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Garrido-Hidalgo A, García-Coiradas J, Echevarría-Marín M, Llanos S, Valle-Cruz JA, Marco F. Understanding limb necrotizing infections: A comprehensive approach. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024:S1888-4415(24)00075-4. [PMID: 38642737 DOI: 10.1016/j.recot.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 03/24/2024] [Accepted: 03/30/2024] [Indexed: 04/22/2024] Open
Abstract
INTRODUCTION Necrotizing soft tissue infections (NSTI) are increasing, posing a significant risk of morbidity and mortality. Due to nonspecific symptoms, a high index of suspicion is crucial. Treatment involves a multidisciplinary approach, with broad-spectrum antibiotics, early surgical debridement, and life support. This study analyzes the characteristics, demographics, complications, and treatment of NSTI in a hospital in Madrid, Spain. METHODS A retrospective observational study was conducted, including all surgically treated NSTI patients at our center from January 2016 to December 2022, examining epidemiological and clinical data. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) was prospectively calculated for all patients. RESULTS Twenty-two patients (16 men, 6 women, mean age 54.8) were included. Median time from symptom onset to emergency room visit was 3.5 days. All reported severe treatment-resistant pain; sixteen had fever exceeding 37.8°C (72.7%). Skin lesions occurred in twelve (54.5%), and thirteen had hypotension and tachycardia (59.1%). Treatment involved resuscitative support, antibiotherapy, and radical debridement. Median time to surgery was 8.25h. Intraoperative cultures were positive in twenty patients: twelve Streptococcus pyogenes, four Staphylococcus aureus, one Escherichia coli, and four polymicrobial infection. In-hospital mortality rate was 22.73%. CONCLUSIONS We examined the correlation between our results, amputation rates and mortality with LRINEC score and time to surgery. However, we found no significant relationship unlike some other studies. Nevertheless, a multidisciplinary approach with radical debridement and antibiotic therapy remains the treatment cornerstone. Our hospital stays, outcomes and mortality rates align with our literature review, confirming high morbimortality despite early and appropriate intervention.
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Affiliation(s)
- A Garrido-Hidalgo
- Department of Traumatology and Orthopaedic Surgery, Clínico San Carlos Hospital, Profesor Martín Lagos s/n Street, 28040 Madrid, Spain.
| | - J García-Coiradas
- Department of Traumatology and Orthopaedic Surgery, Clínico San Carlos Hospital, Profesor Martín Lagos s/n Street, 28040 Madrid, Spain
| | - M Echevarría-Marín
- Department of Traumatology and Orthopaedic Surgery, Clínico San Carlos Hospital, Profesor Martín Lagos s/n Street, 28040 Madrid, Spain
| | - S Llanos
- Department of Traumatology and Orthopaedic Surgery, Clínico San Carlos Hospital, Profesor Martín Lagos s/n Street, 28040 Madrid, Spain
| | - J A Valle-Cruz
- Department of Traumatology and Orthopaedic Surgery, Clínico San Carlos Hospital, Profesor Martín Lagos s/n Street, 28040 Madrid, Spain
| | - F Marco
- Department of Traumatology and Orthopaedic Surgery, Clínico San Carlos Hospital, Profesor Martín Lagos s/n Street, 28040 Madrid, Spain; Surgery Department, Complutense University, Madrid, Spain
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Predicting Morbidity and Mortality in Patients with Lower Extremity Necrotizing Fasciitis. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2019; 53:27-32. [PMID: 33536822 PMCID: PMC7847728 DOI: 10.14744/semb.2019.57778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 01/28/2019] [Indexed: 11/20/2022]
Abstract
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.
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Healthcare Resource Utilization Associated with Burns and Necrotizing Fasciitis: A Single-Center Comparative Analysis. J Burn Care Res 2018; 38:e886-e891. [PMID: 28296669 DOI: 10.1097/bcr.0000000000000513] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Necrotizing fasciitis (NF) patients are increasingly managed in burn units. Although treated similarly to burns, the healthcare resource utilization (HRU) in NF appears to be greater. Accurate knowledge of the HRU is important to better allocate resources and to compare outcomes between units. The goal of this study is to provide better understanding of the HRU for NF compared with burns. A retrospective chart review of patients ≥18 years admitted to two regional tertiary referral centers with either NF or burns requiring surgery. The authors examined age, sex, %TBSA, geographic region, anatomical location, length of stay (LOS) in hospital, LOS in intensive care unit, number of operative procedures, number of packed red blood cells transfused, amputation, death, and use of free tissue transfer or skin graft. There were 210 NF and 209 burn patients. The NF cohort had a smaller TBSA (3.3 vs 10.0%), longer LOS (20 vs 14 days), and consequently a longer LOS/%TBSA (6.0 vs 1.5 days). This difference persisted after adjusting for age. More of the NF cohort (44.8%) spent ≥1 day in the intensive care unit. The NF cohort also had more procedures (median 2 vs 1), required blood (46.2 vs 16.7%), died in hospital (13.3 vs 4.3%), had an amputation (12.4 vs 4.8%), or required free tissue transfer (7.6 vs 2.9%). This study shows that NF requires substantially more HRU compared with burns. This information is important in recognizing the impact of these patients on burn units and planning for allocation of appropriate resources.
