Necrotizing Fasciitis Research Articles

S1514 Impact of Liver Cirrhosis on Morbidity and Mortality of Patients Admitted to the Hospital With Necrotizing Fasciitis: A Retrospective Cohort Study

S1514 Impact of Liver Cirrhosis on Morbidity and Mortality of Patients Admitted to the Hospital With Necrotizing Fasciitis: A Retrospective Cohort Study

The Use of Intact Fish Skin Grafts in the Treatment of Necrotizing Fasciitis of the Leg: Early Clinical Experience and Literature Review on Indications for Intact Fish Skin Grafts.

Necrotizing fasciitis (NF) is a serious infectious disease that can initially place the patient's life in danger and, after successful surgical and antibiotic treatment, leaves extensive wounds with sometimes even exposed bones and tendons. Autologous skin grafts are not always possible or require adequate wound bed preparation. Novel intact fish skin grafts (iFSGs; Kerecis® Omega3 Wound, Kerecis hf, Isafjördur, Iceland) have already shown their potential to promote granulation in many other wound situations. Faster wound healing rates and better functional and cosmetic outcomes were observed due to their additionally postulated anti-inflammatory and analgesic properties. Therefore, iFSGs may also be essential in treating NF. We present our initial experience with iFSGs in treating leg wounds after NF and review the literature for the current spectrum of clinical use of iFSGs. We present two male patients (aged 60 and 69 years) with chronic or acute postsurgical extensive leg ulcers six weeks and six days after necrotizing fasciitis, respectively. Both suffered from diabetes mellitus without vascular pathologies of the lower limbs. A single application of one pre-meshed (Kerecis® Graftguide) and one self-meshed 300 cm2 iFSG (Kerecis® Surgiclose) was performed in our operation room after extensive surgical debridement and single circles of negative wound pressure therapy. Application and handling were easy. An excellent wound granulation was observed, even in uncovered tibia bone and tendons, accompanied by pain relief in both patients. Neither complications nor allergic reactions occurred. The patients received autologous skin grafting with excellent functional and cosmetic outcomes. iFSGs have the potential to play a significant role in the future treatment of NF due to the fast promotion of wound granulation and pain relief. Our experience may encourage surgeons to use iFSGs in NF patients, although high-quality, large-sized studies are still required to confirm these results. The observed effects of iFSGs on wounds associated with NF may be transferred to other wound etiologies as well.

The Need To Address Skin Pathologies Amidst Flooding Crisis In Pakistan.

Madam, As the monsoon approached, Pakistan was ravaged by extreme rainfalls and deadly flooding which affected 33 million people, including 16 million children. (1) With this disaster came a horde of water- borne diseases. The officials recorded over 600,000 people reporting to the relief camps with illnesses, including gastroenteritis, skin infections, acute respiratory infection, cases of malaria, and bites ranging from insects to dogs. (2) Among these diseases, skin pathologies are the second most common complaint reported by the flood- affected population and even though they might be the second most common cause of morbidity; small wounds, lacerations, punctures and skin infections resulting from them are the first to appear in the impact phase after any hydrologic disaster, including floods, rendering it crucial to address skin related pathologies as a priority. (3) Skin diseases may not seem important, with malnutrition, gastroenteritis, malaria and dengue looming in the relief camps, Still the lack of attention can lead to disastrous effects ranging from atypical bacteria like vibrio vulnificus and mycobacterium marinum causing skin infections, infestations with scabies to necrotising soft tissue infection (NSTI) complicating traumatic soft tissue injuries (3.4). This significantly increases the burden of diseases and puts great stress on the already crippled healthcare system in the affected areas and also leads to increase suffering which could easily be avoided by timely precautions and preventative measures taken to decrease the burden. Unfortunately, this isn’t the first time Pakistan has been dealing with the aftermath of a hydrologic disaster. In 2010, Pakistan faced a flood crisis resulting in 1600 deaths and 143,780 skin infections as the third most common cause of illness. (5) The numbers of infections aren’t different from the ones being reported in the recent monsoon floods. This warrants an imminent need to develop a flood response system to reduce the risk of dermatological diseases, tailored to the risk and population of the area. Health awareness programs to educate the masses about practicing good hygiene, making use of sunshine to deal with diseases like scabies which are rampant in the camps, and active involvement of community workers with basic first aid kit to treat minor cuts, lacerations could significantly reduce the morbidity and mortality associated with these conditions. ---Continue

