired infections. We report a 43-year-old male with a right medial thigh ulcer and necrotic scrotal skin. The wound culture from surgical debridement grew Streptococcus constellatus, and histology was consistent with stage III necrotizing fasciitis. Regardless of etiology, the mortality rate of patients with necrotizing fasciitis is greatly decreased with early intervention and thorough surgical debridement.

Early diagnosis of necrotizing fasciitis: Imaging techniques and their combined application

Necrotizing fasciitis is a clinical, surgical emergency characterized by an insidious onset, rapid progression, and a high mortality rate. The disease's mortality rate has remained high for many years, mainly because of its atypical clinical presentation, which prevents many cases from being diagnosed early and accurately, resulting in patients who may die from uncontrollable septic shock and multi-organ failure. But unfortunately, no diagnostic indicator can provide a certain early diagnosis of NF, and clinical judgement of NF is still based on the results of various ancillary tests combined with the patient's medical history, clinical manifestations, and the physician's experience. This review provides a brief overview of the epidemiological features of NF and then discusses the most important laboratory indicators and scoring systems currently employed to diagnose NF. Finally, the latest progress of several imaging techniques in the early diagnosis of NF and their combined application with other diagnostic indices are highlighted. We point out promising research directions based on an objective evaluation of the advantages and shortcomings of different methods, which provide a basis for further improving the early diagnosis of NF.

Practical Review of Necrotizing Fasciitis: Principles and Evidence-based Management

Necrotizing fasciitis is a severe, life-threatening soft tissue infection that presents as a surgical emergency. It is characterized by a rapid progression of inflammation leading to extensive tissue necrosis and destruction. Nonetheless, the diagnosis might be missed or delayed due to variable and nonspecific clinical presentation, contributing to high mortality rates. Therefore, early diagnosis and prompt, aggressive medical and surgical treatment are paramount. In this review, we highlight the defining characteristics, pathophysiology, diagnostic modalities, current principles of treatment, and evolving management strategies of necrotizing fasciitis.

[Clinical efficacy of antibiotic bone cement combined with vacuum sealing drainage in treating diabetes mellitus complicated with necrotizing fasciitis]

Objective: To explore the clinical efficacy of antibiotic bone cement combined with vacuum sealing drainage (VSD) in treating diabetes mellitus complicated with necrotizing fasciitis. Methods: The retrospective observational study approach was used. From January 2020 to March 2022, 12 patients with type 2 diabetes complicated with necrotizing fasciitis who met the inclusion criteria were admitted to Wuxi Ninth People's Hospital, including 7 males and 5 females, aged 27 to 76 years. The initial diagnosis of lesions was in the lower limbs. After admission, bedside incision and drainage were performed timely, and a sample of wound exudate was collected for microbial cultivation. At the same time, the comprehensive supportive treatment was performed. At stage Ⅰ, debridement was performed, and the skin and soft tissue defect area was 40 cm×15 cm to 80 cm×25 cm after debridement. The dead space was filled with bone cement containing gentamicin and vancomycin and VSD was performed. After there was no obvious infection on the wound, the antibiotic bone cement was removed and wound repair surgery was performed at stage Ⅱ. The times of debridement, amputation, infection control, wound treatment method and wound healing at stage Ⅱ, total hospitalization day, and recurrence of necrotizing fasciitis during follow-up after the stage Ⅱ surgery. At the last follow-up, the walking function of patients was evaluated according to the scoring standards of American Orthopedic Foot and Ankle Association (AOFAS). Results: Eleven patients had wound infection control with one debridement surgery and did not undergo amputation surgery; one patient had significant foot gangrene, and the infection was controlled after one debridement and amputation of the gangrenous limb. Blood routine and infection indicators gradually returned to normal within 7 days after surgery. At stage Ⅱ, the wounds in 4 patients were sutured directly, the wounds in 6 patients were repaired with full-thickness inguinal skin graft, while the wounds in 2 patients were repaired with pedicled or tongue-shaped flaps at the wound edge. The wounds healed well after surgery, with no ulceration. The total hospitalization day of patients was 20 to 45 days. Follow-up for 3 to 24 months after stage Ⅱ surgery showed no recurrence of necrotizing fasciitis in any patient. At the last follow-up, the walking function was evaluated as excellent in 10 cases and good in 2 cases according to the AOFAS scoring standard. Conclusions: Antibiotic bone cement combined with VSD used in treating type 2 diabetes complicated with necrotizing fasciitis can effectively control infection and reduce the times of debridement, with good wound healing and walking function after surgery.