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Gawaziuk JP, Liu T, Sigurdson L, Buchel E, Hayakawa TEJ, Shiga S, Logsetty S. Free tissue transfer for necrotizing fasciitis reconstruction: A case series. Burns 2017; 43:1561-1566. [DOI: 10.1016/j.burns.2017.04.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 04/03/2017] [Accepted: 04/05/2017] [Indexed: 01/15/2023]
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Narasimhan V, Ooi G, Weidlich S, Carson P. Laboratory Risk Indicator for Necrotizing Fasciitis score for early diagnosis of necrotizing fasciitis in Darwin. ANZ J Surg 2017; 88:E45-E49. [DOI: 10.1111/ans.13895] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 11/27/2016] [Accepted: 12/02/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Vignesh Narasimhan
- Department of Surgery, Royal Darwin Hospital; Darwin Northern Territory, Australia
- Department of General Surgery; The Alfred Hospital; Melbourne Victoria Australia
| | - Geraldine Ooi
- Department of General Surgery; The Alfred Hospital; Melbourne Victoria Australia
- Department of Surgery; Monash University; Melbourne Victoria Australia
| | - Stephanie Weidlich
- Department of Surgery, Royal Darwin Hospital; Darwin Northern Territory, Australia
| | - Phillip Carson
- Department of Surgery, Royal Darwin Hospital; Darwin Northern Territory, Australia
- Flinders University, Northern Territory Medical Program; Darwin Northern Territory, Australia
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Hua C, Sbidian E, Hemery F, Decousser JW, Bosc R, Amathieu R, Rahmouni A, Wolkenstein P, Valeyrie-Allanore L, Brun-Buisson C, de Prost N, Chosidow O. Prognostic factors in necrotizing soft-tissue infections (NSTI): A cohort study. J Am Acad Dermatol 2015; 73:1006-12.e8. [PMID: 26412163 DOI: 10.1016/j.jaad.2015.08.054] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 08/16/2015] [Accepted: 08/19/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Necrotizing soft-tissue infection (NSTI) is uncommon but life-threatening. A recent meta-analysis estimated the overall mortality at 23.5%. OBJECTIVE We sought to identify risk factors associated with mortality in a cohort of patients with NSTI in a tertiary care center. METHODS We identified 512 patients with NSTI between 1996 and 2012 in the national hospital database Program for Medicalization of Information Systems and examined risk factors of mortality with NSTI by univariate and multivariate analysis. RESULTS We included 109 patients with a confirmed diagnosis of NSTI; 31 (28%) died at a median follow-up of 274 days (range 2-6135 days). On multivariate analysis, independent risk factors of mortality were age older than 75 years (hazard ratio [HR] 4.4, 95% confidence interval [CI] 1.8-10.3), multifocal NSTI (HR 5.9, 95% CI 1.9-18.5), severe peripheral vascular disease (HR 5.1, 95% CI 1.5-17.0), hospital-acquired infection (HR 3.9, 95% CI 1.4-10.7), severe sepsis (HR 7.4, 95% CI 1.7-33.1), and septic shock on hospital admission (HR 13.9, 95% CI 3.8-50.4). LIMITATIONS This was a retrospective cohort, which disallows a precise record of the delay between diagnosis and surgery. CONCLUSION Our findings for this robust cohort of patients with a definite diagnosis of NSTI could help clinicians stratify NSTI severity at clinical course onset.
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Affiliation(s)
- Camille Hua
- Département de Dermatologie, AP-HP, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Emilie Sbidian
- Département de Dermatologie, AP-HP, Hôpitaux Universitaires Henri Mondor, Créteil, France; Pôle Recherche Clinique Santé Publique, AP-HP, Hôpitaux Universitaires Henri Mondor, Créteil, France; Inserm, Centre d'Investigation Clinique 1430, Créteil, France; EA EpidermE, Université Paris-Est Créteil, Créteil, France.