Characterization of patients with odontogenic necrotizing soft tissue infections in the head and neck area. A retrospective analysis

Objective Necrotizing soft-tissue infection (NSTI) in the head and neck area may develop from odontogenic infections. The aim of this study was to characterize patients with NSTI in the head and neck with odontogenic origin in a well-defined prospectively collected cohort. Material and methods Patients with NSTI in the head and neck, hospitalized between 2013 and 2017 at Copenhagen University Hospital and registered in the Scandinavian INFECT database were included. Medical records of identified patients and from the INFECT database were screened for a defined set of data including the primary focus of infection, comorbidities, predisposing factors, clinical and radiographic diagnostics, course of treatment, and treatment outcome. Results Thirty-five patients with NSTI in the head and neck area were included in the study. A total of 54% had odontogenic origin, primarily from mandibular molars, and 94% had radiographic signs of infectious oral conditions. Overall, comorbidities were reported in 51% with cardiovascular disease being the most prevalent. In 20%, no comorbidities or predisposing conditions could be identified. The overall 30-day mortality rate was 9%. Conclusions More than half of NSTI cases in the head and neck region had an odontogenic origin, and special attention should be paid to infections related to mandibular molars.

Comparison of National Early Warning Score with shock index in patients with necrotizing fasciitis.

Shock index (SI) and national early warning score (NEWS) are more frequently used as assessment tools in acute illnesses, patient disposition and early identification of critical condition. Both they are consisted of common vital signs and parameters including heart rate, systolic blood pressure, respiratory rate, oxygen saturation and level of conscious, which made it easy to evaluate in medical facilities. Its ability to predict mortality in patients with necrotizing fasciitis (NF) in the emergency department remains unclear. This study was conducted to compare the predictive capability of the risk scores among NF patients. A retrospective cohort study of hospitalized patients with NF was conducted in 2 tertiary teaching hospitals in Taiwan between January 2013 and March 2015. We investigated the association of NEWS and SI with mortality in NF patients. Of the 395 NF patients, 32 (8.1%) died in the hospital. For mortality, the area under the receiver curve value of NEWS (0.81, 95% confidence interval 0.76-0.86) was significantly higher than SI (0.76, 95% confidence interval 0.73-0.79, P = .016). The sensitivities of NEWS of 3, 4, and 5 for mortality were 98.1%, 95.6%, and 92.3%. On the contrast, the sensitivities of SI of 0.5, 0.6, and 0.7 for mortality were 87.8%, 84.7%, and 81.5%. NEWS had advantage in better discriminative performance of mortality in NF patients. The NEWS may be used to identify relative low risk patients among NF patients.

Severe necrotizing soft tissue infections-Is wound microbiology a prognostic factor for clinical outcome?

Necrotizing soft tissue infections (NSTIs) represent similar pathophysiological features, but the clinical course might range from subacute to a rapidly progressive, fulminant sepsis. Initial wound microbiology is the base for the Guiliano classification. The timeline of microbiological colonization has not been described during the clinical course. The role of the different microbiological pathogens on the outcome and mortality is unclear. One hundred eighty patients were included with septic inflammation response syndrome on admission. Initial wound microbiology and the changes in wound microbiology were analysed during the clinical course and correlated with outcome and risk indicators. Overall mortality was 35%. Higher age, a high Charlson Comorbidity Index or ASA score and truncal infections were highly prognostic for a lethal outcome. Microbiological findings revealed significant differences in the persistence of bacteria during the course of disease. Streptococci were only detectable within the first 5 days, whereas other bacteria persisted over a longer period of time. Initial microbiological findings correlated with better prognosis when no causative agent was identified and for gram-negative rods. Varying survival rates were observed for different Streptococci, Staphylococci, Enterococci and other bacteria. The highest odds ratio for a lethal outcome was observed for Enterococci and fungi. Microbiological colonization changes during the clinical course of NSTIs and some microbiologic pathogens are predictive for worsening the outcome and survival. Streptococcus pyogenes is only detectable in the very early phase of NSTI and after 6 days not anymore detectable. Later Enterococci and fungi showed the highest odds ratios for a lethal outcome. Enterococci bacteria and fungi have yet not been considered of clinical relevance in NSTI or even as indicator for worsening the outcome.

