Necrotizing Fasciitis Research Articles

The Needle and the Damage Done: A Retrospective Review of the Health Impact of Recreational Intravenous Drug Use and the Collateral Consequences for Vascular Surgery

The UK has one of the highest rates of recreational drug use and consequent deaths in Europe. Scotland is the "Drug deaths capital of Europe." Intravenous drug use can result in limb- and life-threatening pathology. This study aimed to characterise limb-related admissions associated with intravenous drug use, outcomes and healthcare expenditure. Retrospective data collection between December 2011 and August 2018. Patients were identified through discharge codes. Admission details were extracted from electronic records and a database compiled. Statistical analyses were performed using Statistical Package for the Social Science, P < 0.05 denoted significance. There were 558 admissions for 330 patients (1-9 admissions/patient), mean age 37 years (+/-7.6 SD) and 196 (59.2%; 319 admissions, 57.2%) were male. Three hundred forty-eight (62.4%) admissions were to surgical specialties, predominantly Vascular Surgery (247). Including onward referrals, Vascular ultimately managed 54.8% of admissions. Patients presented with multiple pathologies: 249 groin abscesses; 38 other abscesses; 74 pseudoaneurysms; 102 necrotising soft tissue infections (NSTI); 85 cellulitis; 138 deep venous thrombosis (DVTs); 28 infected DVTs and 70 other diagnoses. Two hundred and seventy-seven admissions (220 patients) required operations, with 361 procedures performed (1-7 operations/admission). There were 24 major limb amputations and 74 arterial ligations. Eleven amputations were due to NSTI and 13 followed ligation (17.6% of ligations). During follow-up 50 (15.2%) patients died, of which 6 (12%) had amputations (OR 3.2, 95% CI 1.04-9.61, P=0.043). Cumulative cost of acute care was £4,783,241. Limb-related sequalae of intravenous drug use represents a substantial surgical workload, especially for Vascular. These are complex, high-risk patients with poor outcomes and high healthcare costs.

Bacteriology and mortality of necrotizing fasciitis in a tertiary coastal hospital with comparing risk indicators of methicillin-resistant Staphylococcus aureus and Vibrio vulnificus infections: a prospective study

BackgroundVibrio vulnificus has been reported as the leading causative pathogen of necrotizing fasciitis (NF) and related fatality in the coastal area. Necrotizing fasciitis caused by methicillin-resistant Staphylococcus aureus (MRSA) and V. vulnificus have high mortality rates. The purpose of this prospective study was to clarify the clinical characteristics between death and survival NF patients, to investigate bacteriologic profile and mortality of NF patients, and to compare risk indicators of MRSA and V. vulnificus NF patients.MethodsThis prospective study was conducted in 184 consecutive NF patients over a period of three years in a tertiary coastal hospital. Differences in mortality, laboratory findings, microbiology and clinical outcomes were compared between the death and survival groups, and the V. vulnificus and MRSA subgroups.ResultsTwenty patients died, resulting in a mortality rate of 10.9%, and there were 108 patients with a monomicrobial infection (58.7%). The death group had a significantly higher incidence of shock at emergency room and bacteremia than did the survival group. Vibrio species (40 cases) and S. aureus (31 cases) were the two major pathogens. Significant differences with respect to hepatic dysfunction, shock, the event with seawater or seafood contact, bacteremia, C-reactive protein, mean platelet counts, and the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score were observes between V. vulnificus and MRSA groups.ConclusionsNF patients with both hepatic dysfunction and diabetes mellitus, bacteremia and shock have significantly higher mortality. We should be aware of the increasing incidence of monomicrobial NF and higher mortality rates of Gram-negative pathogens in the warm coastal area. LRINEC score is not a suitable diagnostic indicator for V. vulnificus NF, which is more rapidly progressive and fulminant than MRSA NF. NF needed team works by early suspicion, immediate surgical intervention and aggressive care, which can successfully decrease mortality.