| | - Francois Hemery
- Département d'Information Médicale, AP-HP, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Jean Winoc Decousser
- Département de Virologie, Bactériologie- Hygiène, Parasitologie-Mycologie, AP-HP, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Romain Bosc
- Service de Chirurgie Plastique, AP-HP, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Roland Amathieu
- Service d'Anesthésie et des Réanimations Chirurgicales, AP-HP, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Alain Rahmouni
- Département d'Imagerie Médicale, AP-HP, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Pierre Wolkenstein
- Département de Dermatologie, AP-HP, Hôpitaux Universitaires Henri Mondor, Créteil, France; Inserm, Centre d'Investigation Clinique 1430, Créteil, France; EA EpidermE, Université Paris-Est Créteil, Créteil, France
| | - Laurence Valeyrie-Allanore
- Département de Dermatologie, AP-HP, Hôpitaux Universitaires Henri Mondor, Créteil, France; Inserm, Centre d'Investigation Clinique 1430, Créteil, France; EA EpidermE, Université Paris-Est Créteil, Créteil, France
| | - Christian Brun-Buisson
- Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, DHU A-TVB, Service de Réanimation Médicale, Créteil, France; UPEC-Université Paris-Est Créteil Val de Marne, Faculté de médecine de Créteil, CARMAS Research Group, Créteil, France
| | - Nicolas de Prost
- Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, DHU A-TVB, Service de Réanimation Médicale, Créteil, France; UPEC-Université Paris-Est Créteil Val de Marne, Faculté de médecine de Créteil, CARMAS Research Group, Créteil, France
| | - Olivier Chosidow
- Département de Dermatologie, AP-HP, Hôpitaux Universitaires Henri Mondor, Créteil, France; Inserm, Centre d'Investigation Clinique 1430, Créteil, France; EA EpidermE, Université Paris-Est Créteil, Créteil, France
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Kulasegaran S, Cribb B, Vandal AC, McBride S, Holland D, MacCormick AD. Necrotizing fasciitis: 11-year retrospective case review in South Auckland. ANZ J Surg 2015. [PMID: 26211758 DOI: 10.1111/ans.13232] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aims of this paper were to review our experience with necrotizing fasciitis at Middlemore Hospital and to define the trends in incidence, inpatient mortality and microbiological profile. METHODS A computerized search of the electronic medical records was undertaken to identify adult patients with a diagnosis of necrotizing fasciitis between January 2000 and December 2010. A retrospective review of the clinical records was performed. RESULTS Of the 138 patients with necrotizing fasciitis identified, 129 had their diagnosis confirmed at operation. The mortality at 30 days was 20.3% (95% confidence interval (CI) 13.9%-28.0%). There was a significant reduction in hospital mortality in each successive year of the study period with an odds ratio of 0.84 (95% CI 0.71-0.98, P = 0.03). A pattern of increasing incidence was noted until February 2004 (95% CI September 2002-July 2005). This was followed by a significant decrease in incidence. The empirical antibiotic regime of clindamycin, gentamicin and penicillin provides satisfactory cover against 95% of the causative pathogens. CONCLUSION This represents the largest single-centre published case series in New Zealand. Despite concerns of increasing incidence and mortality associated with necrotizing fasciitis in New Zealand, the experience in South Auckland shows a decrease in incidence of necrotizing fasciitis since 2004 and a statistically significant decreasing trend in hospital mortality.
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Affiliation(s)
- Suheelan Kulasegaran
- Department of Surgery, South Auckland Clinical School, The University of Auckland, Auckland, New Zealand.
| | - Benjamin Cribb
- Department of Surgery, South Auckland Clinical School, The University of Auckland, Auckland, New Zealand
| | - Alain C Vandal
- Ko Awatea, Counties Manukau Health, Middlemore Hospital, Auckland, New Zealand.,Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Stephen McBride
- Department of Infectious Diseases, Middlemore Hospital, Auckland, New Zealand
| | - David Holland
- Department of Infectious Diseases, Middlemore Hospital, Auckland, New Zealand
| | - Andrew D MacCormick
- Department of Surgery, Manukau Health, Middlemore Hospital, Auckland, New Zealand
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Single-specialty management and reconstruction of necrotizing fasciitis of the upper extremities: clinical and economic benefits from a case series. Ann Plast Surg 2014; 72 Suppl 1:S18-21. [PMID: 24740020 DOI: 10.1097/sap.0000000000000173] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE Patients with necrotizing fasciitis are managed with multiple prompt, radical surgical debridements and critical care support. Debridement and reconstruction are often provided by different surgical teams. Anecdotally, single-specialty management seemed to be a more efficient management strategy. This study aimed to investigate and compare the outcomes of management by plastic surgery versus multiple disciplines through a retrospective economic and clinical analysis of patients with necrotizing fasciitis treated over 8 years. We also present 3 index cases for which our service functioned as the primary management team. METHODS Necrotizing fasciitis cases evaluated and treated by our department, covering both Level I and Level II Trauma Centers, were reviewed for total charges, length of hospital stay, length of intensive care unit (ICU) stay, and number of procedures. The admission Acute Physiology and Chronic Health Evaluation II score was calculated for each patient. Three comparative index cases of upper extremity necrotizing fasciitis managed primarily by the plastic surgery team are presented in greater detail. RESULTS Patients managed primarily by the plastic surgery service had equivalent Acute Physiology and Chronic Health Evaluation II scores to patients managed by multiple services for their necrotizing fasciitis, with the average score higher for patients managed by plastic surgery alone. In a case-matched series of upper extremity necrotizing fasciitis, the patients admitted directly to plastic surgery had shorter average lengths of hospital and ICU stays as well as decreased total number of procedures, resulting in decreased average total hospital charges. There were no amputations among the cases treated primarily by the plastic surgery. The patients also required smaller areas of reconstruction with skin grafting despite large initial areas of debridement compared to those whose reconstructive teams differed from the team performing the debridement. CONCLUSIONS Improved economic and clinical outcomes-as indicated by the reduced lengths of overall and ICU stay, the reduced number of procedures, none of the cases requiring amputation, and the reduced need for skin grafting-may be attainable when the surgeon eventually performing the reconstruction is involved early in management. We propose that, in the interest of improving patient care, a closer collaboration should be established between the reconstructive and primary managing teams.
