Mortality in patients with necrotizing fasciitis

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

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

Is overweight a predictor for a more severe course of disease in cases of necrotizing fasciitis?

PURPOSE

Necrotizing fasciitis is a rare but severe soft tissue infection, and its diagnosis is difficult and often delayed. Immediate treatment comprising extensive debridement, highly dosed broad-spectrum antibiotic therapy and intensive care is necessary to prevent fatal outcomes. Considering the global rise in overweight patients and the known negative effects of obesity on the immune system, the aim of this study was to analyze whether overweight results in a more severe course of necrotizing fasciitis, worse outcomes and an increased mortality rate among overweight patients compared than in normal weight patients.

METHODS

The present study involved a retrospective analysis of 29 patients who were treated for necrotizing fasciitis in our level one trauma center during the eight-year period between 2013 and 2020. Based on their BMIs, the patients were assigned to either the overweight group (BMI > 25) or the normal weight group.

RESULTS

In the study population, being overweight appeared to be a predictor for a more severe course of necrotizing fasciitis. Overweight patients suffered from sepsis significantly more often than normal weight patients (13 vs. 5; p = 0.027). Furthermore, they were dependent on invasive ventilation (26.6 ± 33.8 vs. 5.9 ± 11.9 days; p = 0.046) as well as catecholamine support (18.4 ± 23.7 vs. 3.6 ± 5.7 days; p = 0.039) for significantly longer.

CONCLUSION

Necrotizing fasciitis remains a challenging and potentially fatal disease. Within the patient collective, the severity of the disease and treatment effort were increased among overweight patients.

Necrotizing Fasciitis of the Lower Extremity Treated With Continuous Local Antibiotic Perfusion

Necrotizing fasciitis (NF) is a severe soft tissue infection that can spread rapidly throughout the body, often resulting in fatal outcomes. Negative pressure wound therapy (NPWT) enhances wound healing by applying local negative pressure, and its effectiveness in managing NF has been documented. However, NPWT creates a semi-closed environment at the wound site, posing a risk of infection. Continuous local antibiotic perfusion (CLAP) is an innovative approach that uses localized infusion to deliver high concentrations of antibiotics continuously to the affected area via NPWT. CLAP includes intramedullary antibiotic perfusion (iMAP), which involves the intrathecal administration of antimicrobials, and intra-soft tissue antibiotic perfusion (iSAP), which targets the soft tissue. Previous studies have highlighted the efficacy of CLAP in controlling infections in both bone and soft tissue. Here, we present two cases of lower extremity NF treated with iSAP. In both cases, effective infection control and accelerated wound healing were achieved, leading to wound closure. These outcomes suggest that iSAP is a useful treatment modality for NF that offers a reduced treatment period and minimizes the procedural burden on patients.

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.

Prognostic Factors in Necrotizing Fasciitis: Insights from a Two-Decade, Two-Center Study Involving 209 Cases

INTRODUCTION

Necrotizing fasciitis (NF) is a critical disease with high morbidity and mortality rates that poses significant challenges in diagnosis and treatment. Prognostic factors for the clinical course of NF remain unclear and are currently under research. This study aims to identify such factors in a large cohort of patients which represents a major comprehensive investigation of prognostic factors for NF.

METHODS

Retrospective analysis was conducted on necrotizing fasciitis cases from 2003 to 2023 at two German hospitals. Data included demographics, comorbidities, laboratory findings, infection site, causative microorganisms and outcomes. Statistical analysis involved t-tests, chi-square tests, and ROC analysis.

RESULTS

A total of 209 patients were included, with a mortality rate of 18%. Patients were categorized into survivors (n = 171) and non-survivors (n = 38). Non-survivors were significantly older (68.9 ± 13.9 years vs. 55.9 ± 14.3 years; p < 0.01) and exhibited a higher prevalence of peripheral vascular diseases, cancer, and heart, liver, or renal insufficiency. Laboratory findings and scoring results also varied significantly between the two groups. The ROC curve analysis identified age as a predictor of mortality, with an optimal cut-off value of 68.5 years (sensitivity: 60.5%, specificity: 81.9%). Higher age was associated with increased mortality risk.

CONCLUSIONS

The patient's age stands out as the primary predictive element for mortality in necrotizing fasciitis. Additionally, we advocate for employing the Laboratory and Anamnestic Risk Indicator for Necrotizing Fasciitis (LARINF-score), which holds substantial prognostic significance and is straightforward to calculate. Considering our findings, crafting a clinical algorithm or scoring mechanism to forecast mortality in NF would be a promising target for future research.

Negative Pressure Wound Therapy With and Without Instillation in Necrotizing Soft Tissue Infections

Background: Necrotizing soft tissue infections (NSTIs) are rare but deadly infections that require early and often extensive surgical debridement. After debridement, patients frequently have substantial morbidity because of large, open wounds. Hypothesis: Negative pressure wound therapy with instillation (NPWTi) results in higher wound closure rates compared with traditional negative pressure wound therapy (NPWT) or wet to dry dressings (moist wound care dressing). Patients and Methods: A prospectively maintained Acute and Critical Care Surgery database spanning 2008-2018 was queried for patients with a diagnosis of necrotizing fasciitis, Fournier gangrene, or gas gangrene. Data were collected on patient comorbidities, operative management, and clinical outcomes. Patients were stratified by use of moist wound care dressing, traditional NPWT, or NPWTi. Data were analyzed using analysis of variance (ANOVA), χ2, and logistic regression. Results: During the 10-year study period, patients were treated for NSTI; 173 were managed with moist wound care dressing, 150 with NPWT, and 48 with NPWTi. Patients were similar in terms of demographics, body mass index (BMI), diabetes mellitus, and smoking rates. Overall, complication rates were not substantially different, but mortality was higher in the moist wound care dressing group (16.2% vs. 10.7% NPWT vs. 2.1% NPWTi; p = 0.02). In the moist wound care dressing group, 81.5% of patients had an open wound at discharge compared with 52.7% of the NPWT group and only 14.6% of the NPWTi group (p < 0.001). On multivariable regression, NPWTi was associated with closure rates five times higher than the NPWT group (odds ratio [OR], 5.28; 95% confidence interval [CI], 2.40-11.61; p < 0.001) after controlling for smoking status, intravenous drug use, number of operations, and involvement of the most common region of the body. Conclusions: Negative pressure wound therapy with instillation is associated with higher rates of wound closure without increasing complication rates in patients with NSTI compared with traditional NPWT or moist wound care dressing. Although prospective studies are needed, this indicates the potential to improve patient quality of life through reduced pain and outpatient home health needs.