Evaluation of prognostic indicators for necrotizing fasciitis

Necrotizing Fasciitis (NF) is a rapid spreading lethal infection of the skin, muscles and soft tissues, with progressive inflammation along tissue planes and local destruction. The varied clinical presentation often leads to misdiagnosis. Various co-morbidities can influence the clinical course of the disease. Considering the life-threatening nature of the condition, this study is undertaken to identify significant prognostic factors, which will facilitate early diagnosis and intervention for an optimal outcome. This is a prospective study of 40 cases of Necrotizing Fasciitis, for 2 years. Maximum patients were in the age group of 51 to 70 years. 55% of patients had necrotizing fasciitis of the lower limb. Pain and fever were the commonest presenting features. 58% of patients presented with clinical features of less than 7 days duration. Trauma was the aetiological factor in 28% of patients. Diabetes Mellitus was the commonest co-morbidity (65%). E. coli was the commonest isolate in culture reports. The LRINEC Score was more than 8 in 25% of patients and less than 5 in 60% cases. Two patients required amputation, 30 underwent surgical debridement and 8 were subjected to fasciotomy. Out of the 38 cases, another 3 patients required amputation subsequently. Length of hospital stay was more than 3 weeks in 63% of cases. Mortality was noted in 12.5% of patients. The hemodynamic status of the individual at the time of presentation and during the post-operative period has a significant prognostic value. Diabetes Mellitus is a common co-morbidity existing in patients with Necrotizing Fasciitis. Other co-morbidities like hepatic and renal dysfunction, hypertension, Peripheral Vascular Disease, immune-deficient states, also affect the treatment outcome. Initial surgical debridement is of extreme importance and should be a thorough one. Early diagnosis, aggressive surgical debridement, with balanced fluid resuscitation and adequate nutritional support and a multidisciplinary approach is the key to a successful outcome.

An observational prospective study of microbiological profiling in necrotizing fasciitis patients at tertiary care centre

Background: Necrotizing fasciitis (NF) is described as the most aggressive form of skin and soft tissue infections. NF requires prompt diagnosis and urgent surgical procedure along with appropriate antibiotic coverage. Still NF has high morbidity and mortality. The aim of the study was to provide microbiological profile in necrotizing fasciitis patients and discover the appropriate antibiotics regimen to treat them early and appropriately.Methods: This observational prospective study was done of patients of necrotizing fasciitis between June 2016 to June 2018 in the department of plastic surgery in the central area of India.Results: In this study monomicrobial culture was positive in 66.7%, polymicrobial culture was positive 16.7% and no organism was found in 16.7% of patients. In our study most commonly, used antibiotic was colistine followed by tigecycline.Conclusions: Microbiological profiling and early use of sensitive antibiotic is a key to treat the necrotizing fasciitis. It renders the progression of disease and decreases the morbidity and mortality in necrotizing fasciitis.

Diagnostic performance of MRI and CT in diagnosing necrotizing soft tissue infection: a systematic review.

To systematically review the accuracy of MRI and CT in diagnosing necrotizing soft tissue infection (NSTI). MEDLINE and Embase were searched for original studies which reported the diagnostic performance of MRI or CT in detecting NSTI. Individual study quality was assessed using the QUADAS-2 tool. Sensitivity and specificity of MRI and CT were calculated and, if supported by data from at least two studies, pooled using a bivariate random-effects model. Six MRI studies and 7 CT studies were included. There were no major concerns with regard to study quality and applicability. The included studies used multiple diagnostic criteria, with sensitivities and specificities of both MRI and CT ranging between 0 and 100%. T2 hyperintensity of deep fascia was the most commonly used diagnostic MRI criterion (5 studies), yielding a pooled sensitivity of 86.4% (95% confidence interval [CI] 76.1-92.7%) and a pooled specificity of 65.2% (95% CI 35.4-86.6%). Presence of gas was the most commonly used diagnostic CT criterion (3 studies), yielding a pooled sensitivity of 48.6% (95% CI 37.1-60.2%) and a pooled specificity of 93.2% (95% CI 73.3-98.5%). T2 hyperintensity of deep fascia at MRI has high sensitivity and moderate specificity in diagnosing NSTI. Presence of gas at CT has low sensitivity but high specificity. A combination of diagnostic criteria may improve diagnostic performance, but this needs further investigation.

Early Diagnosis and Surgical Management of Necrotizing Fasciitis of the Lower Extremities: Risk Factors for Mortality and Amputation.