Optimization of Diagnostic Criteria for Necrotisius Fasciitis in Diabetes Mellitus

The concept of relevance holds significance in various academic disciplines. It refers to the degree to which The clinical presentation of necrotizing fasciitis (NF) has been documented in historical records dating back to 1871, when it was first described by Joseph Jones, an American military physician, under the term "hospital gangrene." In the year 1924, Meleney made the discovery that the etiological agent responsible for this particular pathological condition is hemolytic streptococcus. The condition was classified as hemolytic streptococcal gangrene. However, in 1972, B. Wilson introduced a significant diagnostic indicator known as fascial necrosis. Hence, the widely acknowledged definition of necrotizing fasciitis, as proposed by B. Wilson, has been established

Necrotizing Fasciitis Caused By Staphylococcus Haemolyticus and Escherichia Coli: A Rare Case Report

Necrotizing fasciitis (NF) is a severe, life-threatening, and rapidly progressive soft tissue infection. It is characterized by myonecrosis and necrotizing cellulitis, which requires expeditious surgical debridement. We report a rare case of necrotizing fasciitis caused by Staphylococcus haemolyticus and Escherichia coli in 21-years-old male patient with history of surgery and using a traditional medication at the right thigh. The patient is underwent an extensive debridement, OREF, and treated with prompt antibiotics in the intensive care unit.

Clinical Profile of Necrotising Soft Tissue Infection Patients in a North Indian Hospital

Background: Necrotizing soft tissue infections (NSTIs) or necrotizing fasciitis are infections of the subcutaneous tissue and fascia with variable involvement of the overlying skin and underlying muscle. They can be initiated by trivial injuries and can be idiopathic. Material & Methods: It is an retrospective observational study conducted in our surgical unit of a tertiary care centre, from January 2017 to December 2022, were observed for age, gender, occupation, socioeconomic status, body mass index (BMI) clinical features, radiological findings (size, site, status, involvement of tissue compartments and bone). A total of 118 patient records were analyzed. Results: 60% patients were over 50 years of age and 64.2% were males. 69.85 cases had body mass index more than 30 kg/m2. 50.9% patients had history of alcohol abuse and 32.1% cases gave history of intravenous drug abuse. 73.6% cases had foul smelling discharge on presentation while fever and sepsis was seen in 64.2% and 52.8% cases, respectively. Lower limb and perineal involvement was seen in more than two third of the cases. 69.4% cases were anaemic while 44.1% had hypoalbuminemia. More than 85% cases had leucocytosis. 40.7% cases required ionotropes and 22.03% cases needed ventilatory support on admission. Diabetes mellitus was the most common associated co morbidity, seen in 53.4% cases. Conclusion: The necrotizing soft tissue infections are a significant health problem and carry high mortality and morbidity rates. The condition carries high association with modifiable risk factors like anaemia, hypoalbuminemia, diabetes mellitus and obesity.

HLA-II-Dependent Neuroimmune Changes in Group A Streptococcal Necrotizing Fasciitis.

Streptococcus pyogenes (Group A Streptococcus, GAS) bacteria cause a spectrum of human diseases ranging from self-limiting pharyngitis and mild, uncomplicated skin infections (impetigo, erysipelas, and cellulitis) to highly morbid and rapidly invasive, life-threatening infections such as streptococcal toxic shock syndrome and necrotizing fasciitis (NF). HLA class II allelic polymorphisms are linked with differential outcomes and severity of GAS infections. The dysregulated immune response and peripheral cytokine storm elicited due to invasive GAS infections increase the risk for toxic shock and multiple organ failure in genetically susceptible individuals. We hypothesized that, while the host immune mediators regulate the immune responses against peripheral GAS infections, these interactions may simultaneously trigger neuropathology and, in some cases, induce persistent alterations in the glial phenotypes. Here, we studied the consequences of peripheral GAS skin infection on the brain in an HLA-II transgenic mouse model of GAS NF with and without treatment with an antibiotic, clindamycin (CLN). Mice expressing the human HLA-II DR3 (DR3) or the HLA-II DR4 (DR4) allele were divided into three groups: (i) uninfected controls, (ii) subcutaneously infected with a clinical GAS strain isolated from a patient with GAS NF, and (iii) GAS-infected with CLN treatment (10 mg/kg/5 days, intraperitoneal). The groups were monitored for 15 days post-infection. Skin GAS burden and lesion area, splenic and hippocampal mRNA levels of inflammatory markers, and immunohistochemical changes in hippocampal GFAP and Iba-1 immunoreactivity were assessed. Skin GAS burden and hippocampal mRNA levels of the inflammatory markers S100A8/A9, IL-1β, IL-33, inflammasome-related caspase-1 (Casp1), and NLRP6 were elevated in infected DR3 but not DR4 mice. The levels of these markers were significantly reduced following CLN treatment in DR3 mice. Although GAS was not detectable in the brain, astrocyte (GFAP) and microglia (Iba-1) activation were evident from increased GFAP and Iba-1 mRNA levels in DR3 and DR4 mice. However, CLN treatment significantly reduced GFAP mRNA levels in DR3 mice, not DR4 mice. Our data suggest a skin-brain axis during GAS NF, demonstrating that peripherally induced pathological conditions regulate neuroimmune changes and gliotic events in the brain.