Necrotizing Fasciitis and Diabetic Foot: Results of a Prompt Identification, Surgery and Antibiotic Therapy (P.I.S.A.) Protocol

Necrotizing fasciitis (NF) is a rapidly progressive, life-threatening infection, involving the skin, soft tissue and fascia. We evaluated outcomes of its surgical management in diabetic foot (DF) patients in a tertiary referral centre. We retrospectively searched for NF in the database of our DF Section from 2016 to 2018. All cases were treated according to a multiprofessional integrated protocol, with Prompt Identification, Surgical debridement and systemic Antibiotic therapy (P.I.S.A. Protocol). We analysed short-term evolution (surgical procedures and major amputations), and long-term outcomes (survival and healing rates). Sixty-eight patients were referred to our DF clinic for suspicion of NF. The diagnosis was confirmed in 54 (79.4%; male/female 40/14; type 1/2 diabetes 6/48; age 62.8 ± 8.1 years; duration of diabetes 13.6 ± 10.1 years). According to the microbiological results, cases were classified as Type 1 (33-61.2%), 2 (7-12.9%) and 3 (14-25.9%). No significant differences were observed. All patients underwent a decompressive fasciotomy. Six patients (11.1%) required also a forefoot amputation and 12 (22.2%) a toe or ray amputation. No major amputation was performed in the short-term period. During the follow-up (26 ± 12 months) 46 patients (85%) healed in 94 ± 11 days. Of the remaining 8: 5 (9.2%) died for other reasons before healing, 2 (3.7%) recurred and one (1.9%) required a major amputation. Our experience reveals a relatively high prevalence of NF in DF; despite this, we observed how, when promptly and aggressively treated, NF has a good prognosis and it is not associated with an excess of limb loss and deaths.

Surviving the perilous: A case report on an urgent approach to necrotizing fasciitis

Necrotizing fasciitis is a rare, fatal, and rapidly progressing bacterial infection of fascia and subcutaneous tissues. Skin necrosis, pain, bullae, and erythema are the common manifestations. Early diagnosis and prompt treatment can improve outcome.

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.

Pediatric Necrotizing Fasciitis

Necrotizing fasciitis (NF) is a rapidly progressing bacterial infection of the subcutaneous tissue that can be lifethreatening. Without prompt diagnosis and treatment, it can lead to septic shock, organ failure, and death. Due to the rarity of this disease in the pediatric population and the fact that initial symptoms are frequently nonspecific, NF in children is often misdiagnosed as cellulitis, which delays the correct treatment. Physicians must maintain a high index of suspicion and keep NF in mind because rapid surgical debridement is necessary to reduce morbidity and mortality. The purpose of this article is to better characterize what is currently known about NF within the pediatric population. In this article, the microbiology, pathophysiology, clinical manifestations, diagnosis, and treatment of pediatric NF are reviewed, and key differences between adult and pediatric NF are highlighted. Key Concepts•One must keep Necrotizing Fasciitis in mind when dealing with soft tissue infections.•A common symptom is a disproportionate level of pain for what can appear to be cellulitis.•Prompt treatment must include early, thorough, and frequently multiple debridements.•As a result of low incidences, collaborative multiple-center studies are needed to improve our level of understanding.

Clinical and Laboratory Parameters for Differential Diagnosis of Necrotizing Faciitis and Cellulitis

ObjectiveS

Necrotizing fasciitis (NF) requires surgical intervention and has high morbidity and mortality. Furthermore, it can be confusing with some skin diseases such as cellulitis. We investigated the roles of clinical and laboratory parameters at the time of admission to the hospital in the differential diagnosis of NF and cellulitis patients.