Objective: In this study, we seek to identify patient characteristics associated with limb loss and mortality while exploring the potential impact a multidisciplinary care team may have. Approach: This was a 10-year retrospective review of patients presenting to our tertiary care center for limb salvage with a diagnosis of lower extremity (LE) necrotizing fasciitis (NF). Patient demographics, clinical history, and outcomes were compared between survivors and nonsurvivors and between those who underwent LE amputation and those who did not. The article adheres to the strengthening the reporting of observational studies in epidemiology statement. Results: Sixty-two patients presented to our tertiary care center for limb salvage with LE NF. Forty-two patients underwent LE amputation: 27 (43.5%) underwent below-knee amputation, 1 (1.6%) underwent above-knee amputation, 8 (12.9%) underwent transmetatarsal amputation and 2 (3.2%) underwent calcanectomy. The overall mortality rate was 16.1% (n = 10). Risk factors for mortality included increased age (p = 0.034), higher Charlson Comorbidity Index (p = 0.011), thrombocytopenia (p = 0.002), hypotension (p = 0.015), erythema (p = 0.010), pain (p = 0.027), diabetes mellitus (p = 0.012), and malignancy (p < 0.001). Risk factors for LE amputation included DM (p = 0.017), peripheral vascular disease (p = 0.033), and an elevated laboratory risk indicator for necrotizing fasciitis (LRINC) (p = 0.033). Innovation: To identify outcomes after admission to a tertiary hospital with a dedicated limb salvage team with LE NF and to analyze risk factors for mortality and amputation. Conclusions: This is a comprehensive analysis of risk factors for mortality and amputation after LE NF. Our institution's experience highlights the importance of a multidisciplinary approach in the care of these patients.

Molecular genotyping and phenotyping of Vibrio vulnificus isolated from diseased, brown-marbled grouper (Epinephelus fuscoguttatus) in Thailand with preliminary vaccine efficacy analysis

Vibrio vulnificus is the major pathogenic bacterium causing mass mortality in groupers (Epinephelus spp.) culture with symptoms as skin and fins hemorrhages and ulcerative necrosis. Microbiological and biochemical characterizations were used to identify Vibrio spp., but it is ambiguous to distinguish V. vulnificus and others. Therefore, molecular genotypic analysis was applied to identify and typing Vibrio spp. isolated from the diseased grouper. Firstly, the identification of Vibrio spp. was assessed by 16 s rRNA before generating the phylogenetic tree. It revealed that 40 samples from 63 samples were V. vulnificus biotype 1. After that, all V. vulnificus samples were classified into subgroup by molecular biotyping based on the 22 virulence genes identification. Accordingly, V. vulnificus can be categorized as subgroup 1, 2, and 3 (marked as G1, G2, and G3, respectively) based on the presence of those studied virulence genes. V. vulnificus isolates containing 16 virulence genes of vvpE, gloB, tlh, Mann Hemo, ManIIA, rimO, vllY, OmpU, vvhA, rtx, hlyIII, pilF, Mann TRAP, vcgC, 16S rRNA type B and nanA has been classified as subgroup 1, whereas subgroup 2 has shown the additional 4 genes including YJ-like nab 1, YJ-like nab 2, cps and sodA, as well as subgroup 3 harboring CM-like nab 1, CM-like nab2, and sodA. Surprisingly, different identification method using 10 house-keeping genes in multi-locus sequence typing (MLST) represented the new three different sequence type (ST) profile. Additionally, phenotypic analysis of isolated V. vulnificus was also performed through the disk diffusion method. This result demonstrated that G1 and G2 were susceptible to tetracycline at 44.4% and 53.8%, respectively, while G3 was susceptible to oxytetracycline (46.2%). Interestingly, G2 which lacking CM-like nab1 and CM-like nab2 alleles exhibited the highest virulent pathogenicity, despite showing a slower growth rate than G1 and G3. Meanwhile, G3, lacking cps gene but containing CM-like nab1 and CM-like nab2 alleles, did not cause mortality in experimental challenge fish. In the case of inactivated vaccine efficiency trial, the FKC-Mixed vaccine revealed the best efficacy when compared with other vaccinated groups (P < 0.05). Altogether, our findings suggested that the molecular genotyping analysis is useful for identifying Vibrio spp. and may apply as the appropriate platform for further characterization of other bacterial species.

