The laboratory risk indicator for necrotizing fasciitis (LRINEC) scoring: the diagnostic and potential prognostic role

Case report: A rare case of simultaneous necrotizing fasciitis of the breast and forearm

Necrotizing fasciitis is an aggressive bacterial infection that causes necrosis of the fascia and subcutaneous tissues with rapid progression and high mortality. Early stages often lead to misdiagnosis, resulting in improper treatment and severe implications. This case study presents a patient with diabetes mellitus combined with hepatitis B who rapidly developed necrotizing fasciitis of the left forearm and left breast after trauma and controlled the infection with early surgical treatment. It is worth noting that early surgical exploration is the gold standard for the diagnosis of necrotizing fasciitis and is the most effective means of reducing mortality and amputation rates in necrotizing fasciitis.

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.

The microbiological profile of necrotising fasciitis at a secondary level hospital in Gauteng

Background

Necrotising fasciitis (NF) is a fulminant soft tissue infection that requires timely diagnosis, urgent surgical debridement, and appropriate antimicrobial therapy. The choice of empiric antimicrobial therapy depends on the microorganisms cultured and the antimicrobial resistance profile of the institution. Necrotising fasciitis has not been studied in our setting.

Objectives

The aim of the study was to audit the microbiological profile of NF and antimicrobial susceptibility profile.

Method

This was a retrospective study in a secondary level hospital from the period of 2014-2020. The patients' demographic data, clinical features, location of infection, comorbidities, laboratory and microbiological profiles were analysed.

Results

There were 53 patients during 2014-2020 with median age of 45.5 (38.5-56.0) years. The majority of the patients were males (35 [66.04%]), had no comorbidities (25 [47.17%]), and the lower limb was the most common anatomic site (17 [32.08%]). Type II (monomicrobial) NF was the predominant type (31 [58.49%]). Staphylococcus aureus was the most prevalent Gram-positive bacteria (18 [38%]) and Escherichia coli, the main species isolated in the Gram-negative bacteria (14 [36%]) with susceptibility to cloxacillin (94%) and amoxicillin and/or clavulanic acid (92%), respectively.

Conclusion

Staphylococcus aureus and Escherichia coli were the most common bacteria with low rate of antimicrobial resistance. Amoxicillin and/or clavulanic acid and an adjunctive clindamycin are appropriate antimicrobial therapy for empiric treatment for NF in our setting.

Contribution

Amoxicillin and/or clavulanic acid and an adjunctive clindamycin can be used as an empiric treatment for NF.

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

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

Pseudomonas otitidis bacteremia in an immunocompromised patient with cellulitis: case report and literature review

BACKGROUND

Pseudomonas otitidis belongs to the genus Pseudomonas and causes various infections, including ear, skin, and soft tissue infections. P. otitidis has a unique susceptibility profile, being susceptible to penicillins and cephalosporins but resistant to carbapenems, due to the production of the metallo-β-lactamase called POM-1. This revealed genetic similarities with Pseudomonas aeruginosa, which can sometimes lead to misidentification.

CASE PRESENTATION

We report the case of a 70-year-old Japanese male who developed cellulitis and bacteremia during chemotherapy for multiple myeloma. He was initially treated with meropenem, but blood culture later revealed gram-negative bacilli identified as P. otitidis using matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS). Carbapenem resistance was predicted from previous reports; therefore, we switched to dual therapy with levofloxacin and cefepime, and favorable treatment results were obtained.

CONCLUSION

This is the first reported case of P. otitidis cellulitis and bacteremia in an immunocompromised patient. Carbapenems are typically used in immunocompromised patients and P. otitidis is often resistant to it. However, its biochemical properties are similar to those of Pseudomonas aeruginosa; therefore, its accurate identification is critical. In the present study, we rapidly identified P. otitidis using MALDI-TOF MS and switched from carbapenems to an appropriate antimicrobial therapy, resulting in a successful outcome.

Necrotizing Fasciitis Occurred in the Lymphedematous leg

Lymphedema is a chronic edema that sometimes occurs after treatment of gynecologic cancer, and cellulitis often occurs concomitantly with lymphedema. On the other hand, necrotizing fasciitis (NF) is a relatively rare, but life-threatening disease. The symptoms in cellulitis and NF are very similar. In this case report, we describe a case in which the diagnosis of NF in a lymphedematous limb was difficult. A 70-year-old woman had secondary lymphedema in bilateral legs and consulted our department. On the first day of lymphedema therapy, the patient complained of vomiting, diarrhea, and fever (37.7 °C) without local fever in the legs. She was diagnosed with acute gastroenteritis. On the next day, swelling and pain in her left leg occurred and her blood pressure was 59/44 mmHg. She was diagnosed with cellulitis accompanied by lower limb lymphedema and septic shock. On the second day, blisters appeared on the left leg, and computed tomography showed NF. We performed debridement under general anesthesia and her vital signs improved postoperatively. Streptococcus agalactiae (B) was detected in blood culture, and we administered bixillin and clindamycin. Postoperatively, necrosis in the skin and fat around the left ankle gradually spread, and it took 5 months to complete epithelialization. The diagnosis was more difficult than usual NF because patients with lymphedema often experience cellulitis. Clinicians should always think of NF to avoid mortality due to delayed treatment. This case report was approved by the institutional ethics committee.

Necrotising Fasciitis During the COVID-19 Pandemic: An Australian Hospital Network Experience

BACKGROUND

The clinical presentations of diseases and the provision of global healthcare services have been negatively affected by the COVID-19 pandemic. Our study aimed to determine the impact of this global pandemic on presentations of necrotising fasciitis (NF).

METHODS

A retrospective study was conducted of adult patients with NF in South West Sydney Local Health District from January 2017 to October 2022. An analysis of sociodemographic and clinical outcomes was performed comparing the COVID-19 cohort (2020-2022) and the pre-COVID-19 cohort (2017-2019).

RESULTS

Sixty-five patients were allocated to the COVID-19 cohort, and 81 patients were in the control cohort. The presentation to hospitals of the COVID-19 cohort was significantly delayed compared to the control cohort (6.1 vs. 3.2 days, P < 0.001). Patients of the age group of 40 years and younger experienced prolonged operative time (1.8 vs. 1.0 h, P = 0.040), higher number of operations (4.8 vs. 2.1, P = 0.008), and longer total length of stay (LoS) (31.3 vs. 10.3 days, P = 0.035) during the pandemic. The biochemical, clinical, or post-operative outcomes of two groups were not significantly different.