Levels of small extracellular vesicles in patients treated with hyperbaric oxygenation.

Hyperbaric oxygen (HBO2) therapy involves the inhalation of pure oxygen in a pressure chamber under increased ambient pressure. Recent research indicates that circulating small extracellular vesicles (sEVs) play important roles in human physiology and pathology. Therefore, the objective of this pilot study was to monitor the impact of HBO2 therapy on the levels of circulating sEVs in the serum of patients with necrotizing soft-tissue infections (NSTI), aseptic bone necrosis (ABN) or idiopathic sudden sensory neural hearing loss (ISSNHL). Serum-derived sEVs were isolated and quantified in 80 patients before and after HBO2 therapy applied for NSTI, ISSNHL and ABN patients as well as in normal controls who received neither HBO2 therapy nor steroids. We observed a significant increase of circulating sEVs in patients with ISSNHL after HBO2 therapy (p < 0.05), as well as significantly elevated levels of sEVs after HBO2 therapy compared to patients with NSTI (p < 0.05) and ABN (p < 0.01). The increase in the levels of sEVs in ISSNHL may be evidence for both the intended reduction of inflammation as a result of steroid therapy and the inhibitory effect of oxidative stress induced by HBO2 therapy. Thus, sEVs released during HBO2 therapy might play an important biological role in mediating the response to therapy and might be a promising approach to gain further insights into the therapeutic efficacy of HBO2 therapy.

Neutrophil-derived reactive agents induce a transient SpeB negative phenotype in Streptococcus pyogenes

BackgroundStreptococcus pyogenes (group A streptococci; GAS) is the main causative pathogen of monomicrobial necrotizing soft tissue infections (NSTIs). To resist immuno-clearance, GAS adapt their genetic information and/or phenotype to the surrounding environment. Hyper-virulent streptococcal pyrogenic exotoxin B (SpeB) negative variants caused by covRS mutations are enriched during infection. A key driving force for this process is the bacterial Sda1 DNase.MethodsBacterial infiltration, immune cell influx, tissue necrosis and inflammation in patient´s biopsies were determined using immunohistochemistry. SpeB secretion and activity by GAS post infections or challenges with reactive agents were determined via Western blot or casein agar and proteolytic activity assays, respectively. Proteome of GAS single colonies and neutrophil secretome were profiled, using mass spectrometry.ResultsHere, we identify another strategy resulting in SpeB-negative variants, namely reversible abrogation of SpeB secretion triggered by neutrophil effector molecules. Analysis of NSTI patient tissue biopsies revealed that tissue inflammation, neutrophil influx, and degranulation positively correlate with increasing frequency of SpeB-negative GAS clones. Using single colony proteomics, we show that GAS isolated directly from tissue express but do not secrete SpeB. Once the tissue pressure is lifted, GAS regain SpeB secreting function. Neutrophils were identified as the main immune cells responsible for the observed phenotype. Subsequent analyses identified hydrogen peroxide and hypochlorous acid as reactive agents driving this phenotypic GAS adaptation to the tissue environment. SpeB-negative GAS show improved survival within neutrophils and induce increased degranulation.ConclusionsOur findings provide new information about GAS fitness and heterogeneity in the soft tissue milieu and provide new potential targets for therapeutic intervention in NSTIs.