Blister beetle bites: a case report

Contacts with insects of the order coleoptera of the families Meloidae and Oedemeridae, in particular the bites of the abscess beetle, lead to acantholysis and the formation of intraepidermal blisters, as well as nonspecific skin damage. The family Meloidae (true abscess beetles) are distributed almost everywhere, with the exception of the territories of New Zealand, Antarctica and the Polynesian islands.&#x0D; Insect species of the Meloidea family have a unique life cycle. Meloidae females lay eggs not only on coleoptera larvae, but also on any other insects, such as crickets, mantises, wasps, bees, on which their metamorphosis continues in the future. Populations of abscess beetles number a large number of individuals, which increases the risk of their meeting with humans. These species have a highly toxic colorless and odorless poison of non-protein nature ― cantharidin.&#x0D; There is a rare clinical case of an abscess beetle bite. The debut of the disease occurred at the time of the patients trip to the island of Goa (India), where he noted insect bites with the appearance of the first blistering rashes and further progression of the skin process. The primary diagnosis was complicated by nonspecific changes detected during the pathomorphological examination of the skin, in the form of subacute dermatitis without classical manifestations of acantholysis with intradermal blisters due to delayed biopsy appointment. Against the background of ongoing treatment (prednisone; corrective therapy with potassium, magnesium, calcium, gastroprotectors; antibiotics; nonsteroidal anti-inflammatory and antimycotic drugs; combined topical glucocorticoids; a course of systemic autohemoozonotherapy) from the skin process, positive dynamics was noted in the form of relief of inflammatory phenomena, partial epithelization of wound defects.&#x0D; Secondary infection of rashes, accompanied, as in this case, by abscessing, is often found with bites of various insect families: cases up to the development of necrotic fasciitis with a fatal outcome are described.&#x0D; The described case is of clinical, scientific and epidemiological interest due to the isolated publications on this nosology and the complexity of diagnosis. Knowledge of the clinical picture of the disease will allow practitioners to develop tactics for managing patients with timely selection of effective therapy.

Effect of immunoglobulin G on cytokine response in necrotising soft-tissue infection: A post hoc analysis.

A marked inflammatory response in necrotising soft-tissue infection (NSTI) may contribute to the severe clinical course. Intravenous polyspecific immunoglobulin G (IVIG) is used by some as adjuvant treatment for NSTI, but in the randomised INSTINCT trial, no effect of IVIG in NSTI patients was seen on physical quality of life. In experimental studies, IVIG may induce immunosuppressive effects by reducing the pro-inflammatory response and neutralising circulating superantigens. However, data on the potential immunomodulatory effects are sparse and remain to be investigated in a clinical setting. In this post hoc analysis of the INSTINCT trial, we aimed to assess the effect of IVIG on various inflammatory cytokines up to day 3 after randomisation. Tumour necrosis factor (TNF), interleukin-1β, interleukin-6, interleukin-10 and granulocyte colony-stimulating factor were measured at admission, days 1, 2 and 3. A total of 100 ICU patients with NSTI were included; 50 were allocated to IVIG (25g/d for 3days) and 50 to placebo. No difference in the overall inflammatory response was observed between groups except from TNF, which was higher in the IVIG group as compared to the placebo group (area under curve-admission to day 3, 93.6 vs 60.2, P=.02). Similarly, no differences were observed in percentage change from baseline to day 3 in any of the studied cytokines between patients allocated to IVIG group and those allocated to placebo group. In ICU patients with NSTI, IVIG did not reduce the plasma concentration of cytokines in the first 3days.

Long-term quality of life in necrotizing soft-tissue infection survivors: a monocentric prospective cohort study

BackgroundCompared to other life-threatening infection survivors, long-term health-related quality of life (QOL) of patients surviving necrotizing soft-tissue infections (NSTI) and its determinants are little known.In this monocentric prospective cohort including NSTI survivors admitted between 2014 and 2017, QOL was assessed during a phone interview using the 36-Item Short-Form Health Survey (SF-36), the Hospital Anxiety and Depression (HAD), the activity of daily living (ADL), instrumental ADL (IADL) scales and the Impact of Event Scale-Revised (IES-R). The primary outcome measure was the SF-36 physical component summary (PCS). NSTI patients were compared according to intensive care unit (ICU) admission status. ICU survivors were matched on SAPS II with non-NSTI related septic shock survivors.ResultsForty-nine NSTI survivors were phone-interviewed and included in the study. Median PCS was decreased compared to the reference population [− 0.97 (− 2.27; − 0.08) SD]. Previous cardiac disease was the only variable associated with PCS alteration [multivariate regression coefficient: − 8.86 (− 17.64; − 0.07), p = 0.048]. Of NSTI survivors, 15.2% had a HAD-D score ≥ 5 and 61.2% an IES-R score ≥ 33. ICU admission was not associated with lower PCS [35.21 (25.49–46.54) versus (vs) 41.82 (24.12–51.01), p = 0.516], but with higher IES-R score [14 (7.5–34) vs 7 (3–18), p = 0.035] and a higher proportion of HAD-D score ≥ 5 (28.6 vs 4.0%, p = 0.036). Compared to non-NSTI septic shock-matched controls, NSTI patients had similar PCS [33.81 (24.58; − 44.39) vs 44.87 (26.71; − 56.01), p = 0.706] but higher HAD-D [3.5 (1–7) vs 3 (1.5–6), p = 0.048] and IES-R scores [18 (8–35) vs 8 (3–19), p = 0.049].ConclusionsLong-term QOL in NSTI survivors is severely impaired, similarly to that of non-NSTI septic shock patients for physical compartments, but with more frequent depressive and/or post-traumatic stress disorders. Only ICU admission and previous cardiac disease were predictive of QOL impairment.