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.

Necrotising soft-tissue infections

The incidence of necrotising soft-tissue infections has increased during recent decades such that most physicians might see at least one case of these potentially life-threatening infections in their career. Despite advances in care, necrotising soft-tissue infections are still associated with high morbidity and mortality, underlining a need for continued education of the medical community. In particular, failure to suspect necrotising soft-tissue infections, fuelled by poor awareness of the disease, promotes delays to first surgical debridement, amplifying disease severity and adverse outcomes. This Review will focus on practical approaches to management of necrotising soft-tissue infections including prompt recognition, initiation of specific management, exploratory surgery, and aftercare. Increased alertness and awareness for these infections should improve time to diagnosis and early referral to specialised centres, with improvement in the prognosis of necrotising soft-tissue infections.

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.

Bilateral non-contiguous necrotizing fasciitis of the lower extremities

Necrotizing fasciitis (NF) is an uncommon soft tissue infection. Multifocal-extremity NF is a rarity with high mortality rates. Herein we report a case of bilateral non-contiguous NF of the lower extremities due to Escherichia coli with a fatal outcome, stressing the necessity of rapid and aggressive intervention in suspected cases.

Secondary craniofacial necrotizing fasciitis from a distant septic emboli: A case report

BACKGROUND

Craniofacial necrotizing fasciitis (CNF) is an uncommon but fatal infection that can spread rapidly through the subfascial planes in the head and neck region. Symptoms usually progress rapidly, and early management is necessary to optimize outcomes.

CASE SUMMARY

A 43-year-old man visited our hospital with left hemifacial swelling involving the buccal and submandibular areas. The patient had fever for approximately 10 d before visiting the hospital, but did not report any other systemic symptoms. Computed tomography scan demonstrated an abscess with gas formation. After surgical drainage of the facial abscess, the patient’s systemic condition worsened and progressed to septic shock. Further examination revealed pulmonary and renal abscesses. Renal percutaneous catheter drainage was performed at the renal abscess site, which caused improvement of symptoms. The patient showed no evidence of systemic complications during the 4-mo post-operative follow-up period.

CONCLUSION

As the patient did not improve with conventional CNF treatment and symptoms only resolved after controlling the infection, the final diagnosis was secondary CNF with septic emboli. Aggressive surgical decompression is important for CNF management. However, if symptoms worsen despite early diagnosis and management, such as pus drainage and surgical intervention, clinicians should consider the possibility of a secondary abscess from internal organs.

A Case Report of Rapidly Necrotizing Fasciitis Post-Falling Down Treated Reconstructively

Necrotizing fasciitis (NF) is a necrotizing soft tissue infection that can result in fast tissue loss, necrosis, and potentially fatal acute sepsis. Diabetes, cancer, alcohol abuse, and chronic liver and renal disease are all risk factors for NF. In this case report, a 19-year-old man with a negative past medical and surgical history was diagnosed with aggressive rapidly progressive necrotizing fasciitis of the left lower extremity after a recent history of falling down from a skateboard. A successful treatment with long-term debridement surgeries followed by reconstructive surgery with skin grafting was made. Although the severity of this condition, the patient was able to resume a normal range of motion of the concerned extremity. NF has been described in the literature, but early diagnosis, which is crucial for successful management, rests a challenge.

Survival and Health-Related Quality of Life after Hospitalization for Necrotizing Soft Tissue Infections of the Upper Extremity: A Long-Term Outcome Study

Introduction  The main aim of the study was to investigate the survival and health-related quality of life (HRQoL) after hospitalization for necrotizing soft tissue infections (NSTIs) of the upper extremity. Materials and Methods  A retrospective study with long-term follow-up of patients surviving NSTIs of the upper extremity was performed. Survival and HRQoL after hospital discharge were the primary outcomes. The HRQoL was measured using the 36-item Short Form (SF-36), EuroQoL-5D-5L (EQ-5D), Quick Disability of Shoulder, Arm and Hand (QuickDASH), and numeric rating scales (NRS) for satisfaction with appearance and pain. Results  A median of 6.5 years after hospitalization, 81% of the 108 patients survived. The response rate was 45% ( n = 38). The SF-36 score was 80 (interquartile range [IQR]: 58-91), the EQ-5D score 1.4 (IQR: 1.2-2.2), the EuroQoL-Visual Analog Scale score 77 (IQR: 67-90), the QuickDASH score 13.6 (IQR: 2.3-30.7), the NRS for satisfaction with appearance 8 (IQR: 7-9), and NRS for pain 1 (IQR: 0-5). Conclusion  Six-and-a-half years after the NSTI, 81% of the patients were still alive. General health prior to the NSTI mainly influenced the risk at secondary mortality. In surviving patients, the HRQoL varied widely, but was adversely affected by female sex, intravenous drug use, NSTI type I or III, and longer length of hospital stay.