CONCLUSION

This multi-centre study showed that the COVID-19 pandemic delayed presentations of NF but did not result in any significant overall changes in operative time, ICU admissions, LoS, and mortality rate. Patients aged less than 40 years in the COVID-19 group were likely to experience prolonged operative time, higher number of operations, and greater LoS.

The performance of clinical risk scores in the diagnosis of necrotising fasciitis

OBJECTIVE

Necrotising fasciitis (NF) is a quickly progressing and potentially life-threatening infection, involving the fascia and subcutaneous tissues. The diagnosis of this disease is challenging, especially due to a lack of specific clinical signs. In order to ensure a better and quicker identification of NF patients, a laboratory risk indicator score has been developed for NF (LRINEC). A variant has widened this score by adding clinical parameters (modified LRINEC). This study shows current outcomes of NF and compares the two scoring systems.

METHODS

This study was conducted between 2011 and 2018, and included patient demographics, clinical presentations, sites of infection, comorbidities, microbiological and laboratory findings, antibiotic therapies and LRINEC as well as modified LRINEC scores. The primary outcome was in-hospital mortality.

RESULTS

A cohort of 36 patients, diagnosed with NF, were included in this study. The mean hospital stay was 56 days (±38.2 days). The mortality rate in the cohort was 25%. The sensitivity of the LRINEC score was 86%. Calculation of the modified LRINEC score showed an improvement of the sensitivity to 97%. The average LRINEC score and modified LRINEC score for patients who died and who survived were equal (7.4 versus 7.9 and 10.4 versus 10.0, respectively).

CONCLUSION

The mortality rate of NF remains high. The modified LRINEC score increased the sensitivity in our cohort to 97%, and this scoring system could be supportive in the diagnosis of NF for early surgical debridement.

Measures of Admission Immunocoagulopathy as an Indicator for In-Hospital Mortality in Patients with Necrotizing Fasciitis: A Retrospective Study

Necrotizing fasciitis is a rapidly progressive infection with a high mortality rate. Pathogens evade the host containment and bactericidal mechanisms by hijacking the coagulation and inflammation signaling pathways, leading to their rapid dissemination, thrombosis, organ dysfunction, and death. This study examines the hypothesis that measures of immunocoagulopathy upon admission could aid in the identification of patients with necrotizing fasciitis at high risk for in-hospital mortality.

Methods

Demographic data, infection characteristics, and laboratory values from 389 confirmed necrotizing fasciitis cases from a single institution were analyzed. A multivariable logistic regression model was built on admission immunocoagulopathy measures (absolute neutrophil, absolute lymphocyte, and platelet counts) and patient age to predict in-hospital mortality.

Results

The overall in-hospital mortality rate was 19.8% for the 389 cases and 14.6% for the 261 cases with complete measures of immunocoagulopathy on admission. A multivariable logistic regression model indicated that platelet count was the most important predictor of mortality, followed by age and absolute neutrophil count. Greater age, higher neutrophil count, and lower platelet count led to significantly higher risk of mortality. The model discriminated well between survivors and non-survivors, with an overfitting-corrected C-index of 0.806.

Conclusions

This study determined that measures of immunocoagulopathy and patient age at admission effectively prognosticated the in-hospital mortality risk of patients with necrotizing fasciitis. Given the accessibility of neutrophil-to-lymphocyte ratio and platelet count measurements determined from a simple complete blood-cell count with differential, future prospective studies examining the utility of these measures are warranted.

Level of Evidence

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Diagnostic and prognostic value of the Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) based on an 18 years' experience

BACKGROUND

Necrotising fasciitis (NF) represents a rare but often life-threatening condition. Early diagnosis and surgical treatment are of vital importance. The LRINEC score was developed to distinguish necrotising fasciitis from other soft tissue infections (STI) at initial evaluation using six laboratory values. In this retrospective study, we attempted to determine the diagnostic and prognostic value of the LRINEC score.

METHODS

A total of 125 patients, hospitalised in our clinic between 2003 and 2021 with a histologically confirmed diagnosis of necrotising fasciitis (NF group) and 319 patients with surgically treated soft tissue infections (STI group) were included in this study. Individual LRINEC scores were calculated and analysed retrospectively.

RESULTS

The sensitivity of the LRINEC score at the cut-off point of ≥ 6 was 59%, whereas the specificity was 82%. The positive and negative predictive values were 57% and 84%, respectively. The mean LRINEC score was significantly higher in the NF group than in the STI group (6.0 compared to 2.4, respectively). All clinical outcome parameters such as amputation and mortality rates (15% vs 1%) were found to be significantly higher in the NF group (p<0.001). Within the NF group, there was no statistically significant association between the LRINEC score and clinical outcomes except for the necessary number of operations.

CONCLUSION

In isolation, we found the LRINEC score not to be a reliable enough diagnostic tool for the differentiation between NF and other soft tissue infections, because of its low sensitivity. Although we cannot recommend it as a prognostic tool either, we do believe it can be a useful adjunct to the clinical suspicion of NF.

The Bacterial Markers of Identification of Invasive CovR/CovS-Inactivated Group A Streptococcus