Methods

Patients with cellulitis and NF located between the nipple level and the knee between January 2018 and January 2021 were included in our retrospective study. The fever, history, complete blood count results, blood biochemistry, C-reactive protein and procalcitonin values of the patients at the time of admission to the emergency department, length of hospital stay, mortality rates, and laboratory risk indicator for necrotizing fasciitis (LRINEC) scores were recorded and evaluated whether there was a difference in both patient groups.

Results

A total of 55 patients, including 26 patients in the NF group and 29 patients in the cellulite group, were included in the study. It was observed that patients with NF applied to the hospital statistically earlier, had higher leukocyte, platelet and neutrophil levels, had longer hospital stays and had higher mortality numbers.

Conclusion

In high leukocyte, platelet, and neutrophil levels in the case of cellulitis patients, the clinician should follow the patient's clinic course closely and keep NF in mind.

Under the Skin: A Case Series of Clostridium sordellii Necrotizing Soft Tissue Infections in Patients Who Inject Drugs

Clostridium sordellii has been well-associated as a cause of obstetric infections but is a less commonly recognized organism of necrotizing skin and soft tissue infections (NSTI). C. sordelli infections are rare with only 14 cases reported in the literature to date. These infections are often associated with profound septic shock and the mortality rate remains high. We report four patients who presented with C. sordellii NSTI over a period of two years at an academic medical center. Notably, injection drug use was the main risk factor for infection in these patients. Appropriate management of C. sordellii NSTI necessitates a combination of antibiotics and emergent surgical intervention. However, despite these efforts, the mortality rate remains high, with three of the four patients dying. Clinicians should consider NSTI in the differential diagnosis when evaluating skin and soft tissue infections in people who inject drugs. Furthermore, it is imperative to educate patients who engage in injection drug use on the potential risks associated with NSTI and inform them of warning signs that warrant immediate medical attention. The devastating consequences of C. sordellii-associated NSTI in this vulnerable population can be mitigated by enhancing awareness and facilitating early intervention.

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.

Clinical complete response maintained for more than 5 years after aggressive chemoradiotherapy for advanced rectal cancer with necrotizing fasciitis: a case report

We report the case of a 65-year-old male diagnosed with advanced rectal cancer associated with necrotizing fasciitis (NF). Since radical surgery, total pelvic exenteration with sacrectomy, was rejected because of detrimental effects on quality of life, chemoradiotherapy (CRT) was chosen as anti-cancer treatment after urgent debridement. Although CRT was paused unintentionally just after delivering the total dose of radiation owing to the relapse of NF, the patient has maintained clinical complete response (cCR) without any distant metastasis for >5 years. Advanced rectal cancer is recognized as an NF risk factor. No definitive treatment strategies have been reported for NF-inducing rectal cancer; however, some reports have demonstrated curative extended surgery. Thus, CRT may be a less-invasive treatment option for NF-inducing rectal cancer, whereas severe adverse effects including re-infection after debridement should be closely monitored.

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.

The effect of hyperbaric oxygen therapy on the clinical outcomes of necrotizing soft tissue infections: a systematic review and meta-analysis

BACKGROUND

To determine the efficacy of hyperbaric oxygen therapy (HBO) in the treatment of necrotizing soft tissue infections (NSTI), we conducted a meta-analysis of the available evidence.

METHODS

Data sources were PubMed, Embase, Web of Science, Cochrane Library, and reference lists. The study included observational trials that compared HBO with non-HBO, or standard care. The primary outcome was the mortality rate. Secondary outcomes were the number of debridement, amputation rate and complication rate. Relative risks or standardized mean differences with 95% confidence intervals were calculated for dichotomous and continuous outcomes, respectively.

RESULTS

A total of retrospective cohort and case-control studies were included, including 49,152 patients, 1448 who received HBO and 47,704 in control. The mortality rate in the HBO group was significantly lower than that in the non-HBO group [RR = 0.522, 95% CI (0.403, 0.677), p < 0.05]. However, the number of debridements performed in the HBO group was higher than in the non-HBO group [SMD = 0.611, 95% CI (0.012, 1.211), p < 0.05]. There was no significant difference in amputation rates between the two groups [RR = 0.836, 95% CI (0.619, 1.129), p > 0.05]. In terms of complications, the incidence of MODS was lower in the HBO group than in the non-HBO group [RR = 0.205, 95% CI (0.164, 0.256), p < 0.05]. There was no significant difference in the incidence of other complications, such as sepsis, shock, myocardial infarction, pulmonary embolism, and pneumonia, between the two groups (p > 0.05).