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

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

Factors Affecting Patients with Concurrent Deep Neck Infection and Cervical Necrotizing Fasciitis

Deep neck infection (DNI) is a severe disease of the deep neck spaces, which has the potential for airway obstruction. Cervical necrotizing fasciitis (CNF) is a fatal infection of the diffuse soft tissues and fascia with a high mortality rate. This study investigated risk factors in patients with concurrent DNI and CNF. A total of 556 patients with DNI were included in this study between August 2016 and December 2021. Among these patients, 31 had concurrent DNI and CNF. The relevant clinical variables were assessed. In univariate analysis, age (> 60 years, odds ratio (OR) = 2.491, p = 0.014), C-reactive protein (CRP, OR = 1.007, p < 0.001), blood sugar (OR = 1.007, p < 0.001), and diabetes mellitus (DM, OR = 4.017, p < 0.001) were significant risk factors for concurrent DNI and CNF. In multivariate analysis, CRP (OR = 1.006, p < 0.001) and blood sugar (OR = 1.006, p = 0.002) were independent risk factors in patients with concurrent DNI and CNF. There were significant differences in the length of hospital stay and therapeutic management (intubation, tracheostomy, incision and drainage) between DNI patients with and without CNF (all p < 0.05). While there were no differences in pathogens between the DNI alone and concurrent DNI and CNF groups (all p > 0.05), the rate of specific pathogen non-growth from blood cultures was 16.95% (89/525) in the DNI alone group, in contrast to 0% (0/31) in the concurrent DNI and CNF group (p = 0.008). Higher CRP and blood sugar levels were independent risk factors for the concurrence of DNI and CNF. With regard to prognosis, there were significant differences in the length of hospital stay and therapeutic management between the groups with and without CNF. While there were no significant differences in pathogens (all p > 0.05), no cases in the concurrent DNI and CNF group showed specific pathogen non-growth, in contrast to 89/525 patients in the group with DNI alone.

Necrotizing Fasciitis Due to Prevotella denticola Infection in an Intravenous Drug User

Intravenous drug users (IVDUs) have an increased risk for various types of local and systemic infections including necrotizing fasciitis (NF), which is a life-threatening bacterial soft tissue infection that requires a prompt diagnosis and treatment. Prevotella denticola is a part of the Prevotella species, which are obligate anaerobic, Gram-negative rods related to Bacteroides genus and often implicated in periodontal and dental disease, but have been associated with soft tissue infections and other systemic complications such as cerebral abscess and endocarditis. This case reports a 30-year-old female IVDU who presented with necrotizing fasciitis of the right anterior thigh with associated right knee septic arthritis due to Prevotella denticola. The patient was treated with emergent irrigation and radical debridement along with IV antibiotic treatment for eight weeks. A review of literature was performed regarding necrotizing fasciitis caused by Prevotella species. Necrotizing fasciitis caused by Prevotella species is rare; however, there must be a high index of suspicion among IVDUs to allow for a prompt diagnosis and treatment.

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

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

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

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

Early diagnosis of craniofacial necrotising fasciitis: Analysis of clinical risk factors

Necrotising fasciitis (NF) is a rapidly progressing fatal disease. Craniofacial necrotising fasciitis (CNF) is limited to the region above the mandibular margin, and early diagnosis is particularly difficult in the absence of related studies. Ten-year data of patients with craniofacial infection were collected from four separate hospitals. Based on the diagnostic criteria, patients were classified into abscess and CNF. The risk factors for early diagnosis were analysed by comparing the two groups. Simple abscess was found in 176 patients, and CNF was detected in 25 patients. The risk factors associated with CNF include old age, presence of odontogenic infection, elevated white blood cell count (WBC), increased C-reactive protein (CRP), high levels of creatinine (Cr) and glucose (Glu) and low levels of haemoglobin (Hb) and albumin (Alb). In addition, fever above 38°C and sinusitis at the time of admission and progressive sepsis after admission were also risk factors. Among the statistically significant risk factors, low Alb level showed the greatest association with CNF progression. Appropriate management of CNF via early diagnosis and extensive surgical intervention based on identified risk factors can reduce the mortality rate, complications and unnecessary medical expenses. Clinical question/level of evidence: Diagnostic, III.

Fournier's gangrene after missed acute perforated appendicitis: A case report

Fournier's gangrene (FG) is a rare progressive necrotizing fasciitis (NF) with high mortality rate. This case report describes a young patient with FG with no known history of disease or invasive therapeutic interventions.

Lactate based Scoring System in the diagnosis of necrotizing fasciitis

INTRODUCTION

Necrotizing fasciitis (NF) is a rare and quickly progressing infection and leads to 100% mortality if untreated. Quick diagnosis and an early and radical surgical treatment are essential for stopping bacterial progression. Unfortunately, the absence of clear clinical signs makes the diagnosis often challenging. Therefore, we searched for easy determinable predictive laboratory markers for NF. This is the first study which includes lactate values in a new score.

MATERIAL AND METHODS

A retrospective analysis of patients with NF (n = 44) and patients with erysipelas (n = 150) was performed. Lactate values, patients` demographics, clinical presentations, site of infection, comorbidities, microbiological and laboratory findings, antibiotic therapies and LRINEC and modified LRINEC Scores were analyzed. Logistic regression analysis was used to derive adjusted weights, and final simple point score was assessed with a ROC curve analysis.

RESULTS

Patients with NF had a mean age of 57 years, patients with erysipelas 65 years. The median hospital length of stay was 8 and 49 days in patients with erysipelas and NF, respectively. While only one patient (0.7 %) in the group of erysipelas died, the mortality rate of patients with NF was 9/44 (20.5 %). The lactate values were statistically significant higher in the NF group 4.1 vs. 2.0 mmol/l (p < 0.001). The new created CologNe-FaDe-Score shows the highest AUC-value with 0.907.

CONCLUSION

With the help of lactate values the CologNe-FaDe-Score consists of easily practicable and highly available parameters, which could sensitize diagnosis.