Unreliable diagnostic accuracy of laboratory risk indicator for necrotizing fasciitis (LRINEC) score but good outcome predictor in necrotizing fasciitis due to Vibrio vulnificus: A retrospective and matched-pair study

The diagnostic accuracy of laboratory risk indicator for necrotizing fasciitis (LRINEC) score system in specific Vibrio vulnificus (V vulnificus) necrotizing fasciitis (NF) have not been fully investigated yet. This aim of our study is to validate the LRINEC score in patients with V vulnificus NF. A retrospective study of hospitalized patients was conducted in a hospital in southern Taiwan between January 2015 and December 2022. Clinical characteristics, variables and outcomes were compared among V vulnificus NF, non-Vibrio NF and cellulitis patients. A total of 260 patients were included, 40 in V vulnificus NF group, 80 in non-Vibrio NF group and 160 patients in cellulitis group. In V vulnificus NF group with an LRINEC cutoff score ≥ 6, the sensitivity was 35% (95% confidence interval [CI]: 29%–41%), specificity was 81% (95% CI: 76%–86%), PPV was 23% (95% CI: 17%–27%), and NPV was 90% (95% CI: 88%–92%). The AUROC for accuracy of the LRINEC score in V vulnificus NF was 0.614 (95% CI: 0.592–0.636). Multi-variable logistic regression analysis revealed that LRINEC &gt; 8 was significantly associated with higher in-hospital mortality (adjusted odds ratio = 1.57; 95% CI: 1.43–2.08; P &lt; .01). The LRINEC score may not be an accurate tool for V vulnificus NF. That should be used with caution as a routine diagnostic tool. However, LRINEC &gt; 8 is significantly associated with higher mortality in V vulnificus NF patients.

Head and Neck Necrotizing Fasciitis: Abbreviated SOFA Score Associated With Death and Infection Spread.

Describe features unique to head and neck (H&N) necrotizing fasciitis (NF) compared to other anatomic regions and specify a prognostic score associated with death and descending necrotizing mediastinitis (DNM). Retrospective cohort. Tertiary care, level 1 trauma center. A single-institution database identified 399 confirmed cases of NF between 2006 and 2021, 33 of which involved the H&N. Patients with confirmed H&N NF were sorted into cohorts based on clinical outcomes, with the "poor" outcomes group defined by death and/or DNM. Thirty-three patients with H&N NF were included. Compared to NF of other regions, patients with H&N NF had a significantly lower mortality rate (6.06% vs 20.8%, p = .041) and significantly lower rates of obesity (27.3% vs 63.7%, p < .001) and hypertension (42.4% vs 60.9%, p = .038). Within the H&N group, there were 2 deaths (6.06%) and 8 cases of DNM (24.2%). Diabetes was associated with poor outcomes (p = .047), as was an abbreviated sequential organ failure assessment score for necrotizing fasciitis (nfSOFA) of 2 or greater (p = .015). H&N NF is unique among other forms of NF, with a lower mortality rate and lower rates of obesity and hypertension in affected patients. Within the H&N cohort, worse outcomes were associated with diabetes as well as a nfSOFA score of 2 or greater. Timely surgical debridement alongside broad-spectrum antibiotics remains the mainstay of treatment for NF; however, this simple prognostic score may play a role during the early stages of care for patients with H&N NF.

Treatment strategies for orbital gas-producing necrotizing fasciitis secondary to odontogenic maxillary sinusitis: Technical notes

This paper presents treatment strategies for orbital necrotizing fasciitis (NF) in a case of a 33-year-old male diagnosed with orbital NF, which developed after dental root canal treatment. Although orbital NF is rare, it is rapidly progressive and can easily lead to the loss of tissue and visual function, sometimes to a life-threatening extent. Prompt and adequate treatment has been a challenge yet remains quite essential. In addition to the conventional approach to NF, such as immediate antibiotic administration and drainage, orbital NF patients like this case were often treated by incorporating additional steps, which include: 1) performing minimally invasive but adequate removal of necrotic tissue through intraoperative use of ultrasound equipment and postoperative use of proteolytic enzyme-containing ointment for chemical debridement; 2) managing intraorbital pressure by lateral cantholysis and orbital floor removal (decompression); and 3) maintaining the aerobic conditions of the wound after surgical drainage via orbital wall removal. Thus far, satisfactory results in patients with extensive NF of the orbit, including the presented case, were achieved with regards to preserving periorbital tissues, vision, and ocular motility through a multidisciplinary approach. These should be considered as optional means of preserving the orbital tissue and visual function.