Necrotizing fasciitis is a severe infectious disease that results in significant mortality. Streptococcus pyogenes (group A Streptococcus, GAS) is one of the most common bacterial pathogens of monomicrobial necrotizing fasciitis. The early diagnosis of necrotizing fasciitis is crucial; however, the typical cutaneous manifestations are not always presented in patients with GAS necrotizing fasciitis, which would lead to miss- or delayed diagnosis. GAS with spontaneous inactivating mutations in the CovR/CovS two-component regulatory system is significantly associated with destructive diseases such as necrotizing fasciitis and toxic shock syndrome; however, no specific marker has been used to identify these invasive clinical isolates. This study evaluated the sensitivity and specificity of using CovR/CovS-controlled phenotypes to identify CovR/CovS-inactivated isolates. Results showed that the increase of hyaluronic acid capsule production and streptolysin O expression were not consistently presented in CovS-inactivated clinical isolates. The repression of SpeB is the phenotype with 100% sensitivity of identifying in CovS-inactivated isolates among 61 clinical isolates. Nonetheless, this phenotype failed to distinguish RopB-inactivated isolates from CovS-inactivated isolates and cannot be utilized to identify CovR-inactivated mutant and RocA (Regulator of Cov)-inactivated isolates. In this study, we identified and verified that PepO, the endopeptidase which regulates SpeB expression through degrading SpeB-inducing quorum-sensing peptide, was a bacterial marker to identify isolates with defects in the CovR/CovS pathway. These results also inform the potential strategy of developing rapid detection methods to identify invasive GAS variants during infection. IMPORTANCE Necrotizing fasciitis is rapidly progressive and life-threatening; if the initial diagnosis is delayed, deep soft tissue infection can progress to massive tissue destruction and toxic shock syndrome. Group A Streptococcus (GAS) with inactivated mutations in the CovR/CovS two-component regulatory system are related to necrotizing fasciitis and toxic shock syndrome; however, no bacterial marker is available to identify these invasive clinical isolates. Inactivation of CovR/CovS resulted in the increased expression of endopeptidase PepO. Our study showed that the upregulation of PepO mediates a decrease in SpeB-inducing peptide (SIP) in the covR mutant, indicating that CovR/CovS modulates SIP-dependent quorum-sensing activity through PepO. Importantly, the sensitivity and specificity of utilizing PepO to identify clinical isolates with defects in the CovR/CovS pathway, including its upstream RocA regulator, were 100%. Our results suggest that identification of invasive GAS by PepO may be a strategy for preventing severe manifestation or poor prognosis after GAS infection.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Necrotizing fasciitis of the extremities in high and low Charlson Comorbidity Index: A multi-center retrospective cohort study

BACKGROUND

Necrotizing fasciitis (NF) is a life-threatening and acute progressive soft tissue infection and needs early surgical intervention, that is, debridement or amputation. Surgical strategy or prognosis is influenced by the speed of progression and patients' general condition, which can be calculated by the Charlson Comorbidity Index (CCI). The purpose of this study was to investigate the association between the CCI scores and prognosis of patients with NF of the upper/lower extremities.

METHODS

In the retrospective cohort study, we analyzed patients with NF of the upper/lower extremities who were determined to undergo surgery by orthopedic surgeons at four tertiary hospitals between August 2003 and April 2016. We divided the patients into two groups, Group L (low CCI scores of 0-2) and Group H (high CCI scores of ≥3). The primary event of this study was defined as death or amputation. Mortality cases were included when amputation was informed with documented certification but patients died while waiting for surgery. We compared the patients' background, laboratory data on admission, the laboratory risk indicator for necrotizing fasciitis (LRINEC) score, and primary outcome between the two groups.

RESULTS

Of the 56 patients, 28 patients were classified into Group L and the other 28 patients into Group H. The data in this study showed that patients in Group H had lower white blood cell counts and hemoglobin and higher creatinine than Group L, but there was no difference in LRINEC scores between the two groups. Streptococcus pyogenes was the most common infectious agent in Group L (54%) but not in Group H (11%). Poorer outcome was observed in Group H compared with Group L (4 mortality and 16 amputation vs. no mortality and 9 amputation, P = 0.007).

CONCLUSIONS

Laboratory data and causative microorganisms were different between high CCI and low CCI patients with NF. High CCI scores were associated with limb amputation or death caused by NF of the upper/lower extremities; whereas, low CCI scores were more likely associated with S. pyogenes monoinfection.

Clinical outcome of multidisciplinary treatment of vulvar necrotising fasciitis

OBJECTIVE

Vulvar necrotising fasciitis (VNF) is a severe soft tissue infection associated with substantial morbidity and high mortality. At Stony Brook Medicine, US, patients with known or suspected VNF are treated by a structured multidisciplinary team consisting of members of the Departments of Emergency Medicine and Medicine, the Divisions of Gynecologic Oncology, Burn and Surgical Intensive Care Units, Infectious Disease and Plastic Surgery, and the nursing, nutrition, physical/occupational therapy and social work services.

METHOD

This is a retrospective review of patients presenting to Stony Brook University Hospital with VNF over an 18-month period.

RESULTS

A total of 10 patients were treated for VNF during the study period. All patients were treated by the structured multidisciplinary team, including extensive initial surgical debridement by the gynaecologic oncologists. All patients survived to discharge.

CONCLUSION

The results of this review demonstrated that prompt diagnosis, rapid implementation of appropriate antibiotic coverage, surgical debridement of necrotic tissue, and comprehensive care delivered by a structured multidisciplinary team contributed to positive clinical outcomes and decreased the risk of death from VNF.

The LRINEC Score-An Indicator for the Course and Prognosis of Necrotizing Fasciitis?

Background: The Laboratory Risk Indicator for Necrotizing Fasciitis score (LRINEC) is a simple tool used to support early diagnosis of Necrotizing Fasciitis (NF). The aim of this study was to investigate whether the LRINEC is suitable as a progression and prognosis parameter in patients with NF. Methods: In this retrospective study, laboratory data of 70 patients with NF were analyzed. The LRINEC was calculated for every patient at the time of hospital admission and postoperatively after surgical interventions. Furthermore, the LRINEC was examined as a prognostic factor for survival. Results: The overall lethality of our series was 20 out of 70 (28.6%). A highly significant LRINEC decrease was found for serial debridements. The largest decrease was observed after the first debridement. There was a significant difference between the initial LRINEC of deceased and surviving patients. A cut off value of >6.5 (7 LRINEC points) resulted in an optimal constellation of sensitivity (70%) and specificity (60%) to predict lethality in patients with NF. Conclusions: The LRINEC significantly decreases after surgical debridement. An initial LRINEC equal or greater than seven is an independent prognostic marker for lethality and can help to identify high-risk patients.

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 Amputation in Patients With Necrotizing Fasciitis: The ANF Risk Scoring System

Background: Necrotizing fasciitis (NF) is a life-threatening infection of the skin and soft tissue that spreads quickly and requires immediate surgery and medical treatment. Amputation or radical debridement of necrotic tissue is generally always required. The risks and benefits of both the surgical options are weighed before deciding whether to amputate or debride. This study set forth to create an easy-to-use risk scoring system for predicting the risk scoring system for amputation in patients with NF (ANF).