[Necrotizing Fasciitis]

Necrotizing fasciitis (NF) is a soft tissue infection spreading along the fasciae to the surrounding subcutaneous fat, overlying skin and finally musculature, that may rapidly lead to septic shock and death. In order to avoid a massive systemic spread of the infective process, an immediate and extensive radical debridement of necrotic tissues is mandatory complemented by a broad spectrum intravenous antibiotic therapy. Nevertheless, mortality is persistently high at 20-40 %. Because of the lack of specific clinical features in the initial stage of the disease, it is often underestimated or confused with cellulitis or abscess. Hence, early diagnosis is missed or delayed in 85 %-100 % of cases with the passage of valuable time.The aim of this review is to give an overview of the clinical and laboratory elements to be considered for diagnosis as well as the essential therapeutic patterns.

Necrotizing fasciitis of the upper extremity: a retrospective analysis of 19 cases

Necrotizing fasciitis (NF) is both a limb-and life-threatening disease that affects skin, hypodermis as well as superficial fascia and deep fascia by rapidly progressive necrosis. Although this serious infection frequently occurs in the extremities, upper limb NF is a rare clinical presentation. The present study attempted to evaluate the clinical profiles, paraclinical findings, treatment modalities, outcomes and predictors of morbidity and mortality in patients with NF of the upper extremity. The validity of the Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) scoring system was also assessed. Nineteen patients who were treated between January 2010 and December 2019 for NF of the upper extremity were eligible for this study. Data including demographics, clinical signs, paraclinical findings, treatment and outcomes were collected retrospectively from our medical records. Fisher's exact test was used to analyze predictive factors for mortality and morbidity. The mean age was 62 years, with a male predominance. The most common comorbidity was diabetes mellitus (42%). Main clinical manifestations were pain (79%), tense edema (79%) and a large infiltrated swollen erythematous plaque (58%). Severe sepsis and septic shock were identified in 32% and 21% of patients, respectively. Thirteen of our 19 patients (68%) were identified as having a high or intermediate likelihood of NF based of the LRINEC scoring system, while the other 6 (32%) were classified as having low likelihood. All patients received systemic broad spectrum antibiotic therapy in addition to surgical debridement. Two patients (10%) died and one (5%) required amputation. Mortality was associated with septic shock (p = 0.006), delay in surgery >24 h (p = 0.018), creatininemia >141 mmol/l (p = 0.018) and LRINEC score ≥ 8 (p = 0.035). Otherwise, anemia (p = 0.021), hypercreatininemia (p = 0.001) and delayed surgical debridement (p = 0.001) were risk factors for morbidity and mortality. The surviving patients underwent reconstructive surgery (skin grafting after wound preparation by using vacuum therapy) with positive outcome. Early diagnosis coupled with emergent surgical debridement and broad-spectrum empiric antibiotic therapy are the keystones of a successful outcome. The LRINEC score was not strongly correlated to the true diagnosis of NF and was a prognostic tool rather than a diagnostic one.

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

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

[Necrotizing fasciitis-a surgical emergency]

Necrotizing fasciitis is a fulminant and potentially life-threatening infection of the skin and soft tissue. It is usually caused by a combination of different bacteria and is often due to assumed minor trauma. Clinically, only relatively insignificant skin changes are initially present, such as blistering or erythema. They are often accompanied by excessive pain. In the further course, the massive systemic reaction becomes predominant. The diagnosis of necrotizing fasciitis is primarily clinical, which can be supported by laboratory parameters (LRINEC score) and computed tomography imaging. Decisive for the prognosis is the immediate initiation of surgical treatment by radical debridement. Additionally, the calculated administration of a combination of different antibiotics should be initiated. As part of the further complex intensive care treatment, a regular reevaluation of the wounds is carried out. Multiple débridements are always necessary until plastic surgery for defect coverage can be carried out.

Necrotising fasciitis deaths in Australia: patient characteristics and potential areas for improvement in clinical management

BACKGROUND

Necrotising fasciitis (NF) is a life-threatening bacterial infection with high mortality. This retrospective study aimed to investigate patient characteristics and potential areas for improvement in clinical management in NF cases in Australia.

METHODS

Retrospective analysis of surgical death data from all public and private Australian hospitals in every state and territory, excluding New South Wales, collected through the Australian and New Zealand Audit of Surgical Mortality for the 9-year period, January 2009 to February 2018.

RESULTS

A total of 290 NF cases were identified. Among these NF cases, obesity and diabetes mellitus were two of the most common comorbidities, with a prevalence of 26% and 41%, respectively. A total of 41 clinical management issues (CMIs) were identified among 36 NF cases. A larger proportion of NF cases had CMIs compared with non-NF surgical mortality cases. Delay in diagnosis was the leading CMI (n = 28, 68.3%), followed by delay to surgery (n = 7, 17.1%). The majority of delayed diagnoses were attributed to non-surgical clinicians in the hospital.

CONCLUSION

CMIs were identified in a larger proportion of NF cases than in other non-NF surgical mortality cases, suggesting that there are areas for improvement in NF diagnosis and management in Australia. The leading potentially avoidable issue identified in NF deaths was delay in diagnosis. This highlights the importance of awareness among non-surgical clinicians that NF is a surgical emergency requiring urgent debridement.

What Demographic and Clinical Factors Are Associated with In-hospital Mortality in Patients with Necrotizing Fasciitis?

BACKGROUND

Necrotizing fasciitis is a rare infection with rapid deterioration and a high mortality rate. Factors associated with in-hospital mortality have not been thoroughly evaluated. Although predictive models identifying the diagnosis of necrotizing fasciitis have been described (such as the Laboratory Risk Indicator for Necrotizing Fasciitis [LRINEC]), their use in predicting mortality is limited.

QUESTIONS/PURPOSES

(1) What demographic factors are associated with in-hospital mortality in patients with necrotizing fasciitis? (2) What clinical factors are associated with in-hospital mortality? (3) What laboratory values are associated with in-hospital mortality? (4) Is the LRINEC score useful in predicting mortality?