Utilization of Lrinec Score for Early Diagnosis of a Necrotizing Soft Tissue Infection by Serratia Marcesens Complicated with Deep Vein Thrombosis

Necrotizing fasciitis (NF) has a rapid clinical course and is associated with high mortality. Moreover, it involves a high index of suspicion and early aggressive intervention to reduce the risk of mortality. The overlap in clinical presentation in similar pathologies like abscesses, cellulitis, and deep vein thrombosis, can mask underlying NF, making the diagnosis even more challenging. This case presents multiple comorbidities that expedited the development of NF, while demonstrating a pragmatic approach to treating NF while balancing anticoagulation and emergent surgical intervention. The utilization of clinical judgement and a risk stratification score can help identify early cases of NF allowing for aggressive intervention.

Study of the effectiveness of laboratory risk indicator for necrotizing fasciitis scoring system in the diagnosis of necrotizing fasciitis among patients presenting with soft tissue infections

Background: Necrotizing soft tissue infection (NSTI) is an uncommon but life threatening disease with a high mortality rate. Delay in diagnoses and in surgery for debridement is associated with increased mortality rates. Hence here we would like to use this scoring system - laboratory risk indicator for necrotizing fasciitis (LRINEC) in patients presenting to our hospital with necrotizing soft tissue infection and if found to have good predictive values, it would be a boon to developing countries like India where the mortality of the disease is high (7% to 76%).Methods: Patients presenting with symptoms suggestive of soft tissue infection underwent clinical examination and basic laboratory investigations. Following which, information collected using semi structured proforma cum observational checklist. LRINEC scoring system applied to each of the study subjects at admission. The confirmatory diagnosis of necrotizing fasciitis done on patients who undergo surgery vide histopathology, irrespective of the result of the LRINEC scoring system. Tissue cultures and sensitivity patterns analyzed.Results: A total of 100 patients were enrolled. LRINEC score has an ability to diagnose necrotizing fasciitis from other soft tissue infections. High LRINEC score had more incidences of features of sepsis. Presence of the co morbidities tended to increase the LRINEC score. And defines patients with a high LRINEC score of &gt;8 had higher mortality rate.Conclusions: LRINEC score is a simple clinical tool for the diagnosis of necrotizing fasciitis from other soft tissue infections. LRINEC scoring system and clinical assessment should be used concurrently for diagnosing necrotizing fasciitis from other soft tissue infections.

Clinical and Financial Outcomes of Necrotizing Soft-Tissue Infections in Safety-Net Hospitals

Background Prior work has demonstrated inferior outcomes for a multitude of medical and surgical conditions at hospitals with high burdens of underinsured patients (safety-net). The present study aimed to evaluate trends in incidence, clinical outcomes and resource utilization in the surgical management of necrotizing soft-tissue infections (NSTI) at safety-net hospitals.Materials and methods Adults requiring surgical debridement/amputation following NSTI-related hospitalizations were identified in the 2005-2018 National Inpatient Sample. Safety-net status (SNH) was assigned to institutions in the top tertile for annual proportion of underinsured patients. Logistic multivariable regression was utilized to evaluate the association of SNH with mortality, hospitalization duration (LOS), costs and discharge disposition.Results Of an estimated 212,692 patients, 76,719 (36.1%) were managed at SNH. The annual incidence of NSTI admissions increased overall while associated mortality declined. After adjustment, SNH status was associated with greater odds of mortality (adjusted odds ratios: 1.14, 95% CI: 1.03-1.26), LOS (β: +1.8 d, 95% CI: 1.3-2.2) and costs (β: +$4,400, 95% CI: 2,900-5,800). SNH patients had similar rates of amputation but lower likelihood of care facility or home health discharge.Conclusion With a rising incidence and overall reduction in mortality, safety-net hospitals persistently exhibit greater mortality and resource use for surgical NSTI admissions. Variation in access, disease presentation and timeliness of operative intervention may explain the observed findings.