A case of necrotizing fasciitis developing after cesarean section

Necrotizing fasciitis (NF) is a rare condition that is observed in obstetric and gynecological practices. It is a rapidly progressive and often fatal complication. Failure to obtain an early diagnosis and delay in initiating appropriate treatment can lead to significant morbidity and mortality. Our case was 25 years old, and she was in her first pregnancy. The patient had no systemic disease or history of previous surgery. Our patient’s baby was delivered by cesarean section with an indication of emergency fetal distress. During the cesarean section, it was observed that the amniotic fluid contained very dark meconium. No complications occurred during the cesarean section. Our patient presented with complaints of severe pain, bullae, and hyperemia at the level of the incision line one week later. In her vital findings, fever was 39.3 ºC, blood pressure was 90/60 mmHg, and heart rate was 110 /min. In laboratory tests, white blood cell count was 25,280 /mm3, C-reactive protein (CRP) was 431 mg/dL, and sedimentation was 100 mm/hour. On the ultrasonographic examination, air, significant edema, and thickening were observed in the incision line, skin, and subcutaneous tissues. On the computed tomography scan, thickening of the skin and subcutaneous tissues, fluid locations, and areas of air densities were observed over a wide area extending to the level of the thoracic 10th and 11th vertebrae superiorly and to the mons pubis inferiorly. Based on these findings, the patient was diagnosed with NF. After broad-spectrum antibiotic therapy and fluid-electrolyte support, extensive surgical debridement was performed under emergency conditions. Before applying the skin graft, vacuum-assisted wound closure was performed, and a very good response was obtained. The patient, whose pathology result was compatible with necrotizing fasciitis, was discharged on the 20th post-operative day. In this case, we aimed to present a case of NF after cesarean section.

Web-Based Expert System for Diagnosis Mycetoma Using Dempster-Shafer Methods

Health is very important and valuable for humans, because without good health, every human being will experience difficulties in carrying out their daily activities. Mycetoma disease, also known as fungal infection and flesh-eating disease, affects people who live in rural or remote areas and have limited access to health care and medicines. So to overcome this problem, we need an expert system that is able to diagnose mycetoma based on the symptoms suffered. The expert system for diagnosing mycetoma using the Dempster Shafer method is designed as a tool for early identification of mycetoma. The Dempster Shafer method was chosen because data collection (weight) for the Dempster Shafer calculation is relatively easy to do just by giving an expert's trust value for a symptom. The calculation process for obtaining conclusions is also relatively easy to do because in the calculations the Dempster-Shafer theory only involves the probabilities of all possible diseases from each symptom.

Predicting necrotising soft tissue infections in people who inject drugs: poor performance of the Laboratory Risk Indicator for Necrotising Fasciitis score and development of a novel clinical predictive nomogram in a retrospective cohort with internal validation.

Necrotising soft tissue infections (NSTI) can threaten life and limb. Early identification and urgent surgical debridement are key for improved outcomes. NSTI can be insidious. Scoring systems, like the Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC), exist to aid diagnosis. People who inject drugs (PWID) are high risk for NSTI. This study aimed to assess the utility of the LRINEC in PWID with lower limb infections and develop a predictive nomogram. A retrospective database of all hospital admissions due to limb-related complications secondary to injecting drug use between December 2011 and December 2020 was compiled through discharge codes and a prospectively maintained Vascular Surgery database. All lower limb infections were extracted from this database, dichotomised by NSTI and non-NSTI with the LRINEC applied. Specialty management times were evaluated. Statistical analyses involved: chi-square; Analysis of "variance"; Kaplan-Meier, and receiver operating characteristic curves. Nomograms were developed to facilitate diagnosis and predict survival. There were 557 admissions for 378 patients, with 124 (22.3%; 111 patients) NSTI. Time from admission to: theatre and computed tomography imaging respectively varied significantly between specialties ( P =0.001). Surgical specialties were faster than medical ( P =0.001). Vascular surgery received the most admissions and had the quickest time to theatre. During follow-up there were 79 (20.9%) deaths: 27 (24.3%) NSTI and 52 (19.5%) non-NSTI. LRINEC ≥6 had a positive predictive value of 33.3% and sensitivity of 74% for NSTI. LRINEC <6 had a negative predictive value of 90.7% and specificity of 63.2% for non-NSTI. Area under the curve was 0.697 (95% CI: 0.615-0.778). Nomogram models found age, C-reactive protein, and non-linear albumin to be significant predictors of NSTI, with age, white cell count, sodium, creatinine, C-reactive protein, and albumin being significant in predicting survival on discharge. There was reduced performance of the LRINEC in this PWID cohort. Diagnosis may be enhanced through use of this predictive nomogram.