Methods: This retrospective study included 1,506 patients diagnosed with surgically confirmed NF at three general hospitals in Thailand from January 2009 to December 2012. All diagnoses were made by surgeons who strictly observed the guidelines for skin and soft tissue infections produced by the Infectious Diseases Society of America. Patients were randomly allocated to either the derivation (n = 1,193) or validation (n = 313) cohort. Clinical risk factors assessed at the time of recruitment were used to create the risk score, which was then developed using logistic regression. The regression coefficients were converted into item scores, and the total score was calculated.

Results: The following four clinical predictors were used to create the model: female gender, diabetes mellitus, wound appearance stage 3 (skin necrosis and gangrene), and creatinine ≥1.6 mg/dL. Using the area under the receiver operating characteristic curve (AuROC), the ANF system showed moderate power (78.68%) to predict amputation in patients with NF with excellent calibration (Hosmer-Lemeshow χ² = 2.59; p = 0.8586). The positive likelihood ratio of amputation in low-risk (score ≤ 4) and high-risk (score ≥ 7) patients was 2.17 (95%CI: 1.66–2.82) and 6.18 (95%CI: 4.08–9.36), respectively. The ANF system showed good performance (AuROC 76.82%) when applied in the validation cohort.

Conclusion: The developed ANF risk scoring system, which includes four easy to obtain predictors, provides physicians with prediction indices for amputation in patients with NF. This model will assist clinicians with surgical decision-making in this time-sensitive clinical setting.

Local Trends of Antibiotic Prescriptions for Necrotizing Fasciitis Patients in Two Tertiary Care Hospitals in Central Malaysia

Background: Necrotizing fasciitis (NF) is a rapidly progressive inflammatory infection of the soft tissue (also known as the fascia) with a secondary necrosis of the subcutaneous tissues, leading to a systemic inflammatory response syndrome (SIRS), shock and eventually death despite the availability of current medical interventions. The clinical management of this condition is associated with a significant amount of morbidity with a high rate of mortality. The prognosis of the disease is affected by multiple factors, which include the virulence of the causative pathogen, local host immunity, local wound factors and empirical antibiotics used. The local trends in the prescription of empirical antibiotics are often based on clinical practice guidelines (CPG), the distribution of the causative microorganism and the cost-effectiveness of the drug. However, there appears to be a paucity of literature on the empirical antibiotic of choice when dealing with necrotizing fasciitis in the clinical setting. This paper will outline common causative microorganisms and current trends of prescription in two tertiary centres in Central Malaysia. Methods: This was a cross-sectional study using retrospective data of patients treated for NF collected from two tertiary care hospitals (Hospital Seremban and Hospital Ampang) in Central Malaysia. A total of 420 NF patients were identified from the five years of retrospective data obtained from the two hospitals. Results: The top three empirical antibiotics prescribed are ampicillin + sulbactam (n = 258; 61.4%), clindamycin (n = 55; 13.1%) and ceftazidime (n = 41; 9.8%). The selection of the antibiotic significantly impacts the outcome of NF. The top three causative pathogens for NF are Streptococcus spp. (n = 79; 18.8%), Pseudomonas aeruginosa (n = 61; 14.5%) and Staphylococcus spp. (n = 49; 11.7%). The patients who received antibiotics had 0.779 times lower chances of being amputated. Patients with a lower laboratory risk indicator for necrotizing fasciitis (LRINEC) score had 0.934 times lower chances of being amputated. Conclusions: In this study, the most common empirical antibiotic prescribed was ampicillin + sulbactam followed by clindamycin and ceftazidime. The antibiotics prescribed lower the risk of having an amputation and, hence, a better prognosis of the disease. Broad-spectrum empirical antibiotics following surgical debridement reduce the mortality rate of NF.

Prognostic factors for mortality in 123 severe cases of necrotizing fasciitis in 5 hospitals in the Netherlands between 2003 and 2017

Purpose

Necrotizing fasciitis (NF) is a severe soft tissue infection with a high morbidity and mortality. With early diagnosis and treatment this could be reduced. Unfortunately, the diagnosis of necrotizing fasciitis can be very difficult. In recent years many risk factors have been identified. In 2004, the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was developed. A tool that could help diagnosing NF. In this study, we search for prognostic factors for mortality in necrotizing fasciitis.

Methods

All adult patients with histopathological or surgical confirmed NF needed to be admitted to the intensive care unit for at least 24 h between January 2003 and December 2017 in five hospitals from the Nijmegen teaching region were included. We excluded patients with other forms of soft tissue infections or patients with an intensive care unit (ICU) stay of < 24 h because we exclusively wanted to include patients with a fulminant course of necrotizing fasciitis.

Results

We have included 123 cases. The overall mortality was 31.7% (N = 39). The overall mean LRINEC score was 7.4 ± 2.7. Patients who died as the result of NF had a significantly higher median LRINEC score (8 vs. 7, p = 0.034). Other parameters found to be associated with mortality are age ≥ 60 years, cardiovascular disease in the medical history, ≥ 2 comorbidities, and lactate level greater than 1.7 mmol/L.

Conclusion

LRINEC score should be calculated in all patients presenting with NF to provide an additional source for clinical outcome. A high LRINEC score could implicate a higher risk of mortality. Especially in elderly patients, with a cardiac history, more than two comorbidities or a lactate level greater than 1.7 mmol/L.

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.

Predictive ability of LRINEC score in the prediction of limb loss and mortality in diabetic foot infection

It was aimed to analyze the effectiveness of the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score in predicting amputation and mortality in diabetic foot infection (DFI). Data of 416 patients who were hospitalized for DFI were recorded retrospectively. LRINEC scores were calculated for each patient from laboratory data. The diagnostic performance of LRINEC score was investigated in amputated/nonamputated and survived/deceased patient groups. Median LRINEC score of patients who underwent amputation was higher than those without amputation (P < 0.001). The area under the curve (AUC) value for LRINEC score was 0.638 with the cut-off point of ≥5 in predicting amputation. Median LRINEC score of deceased patients was higher than those who survived (P= 0.022). AUC value for LRINEC score was 0.663 with the cut-off point of ≥7 in predicting mortality. LRINEC score may be a promising scoring system in predicting both amputation and mortality in DFI.