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BRINK M, ARNELL P, LYCKE H, ROSEMAR A, HAGBERG L. A series of severe necrotising soft-tissue infections in a regional centre in Sweden. Acta Anaesthesiol Scand 2014; 58:882-90. [PMID: 24924532 DOI: 10.1111/aas.12345] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2014] [Indexed: 01/27/2023]
Abstract
BACKGROUND Necrotising soft-tissue infections (NSTIs) are rare conditions with high morbidity and mortality. Patients with NSTIs are often transferred to tertiary hospitals, but the question of whether the potential benefits of highly specialised care outweigh the risks associated with inter-hospital transfers has been raised. METHODS Prospective study including all patients with NSTIs treated at the intensive care unit at Sahlgrenska University Hospital/East between January 2008 and December 2011. RESULTS Twenty-nine patients with NSTIs were identified. Their median age was 54 years and 69% were men. Major co-morbidities were present in 45%. Seventeen patients (59%) were referred from other hospitals. Only 33% of the patients were correctly diagnosed or suspected of having NSTIs in the emergency department. Group A Streptococcus was the most common microbiological finding (41%), followed by Enterobacteriaceae (17%). The median time from hospitalisation to the first dose of antibiotics was 6 h and the median time to primary surgery was 16 h. Hyperbaric oxygen therapy was given to 86%, and intravenous immunoglobulin was given in 52% of the cases. The 30-day mortality was 14% (4/29). The times to the first dose of antibiotics, intensive care unit admission and primary surgery did not differ between transferred and directly admitted patients, and there was no difference in outcome between the groups. CONCLUSIONS Patients with NSTIs develop severe local and systemic symptoms and require extremely resource-demanding hospitalisation. Inter-hospital transfer was not associated with a delay in key interventions and could not be identified as a risk factor for adverse outcome.
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Affiliation(s)
- M. BRINK
- Department of Infectious Diseases; The Sahlgrenska Academy at the University of Gothenburg; Gothenburg Sweden
| | - P. ARNELL
- Department of Anaesthesia and Intensive Care; Sahlgrenska University Hospital; Gothenburg Sweden
| | - H. LYCKE
- Department of Anaesthesia and Intensive Care; Sahlgrenska University Hospital; Gothenburg Sweden
| | - A. ROSEMAR
- Department of Surgery; Sahlgrenska University Hospital; Gothenburg Sweden
| | - L. HAGBERG
- Department of Infectious Diseases; The Sahlgrenska Academy at the University of Gothenburg; Gothenburg Sweden
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Das DK, Baker MG, Venugopal K. Risk factors, microbiological findings and outcomes of necrotizing fasciitis in New Zealand: a retrospective chart review. BMC Infect Dis 2012; 12:348. [PMID: 23234429 PMCID: PMC3538518 DOI: 10.1186/1471-2334-12-348] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Accepted: 12/10/2012] [Indexed: 02/06/2023] Open
Abstract
Background The incidence and mortality from necrotizing fasciitis (NF) are increasing in New Zealand (NZ). Triggered by a media report that traditional Samoan tattooing was causing NF, we conducted a chart review to investigate the role of this and other predisposing and precipitating factors and to document NF microbiology, complications and interventions in NZ. Methods We conducted a retrospective review of 299 hospital charts of patients discharged with NF diagnosis codes in eight hospitals in NZ between 2000 and 2006. We documented and compared by ethnicity the prevalence of predisposing and precipitating conditions, bacteria isolated, complications and interventions used. Results Out of 299 charts, 247 fulfilled the case definition. NF was most common in elderly males. Diabetes was the most frequent co-morbid condition, followed by obesity. Nearly a quarter of patients were taking non-steroidal anti-inflammatory drugs (NSAID). Traditional Samoan tattooing was an uncommon cause. Streptococcus pyogenes and Staphylococcus aureus were the two commonly isolated bacteria. Methicillin-resistant Staphylococcus aureus was implicated in a relatively small number of cases. Shock, renal failure, coagulation abnormality and multi-organ dysfunction were common complications. More than 90% of patients underwent surgical debridement, 56% were admitted to an intensive care unit (ICU) and slightly less than half of all patients had blood product transfusion. One in six NF cases had amputations and 23.5% died. Conclusion This chart review found that the highest proportion of NF cases was elderly males with co-morbidities, particularly diabetes and obesity. Tattooing was an uncommon precipitating event. The role of NSAID needs further exploration. NF is a serious disease with severe complications, high case fatality and considerable use of health care resources.