CONCLUSION

The current evidence suggests that the use of HBO in the treatment of NSTI can significantly reduce the mortality rates and the incidence rates of complications. However, due to the retrospective nature of the studies, the evidence is weak, and further research is needed to establish its efficacy. It is also important to note that HBO is not available in all hospitals, and its use should be carefully considered based on the patient's individual circumstances. Additionally, it is still worthwhile to stress the significance of promptly evaluating surgical risks to prevent missing the optimal treatment time.

Necrotizing Fasciitis: Myalgia Is Diagnostic? A Case Series and Literature Review

Necrotizing fasciitis, commonly known as "flesh-eating disease," is an aggressive soft tissue infection that destroys the fascia, subcutaneous tissue, and skin. Specific clinical features (crepitus or radiologic features of gas in tissues) either appear late or are of poor sensitivity. Thus, a high index of clinical suspicion is required for early diagnosis and prompt treatment, which are the best methods of minimizing its high associated morbidity and mortality. We present 3 cases to demonstrate diagnostic difficulties and challenges in management and highlight the feature of pain on muscular activity.

Ultrasound for the diagnosis of necrotizing fasciitis: A systematic review of the literature

BACKGROUND

Necrotizing fasciitis (NF) is a deadly disorder that can be challenging to diagnose on history and examination alone. Point-of-care ultrasound (POCUS) is widely available and has been increasingly used for diagnosing skin and soft tissue infections. We performed a systematic review to determine the accuracy of POCUS for diagnosing NF with subgroup analyses of the accuracy of specific POCUS examination components.

METHODS

PubMed, Scopus, CINAHL, LILACS, the Cochrane databases, Google Scholar, and bibliographies of selected articles were assessed for all retrospective, prospective, and randomized control trials evaluating the accuracy of POCUS for diagnosing NF. Data were dual extracted into a predefined worksheet and quality analysis was performed with the QUADAS-2 tool. Data were summarized and an overall summary was completed.

RESULTS

We identified three papers (n = 221 patients; 33% NF) that met our inclusion criteria. The overall sensitivity ranged from 85.4%-100% while the specificity ranged from 44.7% to 98.2%. Fluid accumulation along the fascial plane was the most sensitive (85.4%; 95% CI 72.2% - 93.9%), while subcutaneous emphysema was the most specific (100%; 95% CI 92.5% - 100%).

CONCLUSIONS

POCUS has good sensitivity and specificity for the diagnosis of NF. POCUS should be considered as an adjunct to the initial clinical decision making for the diagnosis of NF.

Necrotising fasciitis: a case series set in rural Australia

Necrotising fasciitis (NF) is a rapidly progressive infection of soft tissue and fascia. Early diagnosis and prompt extensive surgical debridement decrease mortality. This remains a challenge for rural surgeons who have limited experience with the disease, in a setting where patient transfers to tertiary centres are lengthy and often delayed. To assist clinical decision making in this setting, a case series of five NF presentations in a rural Australian hospital were retrospectively analysed for presentation, investigation, treatment and clinical outcomes. Three underwent abdominal wall debridement and two underwent below knee amputation. Results demonstrate early recognition of NF and the extent of surgical intervention prior to acute transfer are key to successful outcomes. Expedient diagnosis and early extensive debridement at the initial contact reduce mortality and should be the goal of management in this setting.

Necrotizing Fasciitis of the Breast: A Case Series and Review of the Literature

Abstract Background: Primary necrotizing fasciitis of the breast is a rare clinical condition and therefore a challenge for the clinical doctor. Its severity is associated with high morbidity and mortality. Patients and Methods: In the current article we present three cases that we treated in our surgical department with a combination of empirical antibiotic treatment, complete surgical debridement in stages, and negative pressure wound therapy. Conclusions: It appears that prompt diagnosis and surgical intervention are key for the successful management of these cases. The recognition of early clinical signs as well as risk factors are issues of great importance. A high index of suspicion is required for the early diagnosis and treatment, aiming to the best outcome for the patient.

