Epidemiological Situation of Necrotizing Fasciitis and Factors in Thailand and Factors Associated with Its Morbidity and Mortality, 2014-2018

Necrotizing fasciitis: an update on epidemiology, diagnostic methods, and treatment

PURPOSE OF REVIEW

The aim of this review is to discuss the latest evidence of epidemiology, diagnostic methods, and treatment of necrotizing soft tissue infections (NSTIs) with a particular focus on necrotizing fasciitis (NF).

RECENT FINDINGS

NSTIs have been historically referred to as NF but encompass a broader range of infections, with variable rates ranging from 0.86 to 32.64 per 100 000 person-years, influenced by factors such as climate and seasonal variations. They have diverse microbiological profiles categorized into different types based on the involved pathogens, including polymicrobial or monomicrobial infections caused by organisms such as group A streptococcus (GAS), Staphylococcus aureus , some Gram-negative pathogens, and filamentous fungi following trauma and natural disasters. Diagnosis relies on clinical symptoms and signs, laboratory markers, and imaging. However, the gold standard for diagnosis remains intraoperative tissue culture. Treatment involves repeated surgical debridement of necrotic tissues in addition to intravenous antibiotics. Adjuvant therapies with intravenous immunoglobulin (IVIG) and hyperbaric oxygen therapy (HBOT) might have a role. Soft tissue reconstruction may be necessary following surgery.

SUMMARY

Prompt diagnosis and proper medical and surgical management of NSTI will improve outcomes.

Retroperitoneal necrotizing fasciitis mimicking perforated appendicitis: A case report

INTRODUCTION

Necrotizing fasciitis (NF) is a rare and rapidly progressing soft tissue infection. The commonly involved body parts are the extremities and trunk. Necrotizing fasciitis (NF) involving the retroperitoneum is very uncommon but associated with higher morbidity and mortality. There are only a few patients survived according to the report.

PRESENTATION OF CASE

This is a 19-year-old male patient presented with abdominal pain, high-grade fever, vomiting and abdominal distension for 3 days. On physical examination, he was hypotensive, tachycardic and febrile. He had a distended, tender abdomen, and hypoactive bowel sound. There were no significant pertinent findings on the other systems. Laboratory tests showed leukocytosis, thrombocytopenia, and elevated liver enzymes. After optimizing with resuscitation and initiating antibiotics, a laparotomy was performed. The finding was 300 ml of hemorrhagic fluid, ischemic cecum and ascending colon, and retroperitoneal necrosis. Subsequently, multiple debridement and right hemicolectomy with stoma was performed. Despite the close monitoring in the ICU, the patient died of uncontrolled sepsis.

CLINICAL DISCUSSION

Necrotizing fasciitis (NF) is a rapidly progressing infectious condition that requires urgent intervention. While it is rare for the retroperitoneum to be affected by NF, it is associated with a high mortality rate. The symptoms of retroperitoneal NF are not specific, making it difficult to diagnose. Here, we present a case of retroperitoneal NF with signs and symptoms of generalized peritonitis, resembling perforated appendicitis.

CONCLUSION

When patients are presented with a case of generalized peritonitis, it is important to include retroperitoneal NF as a potential differential diagnosis.

Impact of Comorbidities on the Cause of Death by Necrotizing Soft Tissue Infections