Is Neutrophil Lymphocyte Ratio, Platelet Lymphocyte Ratio or Red Blood Cell Distribution Width Associated with Risk of Mortality in Patients with Necrotizing Fasciitis.

Neutrophil lymphocyte ratio (NLR), platelet lymphocyte ratio (PLR), and red blood cell distribution width (RDW) are novel biomarkers to indicate the inflammatory/immune response, and demonstrated to be effective in diagnosis, severity evaluation, and prognosis in a variety of chronic or acute conditions. This study aims to examine whether NLR, PLR and EDW are independently associated with mortality in necrotizing fasciitis (NF). This study retrospectively enrolled patients diagnosed with NF and based on vitality status during hospitalization or within 30 days after discharge, survival and non-survival groups were defined. For distinctly comparing NLR, PLR, RDW and others, we enrolled the matched healthy controls of the same age and sex as the survivors of NF in a 1:1 ratio, which constituted the healthy control group. Comparisons were made between three groups. Variables tested with a P value < 0.10 were further entered into the multivariate logistic regression model to identify their independent association with mortality. A total of 281 subjects were included, including 127 healthy controls, 127 survivors, and 27 nonsurvivors with NF, respectively, indicating a mortality rate of 17.5%. ROC analysis showed that the optimal cutoff value for NLR, PLR and RDW was 11.1, 196.0 and 15.5%, respectively, and was tested as significant only for the first two (P < 0.001, = 0.004). Multivariate logistic analysis showed that NLR ≥ 11.1 (OR, 2.51) and PLR ≥ 196.0 (OR, 2.09) were independently associated with an increased risk of mortality in NF patients, together with age ((OR, 1.28, for each 10-year increment), comorbid diabetes mellitus (OR, 2.69) and liver disease (OR, 1.86), and elevated creatinine level (OR, 1.21 for each 10 umol/L elevation). Elevated NLR and PLR are significant and independent predictors of mortality and can be considered for use when evaluating patients at risk of mortality.

The Role of Burn Centres in the Treatment of Necrotizing Soft-Tissue Infections: a Nationwide Dutch Study.

Patients with extensive and complex wounds due to Necrotizing Soft-Tissue Infections (NSTI) may be referred to hospitals with a burn centre. This study describes the characteristics, outcomes, as well as diagnostic challenges of these patients. Patients admitted to three burn centres for the treatment of NSTI in a 5-year period were included. Eighty patients (median age 54 years, 60% male) were identified, of whom 30 (38%) were referred by other centres, usually after survival of the initial septic phase. Those referred from other centres, compared to those primarily admitted to the study hospital, were more likely to have group A streptococcal involvement (62% versus 35%, p=0.02), larger wounds (median 7% versus 2% total body surface area, p<0.001), and a longer length of stay (median 49 versus 22 days, p<0.001). Despite a high incidence of septic shock (50%), the mortality rate was low (12%) for those primarily admitted. Approximately half (53%) of the patients were initially misdiagnosed upon presentation, which was associated with delay to first surgery (16 hours vs 4 hours, p<0.001). Those initially misdiagnosed had more (severe) comorbidities, and less frequently reported pain or blue livid discoloration of the skin. This study underlines the burn centres' function as referral centres for extensively affected patients with NSTI. Besides the unique wound and reconstructive expertise, the low mortality rate indicates these centres provide adequate acute care as well. A major remaining challenge remains recognition of the disease upon presentation. Future studies in which factors associated with misdiagnosis are explored are needed.