OUR EXPERIENCE IN DIAGNOSIS AND TREATMENT OF NECROTIZING FASCIITIS

Background: Necrotizing fasciitis (NF) is a severe, relatively rare and potentially deadly infection, which is usually caused by one or two pathogenic microorganisms. The target areas that are affected are the skin and the subcutaneous tissues of the lower and the upper limbs, the scrotum, the perineal region (Fournier gangrene) and the abdominal wall. The early diagnosis and aggressive surgical treatment are of great importance for the outcome of this potentially lethal disease. &#x0D; Methods: Eleven patients with diagnosis of NF had been treated in the Clinic of Plastic and Reconstructive surgery of St. George Hospital, Plovdiv for a five-year period (2013-2018). Based on the demographic, clinical and laboratory data the presurgical, the following surgical treatment, and the postsurgical management were analyzed.&#x0D; Results: The mean age of the patients was 58.7 years (median: 56 years, range 37–87 years) and 75% were men. Old age (above 65 years) and female gender correlated significantly with lethality. Most often the regions affected were the perineum and the scrotum (46.8%), followed by lower limbs (35.5%), upper limbs and abdominal wall (8.1%). Diabetes mellitus, oncologic diseases, alcohol addiction and chronic hepatic and renal diseases were found to be predisposing factors for development of NF. We started treatment with broad spectrum antibiotics, early and vigorous drainage and meticulous debridement with wide excision of the damaged tissues. Vacuum therapy was applied as part of the treatment of the defects. It allowed continuous wound cleaning and accelerated formation of granulation tissue, followed by definite closure of the defect.&#x0D; Conclusion: The diagnosis of NF needs adequate proceedings and treatment of the cases among surgeons as its clinical presentation is unspecific. The prompt surgical debridement and excision is the mainstay in the treatment of all patients and repeated surgical excisions are required. Plastic surgery is an undeniable stage in the complex treatment of NF regarding the large size of the wound and necessity of definite closure of the soft tissue defects.

Modified Laboratory Risk Indicator for Necrotizing Fasciitis (m-LRINEC) Score System in Diagnosing Necrotizing Fasciitis: A Nested Case-Control Study.

AimThis study aims to present a modified Laboratory Risk Indicator for Necrotizing Fasciitis (m-LRINEC) scoring system and to evaluate its ability in discriminating necrotizing fasciitis (NF) from other severe soft-tissue infections.MethodsPatients with NF diagnosed by surgical findings in our institution between January 2014 and December 2020 were included as the case group, matched by controls with severe soft-tissue infections other than NF in a ratio of 2:1, based on demographics, calendar time and immunosuppressant status. Patients’ demographics, comorbidities and laboratory test results were extracted from medical records. Logistic regression analyses were used to determine the association with NF after adjustment for confounders, whereby m-LRINEC was developed. Receiver operating characteristics (ROC) curves and the area under the curve (AUC) were used to evaluate its discriminating ability.ResultsThere were 177 patients included, 59 in the NF group and 118 in the non-NF group. We added comorbid diabetes and kidney disease to the original LRINEC scoring system, used high-sensitivity C-reactive protein (HCRP) to replace the CRP and redefined the cut-off values for the other four variables, to develop the m-LRINEC system. The cut-off value for m-LRINEC was 17 points, with corresponding sensitivity of 93.2% and specificity of 86.9%, and the AUC was 0.935 (95% CI 0.892 to 0.977; p<0.001).ConclusionThe m-LRINEC scoring system shows a high sensitivity and specificity in discriminating NF from other severe soft-tissue infections. Patients with an m-LRINEC score of >17 points should have a high index of suspicion for the presence of NF. The validity of the m-LRINEC needs to be confirmed in studies with larger samples and better design.

Necrotising soft tissue infection in western Sydney: An 8-year experience.