METHODS

We retrospectively studied all patients with necrotizing fasciitis at our tertiary care institution during a 10-year period. In all, 134 patients were identified; after filtering out patients with missing data (seven) and those without histologically confirmed necrotizing fasciitis (12), 115 patients remained. These patients were treated with early-initiation antibiotic therapy and aggressive surgical intervention once the diagnosis was suspected. Demographic data, clinical features, laboratory results, and treatment variables were identified. The median age was 56 years and 42% of patients were female. Of the 115 patients analyzed, 15% (17) died in the hospital. Univariate and receiver operating characteristic analyses were performed due to the low number of mortality events seen in this cohort.

RESULTS

The demographic factors associated with in-hospital mortality were older age (median: 64 years for nonsurvivors [interquartile range (IQR) 57-79] versus 55 years for survivors [IQR 45-63]; p = 0.002), coronary artery disease (odds ratio 4.56 [95% confidence interval (CI) 1.51 to 14]; p = 0.008), chronic kidney disease (OR 4.92 [95% CI 1.62 to 15]; p = 0.006), and transfer from an outside hospital (OR 3.47 [95% CI 1.19 to 10]; p = 0.02). The presenting clinical characteristics associated with in-hospital mortality were positive initial blood culture results (OR 4.76 [95% CI 1.59 to 15]; p = 0.01), lactic acidosis (OR 4.33 [95% CI 1.42 to 16]; p = 0.02), and multiple organ dysfunction syndrome (OR 6.37 [95% CI 2.05 to 20]; p = 0.002). Laboratory values at initial presentation that were associated with in-hospital mortality were platelet count (difference of medians -136 [95% CI -203 to -70]; p < 0.001), serum pH (difference of medians -0.13 [95% CI -0.21 to -0.03]; p = 0.02), serum lactate (difference of medians 0.90 [95% CI 0.40 to 4.80]; p < 0.001), serum creatinine (difference of medians 1.93 [95% CI 0.65 to 3.44]; p < 0.001), partial thromboplastin time (difference of medians 8.30 [95% CI 1.85 to 13]; p = 0.03), and international normalized ratio (difference of medians 0.1 [95% CI 0.0 to 0.5]; p = 0.004). The LRINEC score was a poor predictor of mortality with an area under the receiver operating characteristics curve of 0.56 [95% CI 0.45-0.67].

CONCLUSIONS

Factors aiding clinical recognition of necrotizing fasciitis are not consistently helpful in predicting mortality of this infection. Identifying patients with potentially compromised organ function should lead to aggressive and expedited measures for diagnosis and treatment. Future multicenter studies with larger populations and a standardized algorithm of treatment triggered by high clinical suspicion can be used to validate these findings to better help prognosticate this potentially fatal diagnosis.Level of Evidence Level III, therapeutic study.

Timing of Redébridement after Initial Source Control Impacts Survival in Necrotizing Soft Tissue Infection

Necrotizing soft tissue infections (NSTIs) are associated with a high mortality rate. There is a lack of literature examining outcomes in NSTI when surgical redébridements are performed in early versus delayed intervals. We hypothesized that early redébridement is associated with improved survival. Patients with NSTIs were prospectively enrolled between January 2006 and December 2011. Patient demographics, comorbidities, primary infection site, laboratory values, tissue cultures, time to surgery, and time between subsequent débridements were obtained. Two study groups with divergent redébridement protocols were observed: a short interval redébridement (SIRD) and an extended interval redébridement (EIRD). Univariate and multivariate statistics were performed. The primary outcome evaluated was in-hospital mortality. Sixty-four patients (46 SIRD, 18 EIRD) were included in the analysis. The two groups had comparable demographics. Polymicrobial NSTI was noted in 61 per cent of patients with Staphylococcus species being the predominant causative organism (59%). Multivariate analysis showed the EIRD protocol to be associated with a significantly increased incidence of acute kidney injury (adjusted odds ratio, 4.9 [1.1 to 22.5]; P = 0.04) and worse overall survival (hazard ratio, 10.6 [2.1 to 53.9]; P = 0.004). Delayed redébridement after initial source control in NSTIs results in worse survival and an increased incidence of acute kidney injury. Further studies to identify the optimal time interval for redébridement are warranted.

Klebsiella pneumoniae necrotizing fasciitis on the upper lip in a patient with uncontrolled diabetes

A 60-year-old woman with a history of diabetes mellitus and chronic renal failure was admitted to the hospital with severe pain in the upper lip, which began 4 days prior to admission, accompanied by a bullous lesion and suspected cellulitis in the upper lip. Immediately after admission, as the patient´s general condition worsened, tests revealed a non-ST elevated myocardial infarction, septic embolism of the lung, as well as septic shock. Her upper lip suddenly presented a gangrenous and necrotic change, which the tissue and blood culture confirmed to be a Klebsiella pneumoniae infection. After a quick response, the patient’s general condition improved. Subsequently, serial debridement was performed to effectively clear away the purulent discharge. While under general anesthesia, the process confirmed full-layer necrosis of the upper lip including the orbicularis oris muscle. Almost half of the entire upper lip sustained a full-layer skin and soft tissue defect, with scar contracture. Six months later, to correct the drooling and lip sealing following the defects, a scar release and an Abbe flap coverage were performed considering both functional and aesthetic aspects. The follow-up revealed a favorable corrective result of the upper lip drooling, and the patient was satisfied from a functional perspective.

[Necrotizing fasciitis-a surgical emergency]

Necrotizing fasciitis is a fulminant and potentially life-threatening infection of the skin and soft tissue. It is usually caused by a combination of different bacteria and is often due to assumed minor trauma. Clinically, only relatively insignificant skin changes are initially present, such as blistering or erythema. They are often accompanied by excessive pain. In the further course, the massive systemic reaction becomes predominant. The diagnosis of necrotizing fasciitis is primarily clinical, which can be supported by laboratory parameters (LRINEC score) and computed tomography imaging. Decisive for the prognosis is the immediate initiation of surgical treatment by radical debridement. Additionally, the calculated administration of a combination of different antibiotics should be initiated. As part of the further complex intensive care treatment, a regular reevaluation of the wounds is carried out. Multiple débridements are always necessary until plastic surgery for defect coverage can be carried out.