Temporal and seasonal trends of hospitalization and mortality associated with necrotizing fasciitis: A retrospective study of 12 years (2002-2013)

Background: Necrotizing fasciitis (NF) is a rare but aggressive infection that affects the superficial fascia and progressively destroys the tissue between the skin and underlying muscles. It is a surgical emergency with significant morbidity and mortality. This study aimed to explore the temporal and seasonal trends in NF infection in Qatar. Methods: A total of 327 patients diagnosed with NF, aged ≥ 18 years, and admitted to the Hamad General Hospital, Qatar, in 2002-2013 were retrospectively reviewed. The hospitalization and mortality rates in the general population in Qatar and the case fatality rate (CFR) were calculated for each year. The patients were grouped into summer, autumn, winter, and spring admissions based on their admission dates. Seasonality was studied by comparing the characteristics, bacteriological status, and outcomes of the patients admitted in different seasons. Results: The hospitalization rate of NF in Qatar was 2.9 per 100,000 population; in the study duration, this rate decreased from 2.8 to 1.6 per 100,000 population in 2002 and 2013, respectively. The mortality rate among NF cases increased from 1.9 to 3.6 per million population, and the CFR increased from 6.7 to 23 per 100 admissions in the same duration. No temporal trends in the hospitalization and mortality rates or CFR were evident in the study duration. Polybacterial infections were higher in autumn than in other seasons. Monobacterial Gram-positive infections were higher in spring than in other seasons, and monobacterial Gram-negative infections were higher in summer than in other seasons (p = 0.02). However, seasonality was not evident after further analysis in terms of species, severity, complications, length of hospital stays, and CFR in patients with NF. Conclusion: No clear trend or seasonality was observed in terms of outcomes; however, seasonality in NF-causing bacteria was evident, as polybacterial infections were significantly higher in autumn than in other seasons, whereas monobacterial infections were more frequent in spring and summer than in other seasons. However, the severity of infections, length of hospital stay, and mortality did not significantly vary. Further microbiological studies are needed to obtain confirmatory data regarding the temporal and seasonal trends of NF.

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.

The EGS grading scale for skin and soft-tissue infections is predictive of poor outcomes: a multicenter validation study

INTRODUCTION

Over the last 5 years, the American Association for the Surgery of Trauma has developed grading scales for emergency general surgery (EGS) diseases. In a previous validation study using diverticulitis, the grading scales were predictive of complications and length of stay. As EGS encompasses diverse diseases, the purpose of this study was to validate the grading scale concept against a different disease process with a higher associated mortality. We hypothesized that the grading scale would be predictive of complications, length of stay, and mortality in skin and soft-tissue infections (STIs).

METHODS

This multi-institutional trial encompassed 12 centers. Data collected included demographic variables, disease characteristics, and outcomes such as mortality, overall complications, and hospital and ICU length of stay. The EGS scale for STI was used to grade each infection and two surgeons graded each case to evaluate inter-rater reliability.

RESULTS

1170 patients were included in this study. Inter-rater reliability was moderate (kappa coefficient 0.472-0.642, with 64-76% agreement). Higher grades (IV and V) corresponded to significantly higher Laboratory Risk Indicator for Necrotizing Fasciitis scores when compared with lower EGS grades. Patients with grade IV and V STI had significantly increased odds of all complications, as well as ICU and overall length of stay. These associations remained significant in logistic regression controlling for age, gender, comorbidities, mental status, and hospital-level volume. Grade V disease was significantly associated with mortality as well.

CONCLUSION

This validation effort demonstrates that grade IV and V STI are significantly predictive of complications, hospital length of stay, and mortality. Though predictive ability does not improve linearly with STI grade, this is consistent with the clinical disease process in which lower grades represent cellulitis and abscess and higher grades are invasive infections. This second validation study confirms the EGS grading scale as predictive, and easily used, in disparate disease processes.

LEVEL OF EVIDENCE

Prognostic/Epidemiologic retrospective multicenter trial, level III.

Necrotizing Fasciitis: A Predictable Burden in Rural Kenya

BACKGROUND

Necrotizing fasciitis (NF) is a devastating disease with substantial morbidity and mortality. Poor outcomes are attributed to delayed diagnosis and management. Tenwek Hospital, a teaching and referral center in rural Kenya, manages many cases despite variable resources. We aimed to understand the burden of NF.

METHODS

All patients with admission NF diagnosis who presented in 2017 were reviewed for demographics, investigations, treatment, and outcomes. The primary outcome was unfavorable outcome defined as in-hospital mortality or amputation. Secondary outcomes were discharge diagnosis of NF and cost. Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was calculated. Logistic regression models were utilized to assess the impact of risk factors.

RESULTS

Sixty-seven patients were identified with an average age of 49.2 (±21) years. Medical comorbidities were present in 48% and history of trauma in 58%. Discharge diagnosis of NF occurred in 61% (N = 41). Overall, mortality occurred in 10% (N = 7) of patients with an initial NF diagnosis. At discharge, patients without NF had favorable outcomes in 96% (N = 25) compared to 78% (N = 32) with NF (p = 0.043). Final NF diagnosis costs 122,098 Kenyan Shillings more (95% confidence interval 36,142-208,054) than non-NF diagnosis (p value = 0.006). Factors associated with unfavorable outcome include diabetes mellitus, any comorbidity, increased heart rate, fever, hyperglycemia, anemia, and discharge NF diagnosis. Increased LRINEC score was associated with discharge NF diagnosis (p = 0.0006) and unfavorable outcome (p = 0.0157).

CONCLUSIONS

Patients with NF in rural Kenya experience delays to presentation, unfavorable outcomes, and substantial costs. Certain factors, including LRINEC score, help predict diagnosis and outcome.