Current and Future Applications of Fluorescence Guidance in Orthopaedic Surgery

Fluorescence-guided surgery (FGS) is an evolving field that seeks to identify important anatomic structures or physiologic phenomena with helpful relevance to the execution of surgical procedures. Fluorescence labeling occurs generally via the administration of fluorescent reporters that may be molecularly targeted, enzyme-activated, or untargeted, vascular probes. Fluorescence guidance has substantially changed care strategies in numerous surgical fields; however, investigation and adoption in orthopaedic surgery have lagged. FGS shows the potential for improving patient care in orthopaedics via several applications including disease diagnosis, perfusion-based tissue healing capacity assessment, infection/tumor eradication, and anatomic structure identification. This review highlights current and future applications of fluorescence guidance in orthopaedics and identifies key challenges to translation and potential solutions.

Early identification of life-threatening soft-tissue infection using dynamic fluorescence imaging: first-in-kind clinical study of first-pass kinetics

Necrotizing soft-tissue infections (NSTIs) are aggressive and deadly. Immediate surgical debridement is standard-of-care, but patients often present with non-specific symptoms, thereby delaying treatment. Because NSTIs cause microvascular thrombosis, we hypothesized that perfusion imaging using indocyanine green (ICG) would show diminished fluorescence signal in NSTI-affected tissues, particularly compared to non-necrotizing, superficial infections. Through a first-in-kind clinical study, we performed first-pass ICG fluorescence perfusion imaging of patients with suspected NSTIs. Early results support our hypothesis that ICG signal voids occur in NSTI-affected tissues and that dynamic contrast-enhanced fluorescence parameters reveal tissue kinetics that may be related to disease progression and extent.

A Quality Improvement Project to Improve the Pathway and Outcomes for Patients with Necrotising Fasciitis

BACKGROUND

Necrotising fasciitis (NF) is a life-threatening illness that requires a multidisciplinary approach between surgeons in multiple specialties, intensivists, and microbiologists. Serial debridements and change of dressings are required prior to reconstruction. The aim of this study was to review the workload and streamline services in a tertiary centre for regional and internal referrals by formalizing an NF pathway agreed upon by all multidisciplinary team stakeholders and securing adequate resources for these complex patients.

METHODS

Retrospective data was collected on all patients with NF referred to the plastic surgery department between January 2017 and September 2018. Referrals were categorized as either regional (debridement had already taken place at another hospital) or internal (conducted on patients admitted through the emergency department).

RESULTS

A total of 41 patients (17 regional and 24 internal referrals) with a median age of 63 years (range, 28 to 85 years) were included in the study. Overall mortality rate was found to be 27%, median length of stay (LOS) amongst internal referrals was 25 days (range, 11 to 94 days), and median intensive care unit LOS was 8 days (range, 0 to 64 days). A total of 121 operations were conducted by 4 surgical specialties with a median time per procedure of 145 minutes (range, 50 to 605). 11 patients underwent reconstruction with split thickness graft and the median number of days between initial debridement to grafting was 13 (range, 2 to 38 days).

CONCLUSIONS

Patients with NF require complex care and treatment. By characterizing and defining the workload involved in treating these patients, it may be possible to improve advanced planning and allocate resources accordingly to ensure that the centre runs as smoothly as possible without interruption to the acute trauma service.

Complications of Severe Odontogenic Infections: A Review

Severe odontogenic infections are routinely treated with little associated morbidity and mortality. Improvements in surgical techniques, antibiotic treatments, and imaging modalities have made associated complications exceedingly rare. A number of complications have been described in the literature including airway obstruction, descending necrotizing mediastinitis, orbital abscess, septic cavernous sinus thrombosis, cerebral abscess, sepsis, necrotizing fasciitis, and Lemierre's syndrome. The purpose of this article is to discuss the pathophysiology of severe odontogenic infections and the risk factors associated with the development of complications. Given the morbidity and mortality of these conditions, it is important to review the clinical features of each and the diagnostic tools that aid in early recognition.