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Affiliation(s)
- Dilip Kumar Das
- Department of Public Health, University of Otago, Wellington, New Zealand.
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Fann WC, Chiang IJ, Hsiao CT, Hong YC, Chen IC. Predicting the mortality of necrotizing fasciitis with blood pressure and white blood cell count. SURGICAL PRACTICE 2012. [DOI: 10.1111/j.1744-1633.2012.00598.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | - I-Jen Chiang
- Graduate Institute of Biomedical Informatics; Taipei Medical University; Taipei
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Safar A, Lennon D, Stewart J, Trenholme A, Drinkovic D, Peat B, Taylor S, Read K, Roberts S, Voss L. Invasive group A streptococcal infection and vaccine implications, Auckland, New Zealand. Emerg Infect Dis 2011. [PMID: 21749758 PMCID: PMC3358186 DOI: 10.3201/eid1706.100804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
We aimed to assess the effect of invasive group A streptococcal (GAS) infection and the potential effects of a multivalent GAS vaccine in New Zealand. During January 2005–December 2006, we conducted prospective population-based laboratory surveillance of Auckland residents admitted to all public hospitals with isolation of GAS from normally sterile sites. Using emm typing, we identified 225 persons with confirmed invasive GAS infection (median 53 years of age; range 0–97 years). Overall incidence was 8.1 cases per 100,00 persons per year (20.4/100,000/year for Maori and Pacific Islanders; 24.4/100,000/year for persons >65 years of age; 33/100,000/year for infants <1 year of age). Nearly half (49%) of all cases occurred in Auckland’s lowest socioeconomic quintile. Twenty-two persons died, for an overall case-fatality rate of 10% (63% for toxic shock syndrome). Seventy-four percent of patients who died had an underlying condition. To the population in our study, the proposed 26-valent vaccine would provide limited benefit.
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Increasing incidence of necrotizing fasciitis in New Zealand: a nationwide study over the period 1990 to 2006. J Infect 2011; 63:429-33. [PMID: 21864570 DOI: 10.1016/j.jinf.2011.07.019] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2011] [Revised: 07/05/2011] [Accepted: 07/08/2011] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Because of concerns following necrotizing fasciitis (NF) reports in the media, we aimed to describe the incidence, mortality, case fatality and distribution of NF in New Zealand (NZ). METHODS By using International Classification of Disease codes to identify NF cases we analyzed the national hospital discharge and mortality data and reviewed 299 charts from 8 hospitals. The sensitivity and positive predictive value (PPV) of the hospital discharge data were calculated by comparing with the mortality dataset and chart review finding respectively. RESULTS Between 1990 and 2006 there was a highly significant rise in annual incidence and mortality rates of NF from 0.18 to 1.69 and from 0 to 0.3 per 100,000 person-years respectively. The causes of this increase are unknown, and were not related to 2004 coding changes for NF. Hospital discharge data had a PPV of 82.6% and sensitivity of 76.8%. The case fatality was 20.8%. Disease risk was highest in the elderly, males, and Pacific and Maori populations. CONCLUSIONS These findings suggest that incidence and mortality of NF are increasing in NZ. Further work is needed to investigate the causes of this increase and the marked ethnic inequalities in disease rates, particularly factors that may be preventable.
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Safar A, Lennon D, Stewart J, Trenholme A, Drinkovic D, Peat B, Taylor S, Read K, Roberts S, Voss L. Invasive Group A Streptococcal Infection and Vaccine Implications, Auckland, New Zealand. Emerg Infect Dis 2011; 17:983-9. [DOI: 10.3201/eid/1706.100804] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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Nisbet M, Ansell G, Lang S, Taylor S, Dzendrowskyj P, Holland D. Necrotizing fasciitis: review of 82 cases in South Auckland. Intern Med J 2009; 41:543-8. [PMID: 20002853 DOI: 10.1111/j.1445-5994.2009.02137.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Early recognition of necrotizing fasciitis (NF) can be difficult, but is important as infections progress rapidly and have significant mortality. The aim of this study of patients with NF was to determine the clinical characteristics at presentation, causative pathogens and subsequent clinical outcome. METHODS We retrospectively reviewed consecutive patients with NF presenting to Middlemore Hospital from January 2000 to June 2006. RESULTS Eighty-two patients were evaluated: 56% male, mean age 54.9 years (standard deviation 18.5), 40% Pacific Islanders. The site of infection was the lower limb in 46 (56%) patients, upper limb in 12 (15%) patients and perineum in 13 (16%) patients. Twenty-two (27%) patients were taking non-steroidal anti-inflammatory drugs, 29 (35%) had diabetes mellitus, 25 (30%) had gout and 17 (21%) had congestive heart failure. Forty-nine (60%) patients had a surgical procedure within 24 h of admission. Streptococcus pyogenes was isolated from tissue or blood cultures in 33 (40%) patients and 26 (32%) patients had polymicrobial infection. Twenty-five (30%) patients died, 17 (68%) within 72 h of admission. Independent predictors of mortality include congestive heart failure (P = 0.033) and a history of gout (P = 0.037). CONCLUSION NF remains an important disease in our community with significant morbidity and mortality. Pacific Islanders were disproportionately represented. Early diagnosis of NF can be difficult and requires a high index of suspicion in all patients presenting with cellulitis or unexplained sepsis. Congestive heart failure and gout are independent predictors of mortality and patients with these conditions and sepsis need early assessment with more aggressive hospital triaging.