Iatrogenic rectal injury associated with fleet enema administration masquerading as Fournier's Gangrene

Rectal injuries secondary to fleet enemas are the result of a chemical irritation as well as mechanical trauma causing localized perforation and mucosal necrosis. These injuries can be managed expectantly. Fournier’s Gangrene is a life-threatening, fulminant soft tissue infection of the genito-perineal region commonly secondary to a perianal infection, requiring extensive debridement of all affected tissue and judicious antibiotic therapy. This distinction is critical in the management of the current case, allowing for limited debridement and judicious observation without a resection of the injured rectum. A diverting colostomy allows for effective faecal management and minimizes contamination of the perineal wound.

Fatal Necrotizing Soft-Tissue Infection Caused by Clostridium tetani in an Injecting Drug User: A Case Report

The aim of this brief report is to raise awareness of necrotizing soft-tissue infections caused by Clostridium tetani in intravenous drug users, highlight the potentially unique dangers of this infection in this specific patient population, and outline the course of treatment currently considered the standard of care.

Red Blood Cell Transfusions and Anemia on Admission Are Associated with Poor Outcomes in Necrotizing Soft Tissue Infections

BACKGROUND

Necrotizing soft tissue infections (NSTIs) are highly morbid infections often requiring critical care and transfusion support. We explored a large 2-year experience from a regional trauma center with a dedicated soft tissue service (STS) in an attempt to identify factors in current care with potential for improving outcomes for these critically ill patients.

METHODS

New adult (>17 years) STS admissions, 2008-2009, were identified from the Trauma Registry. Patient records were extracted and assessed via descriptive statistics, univariate analysis, and multivariable logistic regression models.

RESULTS

Mortality among 253 eligible primary admissions was 8.3% overall and 10.3% for those with an admission diagnosis of NSTI. No significant differences in wound characteristics, use of VAC (vacuum-assisted closure) dressing or hyperbaric oxygen, or wound microbiology emerged between survivors and nonsurvivors. Median time to first debridement was 5 h (interquartile range, 2-21 h). Multivariable modeling indicated association of worse outcome (death or discharge to chronic/rehab care) with age >60 years [odds ratio (OR), 3.82; P < 0.001], anemia (OR, 0.98; P = 0.03), increasing number of transfusions (OR, 1.09; P < 0.001), NSTI diagnosis (OR, 2.47; P = 0.005), preexisting diabetes mellitus (OR, 3.20; P = 0.001), and low admission hemoglobin (OR, 0.80; P = 0.004).

CONCLUSIONS

Mortality was less than previously reported. Number of transfusions and anemia at admission emerged as risk factors for poor outcomes. Future research should focus on the effects of transfusion on NSTI outcomes, on potentially confounding factors, and on whether a restrictive transfusion strategy reduces mortality.

Necrotizing Soft Tissue Infections: A Focused Review of Pathophysiology, Diagnosis, Operative Management, Antimicrobial Therapy, and Pediatrics

Background: Necrotizing fasciitis is a major health problem throughout the world. The purpose of this review is to assist providers with the care of these patients through a better understanding of the pathophysiology and management options. Methods: This is a collaborative review of the literature between members of the Surgical Infection Society of North America and World Society of Emergency Surgery. Results: Necrotizing fasciitis continues to be difficult to manage with the mainstay being early diagnosis and surgical intervention. Recognition of at-risk populations assists with the initiation of treatment, thereby impacting outcomes. Conclusions: Although there are some additional treatment strategies available, surgical debridement and antimicrobial therapy are central to the successful eradication of the disease process.

Necrotizing skin and soft-tissue infections in the intensive care unit

BACKGROUND

Necrotizing skin and soft-tissue infections (NSTI) are rare but potentially life-threatening and disabling infections that often require intensive care unit admission.

OBJECTIVES

To review all aspects of care for a critically ill individual with NSTI.

SOURCES

Literature search using Medline and Cochrane library, multidisciplinary panel of experts.

CONTENT

The initial presentation of a patient with NSTI can be misleading, as features of severe systemic toxicity can obscure sometimes less impressive skin findings. The infection can spread rapidly, and delayed surgery worsens prognosis, hence there is a limited role for additional imaging in the critically ill patient. Also, the utility of clinical scores is contested. Prompt surgery with aggressive debridement of necrotic tissue is required for source control and allows for microbiological sampling. Also, prompt administration of broad-spectrum antimicrobial therapy is warranted, with the addition of clindamycin for its effect on toxin production, both in empirical therapy, and in targeted therapy for monomicrobial group A streptococcal and clostridial NSTI. The role of immunoglobulins and hyperbaric oxygen therapy remains controversial.

IMPLICATIONS

Close collaboration between intensive care, surgery, microbiology and infectious diseases, and centralization of care is fundamental in the approach to the severely ill patient with NSTI. As many aspects of management of these rare infections are supported by low-quality data only, multicentre trials are urgently needed.

Group G streptococcus leading to necrotizing soft tissue infection after left lower extremity radiofrequency venous ablation

A 73-year-old morbidly obese woman developed a severe group G Streptococcus (GGS) necrotizing soft tissue infection (NSTI), superimposed by toxic shock-like syndrome after undergoing radiofrequency venous ablation of her left lower extremity. NSTI secondary to GGS are relatively uncommon, with only nine cases described in the literature. We present a case of GGS NSTI, a debilitating wound infection, occurring after radiofrequency venous ablation. Early identification and treatment are imperative to prevent mortality from NSTI and care must be taken when selecting patients for percutaneous endovascular ablation as they are at risk for such infections.

A Systematic Review of the Laboratory Risk Indicator for Necrotizing Fasciitis Score and Its Utility in Orthopedics for Diagnosing Necrotizing Fasciitis in Adults

Given its association with trauma and surgery, necrotizing fasciitis is a disease orthopedists are likely to encounter. The laboratory risk indicator for necrotizing fasciitis score is an adjunct diagnostic test designed to help diagnose early necrotizing fasciitis infections, but studies evaluating the scoring system have reported conflicting results. The purpose of this systematic review was to provide clarity on the laboratory risk indicator for necrotizing fasciitis score's capabilities and when it is best used. [Orthopedics. 2019; 42(3):e288-e294.].

Validation of the American Association for the Surgery of Trauma emergency general surgery grade for skin and soft tissue infection

INTRODUCTION

Skin and soft tissue infections (SSTIs) present with variable severity. The American Association for the Surgery of Trauma (AAST) developed an emergency general surgery (EGS) grading system for several diseases. We aimed to determine whether the AAST EGS grade corresponds with key clinical outcomes.