Necrotizing fasciitis of the entire head and neck: Literature review and case report

Necrotizing fasciitis (NF) is uncommon but potentially lethal when it is associated with systemic disorders. We report a case of odontogenic NF in a patient with uncontrolled diabetes mellitus. The patient was referred on day 10 since the onset of odontogenic NF. Protective tracheostomy, local facial-cervical fasciotomy were conducted and broadspectrum antibiotics were given, subsequent serial surgical drainage and debridement were performed in theater. Staphylococcus aureus, Pseudomonas aeruginosa, and Klebsiella pneumonia were isolated. Five staged debridements were performed to the targeted anatomic regions thus reducing surgical time and blood loss. The patient survived the acute infection and received subsequent reconstruction. Cervical NF with descending mediastinitis and periorbital NF is associated with high mortality rates. This is the only known report of an adult who survived NF affecting entire scalp, periorbital, cervical, and thoracic region. Early diagnosis and staged surgical planning minimize morbidity and mortality from NF.

Necrotizing fasciitis of the masticator space with osteomyelitis of the mandible in an edentulous patient

Necrotizing fasciitis (NF) is a rapidly progressive necrosis of the subcutaneous tissue and fascia, caused by bacterial infection. Usually presenting in the extremities, trunk, or perineum, it is uncommon in the craniofacial or cervical area. Cervicofacial NF is a potentially fatal infection, which should be managed with early detection and intervention. Most cases have a primary odontogenic source of infection, especially when the masticator space is involved. We report a case of masticator space NF that developed without odontogenic origin in a 78-year old female who was treated with prompt surgical drainage and intravenous antibiotics.

Facial necrotising fasciitis following rhytidectomy

Rhytidectomy is the most common surgical procedure used to rejuvenate the appearance of the aging face and neck. Necrotising fasciitis is a rapidly progressing, life-threatening, bacterial infection of the skin, the subcutaneous tissue, and the fascia. We report a case of necrotising fasciitis of the face caused by a group A streptococcal infection after rhytidectomy on a healthy female patient. An abscess on her hand that had been caused by an infection related to a venous catheter had provided a potential entry for the pathogen, and treatment combined both surgical debridement and antibiotics. The operation had resulted in large tissue losses around the ears, which we treated by healing by second intention.

Exhaustion of the immune system by Group A Streptococcus necrotizing fasciitis: the occurrence of late secondary infections in a retrospective study

BACKGROUND

Necrotizing fasciitis is a potentially lethal condition for which early and adequate treatment with surgical debridement and broad-spectrum intravenous antibiotics are essential for survival. It is hypothesized that Group A Streptococcus (GAS) necrotizing fasciitis causes exhaustion of the immune system, making these patients more susceptible for late secondary infections.

METHODS

A retrospective study was conducted of all patients with necrotizing fasciitis between 2002 and 2016. Patients with necrotizing fasciitis based on macroscopic findings, positive Gram staining, culture or fresh frozen section of fascia biopsies were included. Patients with necrotizing fasciitis were divided into two groups based on the presence of GAS. Of both groups, clinical course, outcome and occurrence of late secondary infections were analyzed. For the occurrence of secondary infections, pneumonia was chosen as reference for late secondary infections.

RESULTS

Eighty-one patients with necrotizing fasciitis were included of which 38 (47%) had GAS necrotizing fasciitis and 43 (53%) had non-GAS necrotizing fasciitis. Patients with GAS necrotizing fasciitis were younger (50 vs. 61 years, p=0.023) and more often classified as ASA I (45% vs. 14%, p=0.002) compared with patients with non-GAS necrotizing fasciitis. In-hospital mortality rate for necrotizing fasciitis was 32%. Patients with comorbidities were more likely to die of necrotizing fasciitis compared with patients without comorbidities (OR 7.41, 95% CI 1.58 to 34.63). Twelve patients (39%) with GAS necrotizing fasciitis developed pneumonia compared with four patients (13%) with non-GAS necrotizing fasciitis (p=0.017; OR 4.42, 95% CI 1.124 to 15.79). Median time from diagnosis to development of pneumonia in patients with GAS necrotizing fasciitis was 10 days (IQR 9).

CONCLUSION

Patients with GAS necrotizing fasciitis have an increased risk to develop late secondary infections during initial treatment for necrotizing fasciitis compared with patients with necrotizing fasciitis without involvement of GAS. This suggests exhaustion of the immune system after severe GAS infection.

LEVEL OF EVIDENCE

III.

Predicting Morbidity and Mortality in Patients with Lower Extremity Necrotizing Fasciitis

Objectives:

Necrotizing fasciitis (NF) is a rare but limb- and life-threatening soft-tissue infection. It is among the most challenging surgical infections faced by surgeons, and is often accompanied by severe systemic toxicity. The aim of this study was to evaluate the predictive power of serum lactate and creatinine levels for mortality and morbidity in lower extremity NF.

Methods:

A retrospective cohort analysis of 87 patients with lower extremity NF was performed to evaluate the management techniques and the amputation and survival rates according to serum lactate and creatinine levels as well as the time between the onset of symptoms and surgery.

Results:

The mean time between the onset of symptoms and surgery was 3.7 days. As the time between the onset of symptoms and surgery increased, the rate of amputation and mortality significantly increased (p<0.001). In all, 66% of the mortality in the group was seen among the 12 patients who had a serum creatinine level greater than 2 mg/dL at the time of presentation. In 12 of 14 patients (85.7%) who underwent amputation/disarticulation, the mean serum lactate level was 5.7 mmol/L (range: 5.1-8.7 mmol/L), and the mean serum creatinine level was 1.92 mg/dL (range: 1.4 to.3.3 mg/dL). The high levels of serum creatinine and lactate were found to be statistically significant in terms of predicting mortality and amputation (p<0.001).