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Affiliation(s)
- M Nisbet
- Infectious Diseases Department, Middlemore Hospital, Auckland, New Zealand.
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May AK, Stafford RE, Bulger EM, Heffernan D, Guillamondegui O, Bochicchio G, Eachempati SR. Treatment of Complicated Skin and Soft Tissue Infections. Surg Infect (Larchmt) 2009; 10:467-99. [DOI: 10.1089/sur.2009.012] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Addison K. May
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Renae E. Stafford
- Department of Surgery, Division of Trauma/Critical Care, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Eileen M. Bulger
- Department of Surgery, University of Washington Harborview Medical Center, Seattle, Washington
| | - Daithi Heffernan
- Department of Surgery, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Oscar Guillamondegui
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Grant Bochicchio
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Soumitra R. Eachempati
- Department of Surgery, New York Weill Cornell Center, New York Presbyterian Hospital, New York, New York
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Steer AC, Jenney A, Kado J, Good MF, Batzloff M, Waqatakirewa L, Mullholland EK, Carapetis JR. Prospective surveillance of invasive group a streptococcal disease, Fiji, 2005-2007. Emerg Infect Dis 2009; 15:216-22. [PMID: 19193265 PMCID: PMC2657613 DOI: 10.3201/eid1502.080558] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
These infections are more common and case-fatality rate is higher in Fiji than in industrialized countries. We undertook a prospective active surveillance study of invasive group A streptococcal (GAS) disease in Fiji over a 23-month period, 2005–2007. We identified 64 cases of invasive GAS disease, which represents an average annualized all-ages incidence of 9.9 cases/100,000 population per year (95% confidence interval [CI] 7.6–12.6). Rates were highest in those >65 years of age and in those <5 years, particularly in infants, for whom the incidence was 44.9/100,000 (95% CI 18.1–92.5). The case-fatality rate was 32% and was associated with increasing age and underlying coexisting disease, including diabetes and renal disease. Fifty-five of the GAS isolates underwent emm sequence typing; the types were highly diverse, with 38 different emm subtypes and no particular dominant type. Our data support the view that invasive GAS disease is common in developing countries and deserves increased public health attention.
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Abstract
Skin and soft tissue infections are a common cause of hospitalization and use of antibiotic therapy, and may result in significant disability. Infections managed by surgeons may vary from simple, noncomplicated cellulitis to severe necrotizing soft tissue infections. The differentiation of necrotizing infections from nonnecrotizing infections is critical to achieving adequate surgical therapy. An understanding of the changing epidemiology of all complicated skin and soft tissue infections is required for selection of appropriate empiric antibiotic therapy.
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20
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The epidemiology of necrotizing fasciitis including factors associated with death and amputation. Epidemiol Infect 2009; 137:1609-14. [PMID: 19351432 DOI: 10.1017/s0950268809002532] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The high morbidity and mortality of necrotizing fasciitis (NF) supports the need for epidemiological studies to characterize the disease and identify patient factors associated with adverse outcomes. A multi-site medical record review of patients diagnosed with NF was performed (n=80, mortality 15%). Variables collected were hypothesized to have association with adverse outcomes from NF, and multivariable analysis was used to detect any such association in this population. Select factors associated with mortality included evidence of underlying conditions (P=0.002), advanced age (P=0.04), young age (P=0.03), and evidence of sepsis (P=0.006). Select factors associated with amputation included diabetes mellitus (P=0.006), evidence of underlying conditions (P=0.03), and cutaneous gangrene noted on admission (P=0.006). These findings demonstrate the important association of NF and extremes of age with mortality and morbidity and support the value of early suspicion with prompt diagnosis and treatment in order to prevent adverse outcomes since the associated risk factors are not immediately modifiable.