This study aimed to assess the risk factors, management, imaging validity, Laboratory Risk Indicator for Necrotising infection (LRINEC) score and outcomes of necrotising soft tissue infection (NSTI) at a western Sydney tertiary hospital. A retrospective study was conducted of all patients with NSTI from 2012 to 2019 at our institution. Patient characteristics, imaging, microbiology and site, LRINEC score, surgical management and outcomes/disposition were collected. Thirty-six patients met the inclusion criteria with mean age of 52 years and body mass index of 38.1; 55.6% were male, 48% of Polynesian descent and 55.6% were diabetic. The most frequent sites of NSTI were perineal (30.6%), lower limb (30.6%), perianal (19.3%) and trunk (11.1%). A total of 64% of patients underwent computed tomography radiological imaging with diagnostic accuracy of 50%. The mean LRINEC score was 7 (1-20). A total of 52.8% were transferred from another facility or non-surgical teams which delayed surgical review by 11.4 h (P < 0.03) and operating time by 12.4 h (P < 0.04) compared with direct emergency department referrals to the on-call surgical team. There was no statistical difference in outcomes in both groups. The overall average time to surgical debridement was 16.2 h (standard deviation 19.6, range 3.4-105.1). The mean hospital length of stay was 20.9 days; 44.4% of patients were transferred for rehabilitation or plastic reconstruction with a single mortality from multi-organ failure. The optimal management of NSTI requires a high index of suspicion and LRINEC score is a useful adjunct in aiding a clinician's decision. Early surgical debridement within 24 h of diagnosis and a multidisciplinary approach is associated with a lower mortality rate.

Case of an Exotic Skin and Soft Tissue Infection Associated with Cyclone Ockhi

Vibrio vulnificus is a halophilic marine gram-negative bacillus that is known to cause fulminant primary septicemia and complicated skin and soft tissue infections in humans. Vibrio vulnificus is referred to as flesh-eating bacteria. In the absence of timely detection and treatment, it results in sepsis with mortality of 50% and septic shock with mortality as high as 100%. Primary septicemia occurs following ingestion of contaminated seafood, and wound infections are acquired following exposure of open wounds to contaminated seawater. Early clinical suspicion and initiation of the appropriate antibiotics is essential to ensure good clinical outcome in case of Vibrio vulnificus septicemia. Here we report the case of a fisherman injured in cyclone Ockhi admitted to our hospital with lower limb cellulitis, who was diagnosed as Vibrio vulnificus wound infection. This case emphasizes the importance of history and clinical examination in antibiotic stewardship.

Cracking Crabs Leading to Vibrio Necrotizing Fasciitis in a Male with Undiagnosed Adrenal Insufficiency

Cracking Crabs Leading to Vibrio Necrotizing Fasciitis in a Male with Undiagnosed Adrenal Insufficiency

Utility of modified Laboratory Risk Indicator for Necrotizing Fasciitis (MLRINEC) score in distinguishing necrotizing from non-necrotizing soft tissue infections

BackgroundWe conducted this study to promote a modified Laboratory Risk Indicator for Necrotizing Fasciitis (MLRINEC) score and evaluate the utility in distinguishing necrotizing fasciitis (NF) from other soft-tissue infections.MethodA retrospective cohort study of hospitalized patients with NF diagnosed by surgical finding was conducted in two tertiary hospital in southern Taiwan between January 2015 and January 2020. Another group was matched by controls with non-necrotizing soft tissue infections based on time, demographics, and immune status. Data such as infectious location, comorbidities, and laboratory findings were recorded and compared. Logistics regression were used to determine the association with NF after adjustment for confounders and MLRINEC score was developed by then. Receiver operating curve (ROC) and the area under the curve (AUC) were used to evaluate its discriminating ability.ResultA total of 303 patients were included; 101 in NF group and 202 in non-NF group. We added serum lactate and comorbid liver disease to the original LRINEC score and re-defined the cut-off values for 3 variables to develop the MLRINEC score. The cut-off value for MLRINEC score was 12 points with corresponding sensitivity of 91.8% and a specificity of 88.4%, and the area under ROC (AUC) was 0.893 (95% CI, 0.723 to 0.948; p < 0.01).ConclusionMLRINEC score shows a high sensitivity and specificity in distinguishing NF from non-necrotizing soft-tissue infections. Patients with a MLRINEC score > 12 points should be highly suspected of presence of necrotizing fasciitis.

Hyperbaric oxygen treatment impacts oxidative stress markers in patients with necrotizing soft-tissue infection

Necrotizing soft-tissue infection (NSTI) is a rare, severe, and fast-progressing bacterial infection associated with a high risk of developing sepsis or septic shock. Increasing evidence indicates that oxidative stress is...