Conclusion:

Based on the results of this study, it was determined that risk factors for mortality include age, late presentation, increased serum creatinine and lactate levels, and that these factors can predict the rate of death from NF at the time of presentation.

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

Background and Aim:

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

Methodology:

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

Results:

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

Conclusions:

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

Utilizing Negative Pressure Wound Therapy with Instillation and Dwell Time for Extensive Necrotizing Fasciitis of the Lower Extremity: A Case Report

Necrotizing fasciitis is a rapidly spreading infection of the soft tissue, which carries significant morbidity and mortality. This condition is treated with broad-spectrum antibiotics, irrigation and surgical debridement of the affected area, and hemodynamic support. Negative pressure wound therapy (NPWT) has been utilized after surgical debridement to promote wound healing, especially when significant debridement has occurred. Newer forms of NPWT such as negative pressure wound therapy with instillation and dwell time (NPWTi-d) have shown even greater promise by reducing the time to clear infections and promoting greater debridement with fewer procedures. This case report demonstrates the successful use of NPWTi-d on a 56-year-old man with a severe case of necrotizing fasciitis of the right lower extremity after extensive debridement. Despite the significant loss of soft tissue and the circumferential devitalization of the lower leg, this patient was able to accept a skin graft in approximately four weeks after admission to the hospital. Three months after initial presentation, his wounds were completely epithelialized and healing well. The advantages of using NPWTi-d include decreased dressing changes, increased wound granulation, and faster infection clearance. The disadvantages of such systems include increased cost, additional technical requirements, and required inpatient monitoring of the system. Despite these disadvantages, the authors believe that NPWTi-d is a reasonable choice for patients similar to the one presented in this case report.

Early Enteral Nutrition is Associated with Reduced Morbidity in Critically Ill Soft Tissue Patients

Soft tissue diseases including necrotizing soft tissue infections are associated with high mortality and morbidity with hospital-acquired infection rates up to 76 per cent. Critically ill patients with soft tissue infections have increased metabolic requirements; however, the effect of early nutrition on inhospital morbidity including nosocomial infection rates remains unclear. We hypothesized that enteral nutrition within 48 hours of intensive care unit admission would be associated with fewer hospital-acquired infections. We conducted a retrospective review of patients with soft tissue infection requiring intensive care unit admission for >72 hours from January 2013 through December 2014 to a high-volume, dedicated soft tissue service. Variables were compared using chisquared, Student's t test, linear regression, and binary logistic regression analysis. Eighty-five patients met inclusion criteria; 80 per cent started enteral nutrition within 48 hours. Twenty-six per cent had a hospital-acquired infection postadmission requiring treatment. Patients started on enteral nutrition within 48 hours had fewer ventilator days (mean 5 vs 12) and shorter hospital length of stay (mean 18 vs 40 days) when adjusted for age, gender, and confounding variables present on admission. Patients receiving early nutrition also had fewer hospital-acquired infections (18 vs 59%) when adjusted for confounding factors (aOR 0.15, P = 0.045). No significant difference in mortality (13.2% early vs 5.9% late, P = 0.4) or for inhospital morbidity when evaluating percentage of goal calories or protein received or time to goal tube feed rate was found. Early enteral feeding is associated with reduced inhospital morbidity in critically ill soft tissue patients, including fewer hospital-acquired infections and ventilator days, and shorter total length of stay.

The roles of early surgery and comorbid conditions on outcomes of severe necrotizing soft-tissue infections

PURPOSE

Severe necrotizing soft-tissue infections (NSTIs) require immediate early surgical treatment to avoid adverse outcomes. This study aims to determine the impact of early surgery and comorbid conditions on the outcomes of NSTIs.

METHODS

A retrospective cohort study was performed on all subjects presenting with NSTI at an academic medical center between 2005 and 2016. Patients were identified based on ICD codes. Those under the age of 18 or with intraoperative findings not consistent with NSTI diagnosis were excluded.

RESULTS

There were 115 patients with a confirmed diagnosis of NSTI with a mean age of 55 ± 18 years; 41% were females and 55% were diabetics. Thirty percent of patients underwent early surgery (< 6 h). There were no significant differences between groups in baseline characteristics. The late group (≥ 6 h) had prolonged hospital stay (38 vs. 23 days, p < 0.008) in comparison to the early group (< 6 h). With every 1 h delay in time to surgery, there is a 0.268 day increase in length of stay, adjusted for these other variables: alcohol abuse, number of debridements, peripheral vascular disease, previous infection and clinical necrosis. Mortality was 16.5%. Multivariable analysis revealed that alcohol abuse, peripheral vascular disease, diabetes, obesity, hypothyroidism, and presence of COPD were associated with an increase in mortality.

CONCLUSIONS

Early surgical intervention in patients with severe necrotizing soft-tissue infections reduces length of hospital stay. Presence of comorbid conditions such as alcohol abuse, peripheral vascular disease, diabetes, obesity and hypothyroidism were associated with increased mortality.

Sepsis and Septic Shock Strategies

Three therapeutic principles most substantially improve organ dysfunction and survival in sepsis: early, appropriate antimicrobial therapy; restoration of adequate cellular perfusion; timely source control. The new definitions of sepsis and septic shock reflect the inadequate sensitivity, specify, and lack of prognostication of systemic inflammatory response syndrome criteria. Sequential (sepsis-related) organ failure assessment more effectively prognosticates in sepsis and critical illness. Inadequate cellular perfusion accelerates injury and reestablishing perfusion limits injury. Multiple organ systems are affected by sepsis and septic shock and an evidence-based multipronged approach to systems-based therapy in critical illness results in improve outcomes.

A case report of primary necrotising fasciitis of the breast: A rare but deadly entity requiring rapid surgical management

•

Primary necrotising fasciitis of the breast is an extremely rare entity.

•

We present the youngest patient described in the literature.

•

Prompt resuscitation and surgical intervention are critical to successful management.