Background: The aim of this study was to identify the cause of death in patients with necrotizing soft tissue infections (NSTIs) stratified by patient's pre-existing comorbidities (American Society of Anesthesiologists [ASA] classification 3/4 vs. ASA 1/2). Differences in clinical presentation, mortality rate, and factors associated with mortality between those two comorbidity groups were investigated. Patients and Methods: A retrospective multicenter study of patients with NSTIs between 2010 and 2020 was conducted. The primary outcome was the cause of death within the first 30 days. Furthermore, factors associated with mortality were identified. All analysis were stratified by severity of comorbidities (ASA 1/2 or ASA 3/4). Results: Of the 187 patients, 39 patients (21%) died within 30 days. American Society of Anesthesiologists 1/2 patients (overall mortality rate, 11%) died more often as direct result of the infection compared with ASA 3/4 patients (overall mortality rate, 33%) (ASA 1/2 group: 92% vs. ASA 3/4 group: 48%; p = 0.013). American Society of Anesthesiologists 3/4 patients died more often due to withdrawal of life-sustaining therapies based on assumed poor outcome after severe critical illness (ASA 1/2 group: 52% vs. ASA 3/4 group: 8%; p = 0.013). Conclusions: Mortality rates of patients with NSTIs varied from 11% in previously healthy patients to 33% in patients with multiple or severe comorbidities. The predominant cause of mortality was overwhelming infection and associated sepsis in healthy patients whereas in patients with multiple or severe pre-existing medical disease, death most often occurred after treatment limitations based on patient's wishes and prognosis.

Necrotizing fasciitis in Indonesian adult with diabetes mellitus: Two case and review article

Background

Necrotizing fasciitis (NF) is a rare and life-threatening form of infection involving rapidly spreading inflammation and extensive necrosis of the skin, subcutaneous tissue, and superficial fascia.

Case presentation

This study reported two cases of NF in a 56-year-old female and a 38-year-old male who demonstrated typical signs and symptoms of NF. Both presented to the hospital with skin necrosis in the lower extremity, sepsis shock, and multiorgan failure. Based on the clinical presentation, physical examination, and additional examination, a diagnosis of NF was made. The LRINEC score was used to distinguish NF from other soft tissue infections. Both patients were treated with empirical antibiotics, surgical debridement and planned to be amputated, but the patients were hemodynamically unstable and passed away before the amputation proceeded.

Discussion

Delay in the diagnosis of NF increases the risk of mortality and the use of the LRINEC score is very helpful in decision making for health workers.

Conclusion

The key to the management of NF is early diagnosis, debridement, removal of necrotic tissue, amputation, and use of empirical antibiotics.

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Early diagnosis of necrotizing fasciitis (NF) is key in the management of the disease.

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The diagnosis of NF is established using the LRINEC score.

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Debridement and amputation play an important role in preventing the spread of microorganisms in NF.

The impact of operative time on the outcomes of necrotizing soft tissue infections: a multicenter cohort study

Background

The primary aim of this study was to identify if there is an association between the operative time of the initial debridement for necrotizing soft tissue infections (NSTIs) and the mortality corrected for disease severity.

Methods

A retrospective multicenter study was conducted of all patients with NSTIs undergoing surgical debridement. The primary outcome was the 30-day mortality. The secondary outcomes were days until death, length of intensive care unit (ICU) stay, length of hospital stay, number of surgeries within first 30 days, amputations and days until definitive wound closure.

Results

A total of 160 patients underwent surgery for NSTIs and were eligible for inclusion. Twenty-two patients (14%) died within 30 days and 21 patients (13%) underwent an amputation. The median operative time of the initial debridement was 59 min (IQR 35–90). In a multivariable analyses, corrected for sepsis just prior to the initial surgery, estimated total body surface (TBSA) area affected and the American Society for Anesthesiologists (ASA) classification, a prolonged operative time (per 20 min) was associated with a prolonged ICU (β 1.43, 95% CI 0.46–2.40; p = 0.004) and hospital stay (β 3.25, 95% CI 0.23–6.27; p = 0.035), but not with 30-day mortality. Operative times were significantly prolonged in case of NSTIs of the trunk (p = 0.044), in case of greater estimated TBSA affected (p = 0.006) or if frozen sections and/or Gram stains were assessed intra-operatively (p < 0.001).

Conclusions

Prolonged initial surgery did not result in a higher mortality rate, possible because of a short duration of surgery in most studied patients. However, a prolonged operative time was associated with a prolonged ICU and hospital stay, regardless of the estimated TBSA affected, presence of sepsis prior to surgery and the ASA classification. As such, keeping operative times as limited as possible might be beneficial for NSTI patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01456-0.