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21
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Steer AC, Jenney A, Kado J, Good MF, Batzloff M, Waqatakirewa L, Mullholland EK, Carapetis JR. Prospective Surveillance of Invasive Group A Streptococcal Disease, Fiji, 2005–2007. Emerg Infect Dis 2009. [DOI: 10.3201/eid15/2.080558] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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22
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Abbas SA, Haloob IA, Taylor SL, Curry EM, King BB, Van der Merwe WM, Marshall MR. Effect of antimicrobial locks for tunneled hemodialysis catheters on bloodstream infection and bacterial resistance: a quality improvement report. Am J Kidney Dis 2009; 53:492-502. [PMID: 19150156 DOI: 10.1053/j.ajkd.2008.09.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2008] [Accepted: 09/18/2008] [Indexed: 11/11/2022]
Abstract
BACKGROUND Catheter-restricted antimicrobial lock (AML) use reduces catheter-associated bloodstream infection (CA-BSI) in clinical trial settings, but may not be as effective in clinical settings and may increase bacterial resistance. DESIGN Quality improvement report analyzed using a cross-sectional time series (unbalanced panel) design. SETTING & PARTICIPANTS The study cohort comprised all prevalent adults treated with hemodialysis through a tunneled catheter for any, but not necessarily all, of the time from January 1, 2003, to June 30, 2006, in Manukau City, New Zealand (135,346 catheter-days, 404 tunneled catheters, 320 patients). QUALITY IMPROVEMENT PLAN Catheter-restricted AMLs (heparin plus gentamicin) for all tunneled catheters from July 1, 2004. MEASURES Repeated observations of CA-BSI, hospitalization, tunneled catheter removal, and death from CA-BSI analyzed by using generalized estimating equations with a single level of clustering for each tunneled catheter and patterns of bacterial resistance analyzed by using simple descriptive statistics. RESULTS AML use was associated with reductions in rates of CA-BSI and hospitalization for CA-BSI by 52% and 69% for patients with tunneled catheters locked continuously with AMLs since their insertion compared with those with tunneled catheters that were not, respectively. AML exposure also was associated with a trend to increased gentamicin resistance amongst coagulase-negative staphylococci isolates, a pattern similar to that observed for BSIs in our general hemodialysis population in which tunneled catheters were not the source of BSI, but different from that in the general non-end-stage renal disease population in the region. LIMITATIONS This is an uncontrolled observational study and cannot prove causality. The follow-up period of 18 months is longer than for other studies, but still too short to definitely answer whether AML use drives bacterial resistance. CONCLUSIONS A change to use of AMLs may improve clinical outcomes; however, additional study of associated bacterial resistance is needed before AML use becomes standard care.
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Affiliation(s)
- Saib A Abbas
- Department of Renal Medicine, Middlemore Hospital, Counties-Manukau District Health Board, Manukau, New Zealand
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23
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Yilmazlar T, Ozturk E, Alsoy A, Ozguc H. Necrotizing soft tissue infections: APACHE II score, dissemination, and survival. World J Surg 2007; 31:1858-1862. [PMID: 17610007 DOI: 10.1007/s00268-007-9132-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND First described more than a century ago, necrotizing soft tissue infections (NSTIs) continue to cause high mortality and morbidity. The aim of this study was to elucidate the factors affecting the outcome of patients presenting with an NSTI. METHODS To determine the factors affecting mortality from NSTIs, the records of 67 patients were retrospectively assessed for the following parameters: age, sex, time between initiation of symptoms and admission to the clinic, presence of systemic coexisting disease, APACHE II score, origin of infection, dissemination of the NSTI, and method of therapy. RESULTS The patients were 41 men (61.2%) and 26 women (38.8%) with a mean age of 54.9 +/- 1.73 years. The overall mortality rate was 49% (33/67). Multivariate analysis determined that APACHE II scores of 13 or higher (p = 0.001) and NSTI dissemination (p = 0.02) were risk factors affecting the mortality of patients with NSTIs. CONCLUSION By considering these two factors, more accurate outcome prediction may be possible, which may be useful for directing the management of patients with NSTIs.
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Affiliation(s)
- Tuncay Yilmazlar
- Department of General Surgery, Uludag University School of Medicine, Gorukle Kampusu, Bursa, 21900, Turkey.