Imaging of Musculoskeletal Soft-Tissue Infections in Clinical Practice: A Comprehensive Updated Review

Musculoskeletal soft-tissue infections include a wide range of clinical conditions that are commonly encountered in both emergency departments and non-emergency clinical settings. Since clinical signs, symptoms, and even laboratory tests can be unremarkable or non-specific, imaging plays a key role in many cases. MRI is considered the most comprehensive and sensitive imaging tool available for the assessment of musculoskeletal infections. Ultrasound is a fundamental tool, especially for the evaluation of superficially located diseases and for US-guided interventional procedures, such as biopsy, needle-aspiration, and drainage. Conventional radiographs can be very helpful, especially for the detection of foreign bodies and in cases of infections with delayed diagnosis displaying bone involvement. This review article aims to provide a comprehensive overview of the radiological tools available and the imaging features of the most common musculoskeletal soft-tissue infections, including cellulitis, necrotizing and non-necrotizing fasciitis, foreign bodies, abscess, pyomyositis, infectious tenosynovitis, and bursitis.

Delayed diagnosis and management of necrotizing fasciitis of the left lower leg: A case report

INTRODUCTION

Necrotizing fasciitis (NF) is a rare, severe soft tissue infection, characterized by rapid and extensive necrosis of the skin, subcutaneous tissue, and superficial and deep fascia. It is frequently misdiagnosed as other infectious diseases, leading to inappropriate treatment and potentially serious consequences. It may be complicated by septic shock and multiple organ failure with a fatal outcome.

PATIENT CONCERNS

A 73-year-old woman presented with continuous itching, skin lesions, pain, and swelling of the outer side of her left leg. The patient was diagnosed with septic shock and multiorgan failure caused by left leg NF.

DIAGNOSIS

Septic shock and multiorgan failure caused by left leg NF.

INTERVENTIONS

Two surgeries were performed on the patient's leg, which effectively treated her septic shock and multiple organ dysfunction.

OUTCOMES

The patient was followed up three times after her discharge. She had a good recovery, was generally well with no significant sequelae, and returned to her regular life.

CONCLUSION

NF is an acute severe illness with high mortality. It is easily misdiagnosed, leading to delayed or erroneous treatment and serious (or potentially fatal) outcomes. Rapid and accurate diagnosis of NF is essential for patient recovery. In difficult cases, multidisciplinary consultations may be helpful. The management of NF includes early and thorough surgical debridement, antibiotics, and symptomatic treatment.

Pseudomonas aeruginosa as a culprit of cervical necrotizing fasciitis: A case report

Introduction and importance

Necrotizing fasciitis is usually a polymicrobial infection and odontogenic source is usually the foci for infection in the neck region. Cervical necrotizing fasciitis due to Pseudomonas is a rare and potentially fatal complication in diabetic patients. The study highlights the importance of early intervention to improve the outcome of the patient.

Case presentation

We report a case of a 48-year female who presented with neck pain for 10 days. On further investigations, she had diabetic ketoacidosis, and a culture of the wound showed Pseudomonas. With appropriate antibiotics and surgical intervention, her condition gradually improved.

Clinical discussion

Necrotizing fasciitis in the neck region with Pseudomonas without odontogenic infections is a rare occurrence. Early medical and surgical intervention leads to a better outcome. The location of the infection and its extensions can affect the prognosis.

Conclusion

Physicians should be aware of cervical necrotizing fasciitis as a complication in diabetic ketoacidosis and install early treatment to improve survivability and the outcome.

•

The hallmark of necrotizing fasciitis is the extensive necrosis of subcutaneous tissue and underlying fascia.

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Cervical necrotizing fasciitis without contiguous spread is a rare occurrence.

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Early surgical intervention can lead to better outcome of the patient.

Retroperitoneal necrotizing soft tissue infections: A case report and literature review

Necrotizing soft tissue infections of the retroperitoneal is a rare disease identity. Here we present a 50-year-old male patient who underwent surgical exploration for retroperitoneal necrotizing soft tissue infection. Postoperatively, he was put on broad-spectrum antibiotics. He passed on after the first exploration and debridement.