Introduction

Necrotising fasciitis of the breast is a rare entity with very few cases reported in the literature. It is rapidly progressive and can lead to sepsis and multi-organ failure without prompt medical and surgical management.

Presentation of case

We describe a case of a non-diabetic 23-year-old female with primary necrotising fasciitis of the right breast. She presented in septic shock with gross breast discolouration and nipple discharge. Immediate resuscitation followed by muscle-sparing mastectomy within 3 h of her presentation was performed. She was managed postoperatively in intensive care. Complications included myocardial infarction and anuria requiring continuous renal replacement therapy. She eventually recovered with close to normal cardiac function and was discharged home after skin grafting of her mastectomy wound.

Conclusion

This is the youngest patient with primary necrotising fasciitis of the breast described in the literature. Prompt resuscitation and an aggressive surgical approach are critical to the successful management of this life threatening pathology.

Evaluation of Factors Associated with Death in Patients with Necrotizing Fasciitis of the Abdominal Wall

BACKGROUND

Necrotizing fasciitis (NF) is a rapidly progressing, life-threatening soft tissue infection. The prognostic factors associated with death from abdominal wall NF are not well understood.

METHODS

The medical records of 61 patients with abdominal wall NF were reviewed retrospectively. Demographic, co-morbidity, laboratory, and clinical data were collected and compared for patients who survived and who did not.

RESULTS

Sixty-one patients met the inclusion criteria, with eight deaths (13.11%). Elevated blood urea nitrogen (BUN) concentration, elevated total bilirubin, and prolonged intensive care unit (ICU) stay were correlated with a greater risk of death.

CONCLUSIONS

Presentation with elevated markers of liver and renal dysfunction, as well as prolonged post-operative ICU stay were associated with a higher risk of death in patients with NF of the abdominal wall.

Comparing culture and molecular methods for the identification of microorganisms involved in necrotizing soft tissue infections

Background

Necrotizing soft tissue infections (NSTIs) are a group of infections affecting all soft tissues. NSTI involves necrosis of the afflicted tissue and is potentially life threatening due to major and rapid destruction of tissue, which often leads to septic shock and organ failure. The gold standard for identification of pathogens is culture; however molecular methods for identification of microorganisms may provide a more rapid result and may be able to identify additional microorganisms that are not detected by culture.

Methods

In this study, tissue samples (n = 20) obtained after debridement of 10 patients with NSTI were analyzed by standard culture, fluorescence in situ hybridization (FISH) and multiple molecular methods. The molecular methods included analysis of microbial diversity by 1) direct 16S and D2LSU rRNA gene Microseq 2) construction of near full-length 16S rRNA gene clone libraries with subsequent Sanger sequencing for most samples, 3) the Ibis T5000 biosensor and 4) 454-based pyrosequencing. Furthermore, quantitative PCR (qPCR) was used to verify and determine the relative abundance of Streptococcus pyogenes in samples.

Results

For 70 % of the surgical samples it was possible to identify microorganisms by culture. Some samples did not result in growth (presumably due to administration of antimicrobial therapy prior to sampling). The molecular methods identified microorganisms in 90 % of the samples, and frequently detected additional microorganisms when compared to culture. Although the molecular methods generally gave concordant results, our results indicate that Microseq may misidentify or overlook microorganisms that can be detected by other molecular methods.

Half of the patients were found to be infected with S. pyogenes, but several atypical findings were also made including infection by a) Acinetobacter baumannii, b) Streptococcus pneumoniae, and c) fungi, mycoplasma and Fusobacterium necrophorum.

Conclusion

The study emphasizes that many pathogens can be involved in NSTIs, and that no specific “NSTI causing” combination of species exists. This means that clinicians should be prepared to diagnose and treat any combination of microbial pathogens. Some of the tested molecular methods offer a faster turnaround time combined with a high specificity, which makes supplemental use of such methods attractive for identification of microorganisms, especially for fulminant life-threatening infections such as NSTI.

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

Background

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

Methods

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

Results

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

Conclusion

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

Pentraxin-3 as a marker of disease severity and risk of death in patients with necrotizing soft tissue infections: a nationwide, prospective, observational study

Background

New biomarkers are needed to assess the severity of necrotizing soft tissue infection (NSTI) at an early stage and to individualize treatment strategies. We assessed pentraxin-3 (PTX3) as a marker of disease severity and risk of death in patients with NSTI.

Methods

We conducted a prospective, observational study in the intensive care unit at Copenhagen University Hospital, where treatment of NSTI is centralized at a national level. We compared PTX3, procalcitonin and C-reactive protein in septic shock versus nonshock patients and in amputated versus nonamputated patients using the Mann-Whitney U test. The prognostic value of the markers for 180-day mortality was assessed using Cox regression analyses.

Results

Patients with NSTI (n = 135) were included over 25 months with up to 2.5-year follow-up; 71 % had septic shock, amputation was undertaken in 20 % and the 180-day mortality was 27 %. Baseline plasma PTX3 level was significantly higher in patients with septic shock (67.3 versus 24.6 ng/mL, p < 0.0001) and in patients who underwent amputation (118.6 versus 43.6 ng/mL, p = 0.019). No significant differences in baseline procalcitonin or C-reactive protein levels were found according to amputation (25.2 versus 7.0 μg/L, p = 0.060 and 202 versus 225 mg/L, p = 0.123), respectively. Baseline PTX3 level above the median was associated with death (p = 0.009, log-rank test) and the univariate Cox regression analysis revealed a significant association between PTX3 level upon admission and 180-day mortality (hazard ratio 2.60 (95 % confidence interval 1.28–5.29), p = 0.008). When adjusted for age, sex, chronic disease and Simplified Acute Physiology Score II, no significant association was found.

Conclusions

High PTX3 level is associated with septic shock, amputation and risk of death in patients with NSTI, but it is not an independent predictor of 180-day mortality in this patient group.

Trial registration

ClinicalTrials.gov Identifier: NCT02180906. Date of registration: June 29, 2014.