Risk factors of synchronous multifocal necrotizing fasciitis: a case control study in comparison with monofocal necrotizing fasciitis in Taiwan

Predictors for gram-negative monomicrobial necrotizing fasciitis in southern Taiwan

BACKGROUND

Necrotizing fasciitis (NF) is a rare and life-threatening necrotizing skin and soft-tissue infection. Infectious pathogens of NF must be detected early and treated rapidly to prevent loss of limb or a fatal outcome. This study aimed to detect more reliable predictors between gram-negative and gram-positive monomicrobial NF of limbs.

METHODS

A total of 100 patients with limb monomicrobial NF were diagnosed prospectively from April 2015 to July 2018. These monomicrobial NF pathogens can be divided into gram-negative and gram-positive groups according to the result of Gram staining and final bacterial reports. Data such as demographics, seawater or seafood contact history, infectious location, comorbidities, presenting signs and symptoms, and laboratory findings were recorded and compared.

RESULTS

A total of 55 patients were infected with gram-negative organisms and 45 patients with gram-positive organisms. Among the 55 cases of monomicrobial gram-negative NF, 48 (87.3%) were caused mainly by Vibrio spp. (38, 69.1%) and Aeromonas spp. (10, 18.2%). A higher incidence of chronic kidney disease, cerebrovascular accident, tachypnea, and septic shock; a higher rate of band forms of leukocytes of more than 3%, serum lactate of more than 20 mg/dL, and C-reactive protein level of less than 150 mg/dL; prolonged prothrombin time; and a lower fibrinogen level were observed in patients with gram-negative infection. In a multivariate analysis, a higher incidence of seawater or seafood contact history (odds ratio [OR]: 66.301; 95% confidence interval [CI]: 7.467-588.702), a higher rate of hyperlactatemia (OR: 7.904; 95% CI: 1.231-50.744), and a low fibrinogen level (OR: 1.013; 95% CI: 1.004-1.023) indicated gram-negative infection.

CONCLUSIONS

In southern Taiwan, NF of limbs mainly affected the lower limbs, exhibited monomicrobial infection, and was predominated by gram-negative bacteria. Gram-negative monomicrobial NF of limbs often occurred in individuals with the more seawater or seafood contact history, hyperlactatemia, and low fibrinogen levels.

A rare case of multi-focal non-contiguous necrotizing soft tissue infections and literature review

Necrotising soft tissue infection (NSTI) is a rare yet life-threatening surgical emergency, characterized by rapidly spreading infection below the epidermis to the soft tissue layers of the dermis, subcutaneous layers, fascia and sometimes muscle. Multi-focal NSTIs have been rarely described in the literature, with reported cases predominantly involving immunocompromised patients. We report a case of an immunocompromised 70-year-old woman who initially presented with concern of a perforated colonic malignancy requiring exploratory laparotomy and within 24 hours while on inotropes, developed rapidly progressing necrotizing fasciitis (NF) of the left thigh with renal failure secondary to sepsis. Despite aggressive debridement, a progress computed tomography later showed multi-focal non-contiguous necrotising myositis of the whole left lower limb and right gluteal regions. Early diagnosis of multi-focal NF especially in immunocompromised patients, repeat assessment, aggressive surgical debridement and prompt antibiotics usage are the key to treatment.