Spontaneous gas gangrene of the lower limb in a patient with rectal cancer: A fatal diagnostic pitfall

Spontaneous gas gangrene of lower limb is rare. It may complicate digestive cancer or neutropenia. We report a case of spontaneous gas gangrene of the lower limb complicating a rectal cancer, initially diagnosed as deep vein thrombosis. The diagnostic delay was fatal.

Morbidity and Mortality of Necrotizing Fasciitis and Their Prognostic Factors in Children

BACKGROUND

This is a prospective study of the clinico-etiologic profile and factors affecting outcomes in 40 children managed for necrotizing fasciitis (NF).

MATERIALS AND METHODS

Demographic details, clinical characteristics, and laboratory parameters were recorded, and the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was calculated. Primary outcome (survival vs. nonsurvival) was noted, and prognostic factors were identified.

RESULTS

Initiating factors included boils (45%), i.v. cannula extravasations (22.5%), and blunt trauma (17.5%). Lesion (s) were predominantly on the lower limbs (35%) and trunk (25%). Twenty-two patients (55%) had <5% body surface area (BSA) involved. Severely deranged clinical and laboratory parameters were common. Ultrasound localized fluid collections. Pus cultures showed methicillin-resistant Staphylococcus aureus (52.5%), methicillin-sensitive S. aureus [27.5%], and polymicrobial growth (20%). Blood culture was positive in 24 patients (60%). Most isolates were sensitive to clindamycin and amoxy-clavulanate. Prognostic factors for mortality (n = 6; 15%) included categorization as "Sick," BSA involvement >10%, thrombocytopenia, raised serum creatinine, late debridement, and polymicrobial blood culture isolates. All six nonsurvivors had a LRINEC score of ≥8 and positive blood cultures. Six patients (20.7%) developed unsightly scars and 5 (17.24%) contractures across joints.

CONCLUSIONS

Pediatric NF has significant morbidity and mortality. Patients with adverse prognostic factors can benefit from early referral to a facility with a critical care unit. Adequate wound management is essential to minimize residual deformity.

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.

Necrotizing Fasciitis of the Upper Extremity - A Review

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

Regional Variations in Microbiology and Outcomes of Necrotizing Soft Tissue Infections: A Systematic Review and Meta-Analysis

Background: Frequency, microbiology, and outcomes of necrotizing soft tissue infections (NSTIs) could vary across the United States because of differences in locoregional and environmental factors. We synthesized the literature from across the regions of the United States on NSTIs in a systematic review/meta-analysis. Methods: PubMed, ProQuest, Scopus, and Web of Science databases were systematically searched and screened. DerSimonian-Laird random-effects meta-analyses were performed using 'meta' package in R to determine pooled prevalences. Meta-regression analyses examined moderator effects of risk factors. Results: Twenty-seven studies (2,242 total patients) were included. Pooled prevalences of polymicrobial and monomicrobial infections were 52.2% and 39.9%, respectively. The prevalence of monomicrobial NSTIs increased over the last two decades (p = 0.018), whereas polymicrobial infections declined (p = 0.003). Meta-regression analysis showed that most polymicrobial NSTIs were Fournier gangrene (p < 0.001), whereas monomicrobial NSTIs mostly affected extremities (p < 0.001). Staphylococcus aureus was the most common organism isolated (predominantly in the South), followed by Bacteroides spp. (predominately in the East) and Streptococcus pyogenes. Methicillin-resistant Staphylococcus aureus (MRSA) accounted for 11.9% of NSTIs, mainly in the South. The overall mortality rate was 17.8% and declined over last two decades (p < 0.001), with the lowest rate reported in the last decade at 13% without any regional differences. Conclusions: Advancement in the management of NSTIs may have contributed to the observed decline in NSTI-related mortality in the United States. However, the proportion of monomicrobial NSTIs seems to be increasing, possibly because of increased comorbidities affecting extremities. Causative organisms varied by region. Multi-center observational studies are warranted to confirm our observations.

Extensive necrotizing fasciitis of scrotum and abdominal wall: Report of two cases and a review of the literature

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.