METHODS

Single-institution retrospective review of patients (≥18 years) admitted with SSTI during 2012 to 2016 was performed. Patients with surgical site infections or younger than 18 years were excluded. Laboratory Risk Indicator for Necrotizing Fasciitis score and AAST EGS grade were assigned. The primary outcome was association of AAST EGS grade with complication development, duration of stay, and interventions. Secondary predictors of severity included tissue cultures, cross-sectional imaging, and duration of inpatient antibiotic therapy. Summary and univariate analyses were performed.

RESULTS

A total of 223 patients were included (mean ± SD age of 55.1 ± 17.0 years, 55% male). The majority of patients received cross sectional imaging (169, 76%) or an operative procedure (155, 70%). Skin and soft tissue infection tissue culture results included no growth (51, 24.5%), monomicrobial (83, 39.9%), and polymicrobial (74, 35.6%). Increased AAST EGS grade was associated with operative interventions, intensive care unit utilization, complication severity (Clavien-Dindo index), duration of hospital stay, inpatient antibiotic therapy, mortality, and hospital readmission.

CONCLUSION

The AAST EGS grade for SSTI demonstrates the ability to correspond with several important outcomes. Prospective multi-institutional study is required to determine its broad generalizability in several populations.

LEVEL OF EVIDENCE

Prognostic, level IV.

Higher LRINEC Scores and Escalation of Anesthesia Care in Necrotizing Soft Tissue Infection

BACKGROUND

The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score may distinguish necrotizing soft tissue infection (NSTI) from non-NSTI. The association of higher preoperative LRINEC scores with escalations of intraoperative anesthesia care in NSTI is unknown and may be useful in communicating illness severity during patient handoffs.

MATERIALS AND METHODS

We conducted a retrospective cohort study of first operative debridement for suspected NSTI in a single referral center from 2013 to 2016. We assessed the association between LRINEC score and vasopressors, blood products, crystalloid, invasive monitoring, and minutes of operative and anesthesia care.

RESULTS

We captured 332 patients undergoing their first operative debridement for suspected NSTI. For every 1-point higher LRINEC score, there was a higher risk of norepinephrine and vasopressin use (relative risk [RR] = 18%, 95% confidence interval [CI] [10%, 26%] and [10%, 27%], respectively), packed red blood cell use (RR = 28% [95% CI 13%, 45%]), and additional crystalloid (17.57 mL/h [95% CI 0.37, 34.76]). Each additional LRINEC point was associated with longer anesthesia (3.42 min, 95% CI 0.94, 5.91) and operative times (2.35 min, 95% CI 0.29, 4.40) and a higher risk of receiving invasive arterial monitoring (RR 1.11, 95% CI 1.05, 1.18). The negative predictive value for an LRINEC score < 6 was > 90% for use of vasopressors and packed red blood cells.

CONCLUSIONS

Preoperative LRINEC scores were associated with escalations in intraoperative care in patients with NSTI. A low score may predict patients unlikely to require vasopressors or blood and may be useful in standardized handoff tools for patients with NSTI.

Necrotizing Soft Tissue Infections in the Vasculopathic Patient: Review of Literature

Background:

Necrotizing soft tissue infection is a surgical emergency associated with high mortality. Its presence in patients with risk factors for peripheral arterial disease such as diabetes mellitus is consistently associated with significantly poorer outcomes. Though it has been over a century since it was initially described in the literature, mortality rates remain high and treatment regimens are not standardized.

Materials and methods:

PubMed and Cochrane databases were searched for articles pertaining to necrotizing soft tissue infections. Articles were screened for relevance with the intent to compare outcomes in prospective studies of patients with diabetes mellitus or peripheral arterial disease. Patient demographics, clinical findings, mortality, rates of amputation, and morbidity were intended to be compared.

Results:

857 articles were identified, 165 duplicates were removed, and 6 prospective trials were identified for inclusion. Due to significant paucity of data, patient heterogeneity, and lack of standardization for surgical management, a descriptive review of the literature in relation to necrotizing soft tissue infections was pursued, with a focus on high-risk patients with peripheral arterial disease or diabetes mellitus.

Conclusions:

Early aggressive surgical intervention or major amputation may reduce mortality at the cost of increased disability and poorer quality of life in the long term, and may be appropriate in vasculopaths with poorly controlled diabetes and rapidly progressive fulminant infection. However, there is a deficiency in high-level evidence supporting surgical decision-making in this setting, with no standardized protocols for amputation. Future research will be needed to clarify the patient population who would benefit from radical amputation versus intention for limb salvage.

Point-of-Care Ultrasound to Diagnose Pyomyositis in a Child

We report a case of a patient presenting with fever, right lower leg swelling, and pain who was found to have a fluid collection between muscle planes noted on point-of-care ultrasound. Point-of-care ultrasound raised the clinician's concern for deep musculoskeletal infection, leading to prompt initiation of antibiotics and magnetic resonance imaging.

Necrotizing fasciitis caused by Kocuria rosea in an immunocompromised patient

This case report describes an immunocompromised patient with a skin boil that progressed to necrotizing fasciitis. The aim of this brief report is to raise awareness regarding necrotizing soft tissue infections caused by an unusual organism, Kocuria rosea, a typically non-pathogenic organism, and outline the course of treatment currently considered to be the standard of care.

Risk factors for mortality in the late amputation of necrotizing fasciitis: a retrospective study

Background

Necrotizing fasciitis (NF) is a rapidly progressive infectious disease that primarily involves the fascia and subcutaneous tissue. If not promptly treated, it can lead to morbidity as well as mortality. It can affect any part of the body, most commonly the extremities. Early and aggressive surgical treatment is the proper way of management. The purpose of this study was to identify the risk factors for mortality in late amputation among NF patients that may be used in routine clinical practice to prevent mortality.

Methods

A retrospective cohort study of hospitalized patients with NF was conducted in a tertiary teaching hospital in Taiwan between March 2015 and March 2018. All collected data were statistically analyzed.