- Uludag Universitesi Tip Fak. Genel Cerrahi ABD, Gorukle, Bursa, Turkey.
| | - Ersin Ozturk
- Department of General Surgery, Uludag University School of Medicine, Gorukle Kampusu, Bursa, 21900, Turkey
| | - Alpaslan Alsoy
- Department of General Surgery, Uludag University School of Medicine, Gorukle Kampusu, Bursa, 21900, Turkey
| | - Halil Ozguc
- Department of General Surgery, Uludag University School of Medicine, Gorukle Kampusu, Bursa, 21900, Turkey
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Conwell LS, Forrest CR, Allen UD, Perlman K, Daneman D. Necrotizing fasciitis in adolescents with poorly controlled type 1 diabetes mellitus: report of two cases. Pediatr Diabetes 2007; 8:397-400. [PMID: 18036068 DOI: 10.1111/j.1399-5448.2007.00244.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Necrotizing fasciitis (NF) is a potentially fatal bacterial infection of the subcutaneous soft tissues. Two cases of polymicrobial NF in adolescents with type 1 diabetes mellitus and poor glycemic control are reported. The perineal region was involved in both cases. One case was precipitated by apparently minimal trauma, the other by high-impact trauma. Diabetes mellitus has been identified as a common comorbidity and predictor of increased mortality in adult patients with NF. The associations between diabetes and the incidence or outcome of NF in children and adolescents are not known. In all cases, early identification and aggressive surgical intervention are important for limiting morbidity and mortality.
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Affiliation(s)
- Louise S Conwell
- Division of Endocrinology, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada M5G 1X8
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25
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Mulla ZD, Gibbs SG, Aronoff DM. Correlates of length of stay, cost of care, and mortality among patients hospitalized for necrotizing fasciitis. Epidemiol Infect 2006; 135:868-76. [PMID: 17083749 PMCID: PMC2870628 DOI: 10.1017/s0950268806007448] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Several previous studies of necrotizing fasciitis (NF) have been single-institution investigations suffering from small samples sizes. This study of 216 NF patients hospitalized in Florida, USA, during 2001 was designed to identify risk factors for length of stay (LOS), total patient charges (TC), and mortality, using a statewide database. Robust gamma mixed regression was used to determine the predictors of LOS and TC while simultaneously accounting for outliers and the clustering of patients in 87 hospitals. Relative risks (RR) for hospital mortality were calculated using binomial regression. The NF hospitalization rate in Florida was 1.3/100,000. The median TC was US$54,533 and cumulative charges for all 216 patients were nearly US$20 million. Patients aged > or =44 years at the time of admission were five times as likely to expire in the hospital than patients who were aged < or =43 years (adjusted RR 5.08, P=0.03). Unexpectedly, diabetes was associated with a 61% reduction in the risk of hospital mortality (adjusted RR 0.39, P=0.04). Age > or =44 years was the most powerful predictor of prolonged LOS, elevated TC, and an increased risk of hospital mortality in patients suffering from NF.
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Affiliation(s)
- Z D Mulla
- Division of Epidemiology, University of Texas School of Public Health at Houston, El Paso, TX 79905, USA.
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26
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Giuly E, Velly L, Gouin F. [Strategies of management of necrotizing soft tissue infections]. ACTA ACUST UNITED AC 2006; 25:978-81. [PMID: 16675185 DOI: 10.1016/j.annfar.2006.03.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Necrotizing soft tissue infections represent a group of rapidly progressive diseases requiring early and repeated debridement, associated with broad spectrum antibiotics. Delay in surgery or inadequate therapy are the main risk factors for death. Most patients need aggressive critical care management and intensive nutritional support. The management of these patients by experimented senior surgeons is mandatory. A plastic surgeon can help debridement in order to preserve possibilities of later myocutaneous or rotational skin flaps. Intravenous immunoglobulins are an efficacious adjunctive therapy for severe group A streptococcal infection.
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Affiliation(s)
- E Giuly
- Département d'anesthésie-réanimation adultes, CHU de La Timone, 264, rue Saint-Pierre, 13385 Marseille cedex 05, France
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Abstract
BACKGROUND Management of necrotizing fasciitis places significant demands upon hospital and medical resources. A successful management usually requires extensive surgical intervention and an adjunct hyperbaric oxygen treatment. The cost impact on the health care system has not been well characterized. We have, therefore, analysed the cost of treating this disease at an Australian tertiary referral hospital with extensive case experience and well-developed financial costing systems and have compared this with the current casemix-based government funding arrangements applying in Victoria, Australia. METHODS Data was extracted from the medical records of 92 sequential patients treated by the Alfred Hospital (Melbourne, Australia) during the four financial years 2000-04. Clinical costing data and government funding data was provided by the hospital's Finance Departments. RESULTS The total Alfred Hospital in-patient costs for treating the patients was $5,935,545 with a mean cost per patient of $64,517 (range, $1025 to $514,889). The total casemix-based funding allocation derived from treating these patients was calculated at $3,208,664 with the per patient mean $34,887 (range, $1331 to $387,168). This analysis does not include allowance for non-Alfred Hospital costs such as those incurred by the ambulance service, referring hospitals, for rehabilitation or as a result of the burden of residual disability. CONCLUSIONS This study has confirmed that a significant economic burden is involved in treating necrotizing fasciitis. There is a substantial difference between the hospital costs and government funding for treating these patients in the Australian setting.
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Affiliation(s)
- Audi B Widjaja
- Plastic Unit, Alfred Hospital, Melbourne, Victoria, Australia.
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