Results

A total of 582 patients with NF were included; 35 of them had undergone amputation (7 primary and 28 late amputations), with a 6% amputation rate. Thirteen amputated patients still died eventually (all in the late amputation group). Significant risk factors for mortality identified in the late amputation group included hemorrhagic bullae (p = 0.001, OR 4.7, 95% confidence interval (CI) 2.68–8.69), peripheral vascular disease (p < 0.001, OR 3.2, 95% CI 1.12–10.58), bacteremia (p = 0.021, OR 2.87, 95% CI 2.07–5.96), and Laboratory Risk Indicator of Necrotizing Fasciitis (LRINEC) score > 8 (p < 0.001, OR 1.97, 95% CI 1.28–4.61). Vibrio vulnificus was the main causative organism based on our study, but the microbiology results showed no significant correlation.

Conclusion

NF patients with hemorrhagic bullae, comorbidity with peripheral vascular disease, presence of bacteremia, or LRINEC score > 8 should receive early and primary amputation in order to prevent mortality.

Urgences dermatologiques en réanimation : infections nécrosantes de la peau et des parties molles et toxidermies graves

Les urgences dermatologiques nécessitant une admission en réanimation sont rares mais associées à une mortalité élevée et à de lourdes séquelles à long terme. Elles sont essentiellement représentées par les infections nécrosantes des tissus mous (également appelées : dermohypodermites bactériennes nécrosantes-fasciites nécrosantes [DHBN-FN]) et par les toxidermies graves que sont les nécrolyses épidermiques (comprenant le syndrome de Lyell ou nécrolyse épidermique toxique [NET], le syndrome de Stevens-Johnson [SJS] et le DRESS (drug reaction with eosinophilia and systemic symptoms)). Elles ont pour caractéristiques communes un diagnostic souvent difficile, la nécessité d’une approche multidisciplinaire et de soins paramédicaux lourds et spécifiques, imposant fréquemment le transfert dans un centre expert. Le traitement des DHBN-FN est médicochirurgical, associant un débridement chirurgical précoce et une antibiothérapie probabiliste à large spectre. La présence de signes de gravité locaux (nécrose, crépitation, douleur intense) ou généraux (sepsis, choc septique) est une indication d’urgence à l’exploration chirurgicale. Sa précocité est le principal facteur pronostique modifiable, les recommandations de thérapeutiques complémentaires (immunoglobulines intraveineuses, oxygénothérapie hyperbare, pansement à pressions négatives, ...) reposant à ce jour sur un faible niveau de preuve. L’élément essentiel de la prise en charge des toxidermies graves est la recherche et l’arrêt du médicament imputable, facteur essentiel du pronostic. Le SJS et le NET, en général associés à une ou plusieurs atteintes muqueuses, entraînent dans les formes les plus graves une défaillance cutanée aiguë. La prise en charge repose sur les soins de support (correction des troubles hydroélectrolytiques, prévention de l’hypothermie, prévention et traitement des épisodes infectieux, analgésie et anxiolyse, soins locaux). Les complications infectieuses et respiratoires sont les principales causes de décès à la phase aiguë. Aucun traitement spécifique n’a fait la preuve de son efficacité à ce jour. Le diagnostic de DRESS est difficile, et la prise en charge doit être multidisciplinaire. Sa gravité tient aux possibles atteintes viscérales associées (hépatique, rénale et cardiaque) qui justifient dans les formes graves d’une corticothérapie urgente.

Diagnosing Necrotizing Fasciitis Using Procalcitonin and a Laboratory Risk Indicator: Brief Overview

Necrotizing fasciitis is a progressive inflammatory disease that requires an early diagnosis to avoid limb salvage and other deadly manifestations. The current protocol is the microbiological and histopathological sampling of the tissue. Once the diagnosis is made, it should be managed with antimicrobial therapy, debridement, and surgical interventions. Such interventions can be invasive and increase the time to treat, which may increase morbidity. Our article discusses procalcitonin, C-reactive protein, and other markers, such as "pain out of proportion," lactate, creatinine, and creatine kinase, to make a quicker diagnosis before proceeding with invasive procedures. We discussed a similar non-invasive approach called the "Laboratory Risk Indicator for Necrotizing Fasciitis" scoring system that can aid in the early diagnosis of necrotizing fasciitis, which can prompt rapid empiric therapy, reducing the chances of morbidity. This scoring system comprises C-reactive protein, white blood cell count, hemoglobin level, creatinine, sodium, and glucose. Such non-invasive, bedside, and quick tests can help in reducing the time required to make the diagnosis and can affect the course of the disease, hence, improving patient outcomes.

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.

Necrotizing fasciitis: case series and review of the literature on clinical and medico-legal diagnostic challenges

Necrotizing fasciitis (NF) is a life-threatening infection of soft tissues spreading along the fasciae to the surrounding musculature, subcutaneous fat and overlying skin areas that can rapidly lead to septic shock and death. Due to the pandemic increase of medical malpractice lawsuits, above all in Western countries, the forensic pathologist is frequently asked to investigate post-mortem cases of NF in order to determine the cause of death and to identify any related negligence and/or medical error. Herein, we review the medical literature dealing with cases of NF in a post-mortem setting, present a case series of seven NF fatalities and discuss the main ante-mortem and post-mortem diagnostic challenges of both clinical and forensic interests. In particular, we address the following issues: (1) origin of soft tissue infections, (2) micro-organisms involved, (3) time of progression of the infection to NF, (4) clinical and histological staging of NF and (5) pros and cons of clinical and laboratory scores, specific forensic issues related to the reconstruction of the ideal medical conduct and the evaluation of the causal value/link of any eventual medical error.

2018 WSES/SIS-E consensus conference: recommendations for the management of skin and soft-tissue infections

Skin and soft-tissue infections (SSTIs) encompass a variety of pathological conditions that involve the skin and underlying subcutaneous tissue, fascia, or muscle, ranging from simple superficial infections to severe necrotizing infections. SSTIs are a frequent clinical problem in surgical departments. In order to clarify key issues in the management of SSTIs, a task force of experts met in Bertinoro, Italy, on June 28, 2018, for a specialist multidisciplinary consensus conference under the auspices of the World Society of Emergency Surgery (WSES) and the Surgical Infection Society Europe (SIS-E). The multifaceted nature of these infections has led to a collaboration among general and emergency surgeons, intensivists, and infectious disease specialists, who have shared these clinical practice recommendations.