Necrotizing Fasciitis Patients Research Articles

Efficacy of LRINEC Scoring in Patients of Necrotizing Fasciitis and its Correlation with the Outcome

ABSTRACTBackground: Necrotizing fasciitis is an expeditiously escalating inflammatory infection of the fascia, with secondary necrosis of the subcutaneous tissues. To aid diagnosis, the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) scoring system was devised to stratify the likelihood of infection in patients on presentation. Objectives: Study aimed to investigate and quantify the relationships between the LRINEC scoring system and the outcomes such as need for amputation, length of hospital and mortality stay in patients with necrotizing fasciitis. Method: A total number of 90 Patients were admitted with a provisional diagnosis of necrotizing fasciitis. LRINEC score was calculated for each case based on six laboratory variables at the time of presentation. Enrolled patients were divided into three groups on the basis of LRINEC score. The differences in mortality, length of hospitalization, number of debridement and the need of amputation between these groups were compared. Results: Increasing age, male gender, DM has a poor prognosis in the outcome of necrotizing fasciitis patients. The amputation rates and mortality rates are better correlated with higher LRINEC score. Conclusion: The LRINEC score helps in stratifying the patients into risk categories such as low risk, moderate risk and high risk categories, according to severity in a much organized way and the appropriate management like surgical debridement can be started timely. LRINEC score is a robust index that is capable of detecting early cases of necrotizing fasciitis and is simple enough for routine use. It is a simplified bedside diagnostic tool for early diagnosis and prediction of outcome in patients of necrotizing fasciitis.

A prospective study of demographic, clinical profile, treatment of necrotizing fasciitis, and its consequences

Background: The infection that spreads along the fascial planes and causes widespread necrosis is known as necrotizing fasciitis (NF). An uncommon but potentially deadly infectious disease, NF places a significant financial strain on both individuals and the health-care system. There are four occurrences for every 100,000 person-years. Patients with type 1 (polymicrobial) NF are typically immune-compromised, whereas those with type 2 (monomicrobial) NF are typically immune-competent with a trauma history. Type 1 NF has a death rate of 21%, while Type 2 NF has a death rate of 14–34%. Furthermore, NF has the potential to significantly lower patients’ quality of life, especially for those who are having an amputation. Another significant issue for public health is the high death rate. Patients with advanced age, diabetes, smoking, immunosuppression, obesity, malnutrition, steroid therapy, and HIV are more likely to have the disease. Injury and diabetes are important factors. Only few studies have conducted to correlate demographic and clinical features treatment and its outcomes. Therefore, the study is conducted to correlate demographic and clinical features, treatment of NF, and its outcomes. Aims and Objectives: The aims of this study were as follows: (1) to study demographic, clinical profile of patients with NF and (2) to analyze the treatment and outcomes of NF. Materials and Methods: This cohort study was carried out for cases that were clinically diagnosed with NF in patients admitted under the Department of Surgery, Karnataka Institute of Medical Sciences, Hubli, from December 2019 to December 2021. After clearance from the Institutional Ethics Committee, 124 cases were selected based on the inclusion and exclusion criteria. Results: A total of 124 patients were enrolled and analyzed in this study. Most common age group to be affected was 51–60 years. One hundred were male and 24 were female, with male: female ratio of 4.2: 1. Lower limb 95 (76.61%) was the most common site to be involved. Most common risk/precipitating factor for developing NF is trauma 43 (34.65%) followed by diabetes 40 (32.25%). Most common antibiotic used in this study was piperacillin combined with tazobactum in 53 patients (43.54%). Total 124 patients, among them 25 patients underwent amputation, 33 patients were in septic shock and succumbed due to same, 13 patients ended up in skin grafting, the mean duration of hospital stay was 13.46 days, and mean number of debridement was 1.129. Conclusion: In this study, mortality was higher (53.23%), but there was a good improvement in all the surviving patients. Early surgical intervention (within 72 h) with broad spectrum antimicrobials has a favorable outcome. Prompt and early surgical intervention with holistic care helps in reducing morbidity and mortality.

Initial skin necrosis presentation at emergency room was associated with fulminant clinical course and mortality in patients with Vibrio necrotizing fasciitis

Necrotizing fasciitis (NF) is a life-threatening infection. Skin necrosis is an important skin sign of NF. The purposes of this study was to investigate the initial skin conditions of Vibrio NF patients between emergency room (ER) to preoperative status, to compare the clinical and laboratory risk indicators of the skin necrosis group and non-skin necrosis group when they arrived at ER, and to evaluate whether initial cutaneous necrosis related to fulminant course and higher fatalities. From 2015 to 2019, seventy-two Vibrio NF patients with surgical confirmation were enrolled. We identified 25 patients for inclusion in the skin necrosis group and 47 patients for inclusion in the non-skin necrosis group due to the appearance of skin lesion at ER. Seven patients died, resulting in a mortality rate of 9.7%. Six patients of skin necrosis group and one patient of non-skin necrosis group died, which revealed the skin necrosis group had a significantly higher mortality rate than the non-skin necrosis group. All the patients in the skin necrosis group and 30 patients of non-skin necrosis group developed serous or hemorrhagic bullous lesions before operation (p = 0.0003). The skin necrosis group had a significantly higher incidence of APACHE score, postoperative intubation, Intensive care unit stay, septic shock, leukopenia, higher counts of banded leukocytes, elevated C-reactive protein (CRP), and lower serum albumin level. Vibrio NF patients presenting skin necrosis at ER were significantly associated with fulminant clinical courses and higher mortality. Physicians should alert the appearance of skin necrosis at ER to early suspect NF and treat aggressively by those clinical and laboratory risk indicators, such as elevated APACHE score, shock, leukopenia, higher banded leukocytes, elevated CRP, and hypoalbuminia.

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.

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.

Treating necrotizing fasciitis patients at the topmost referral hospital in West Java, Indonesia: 6 years experience.

Necrotizing fasciitis is a progressive and rare disease, with high potential to be life-threatening because of its potential for systemic toxicity. Characterized by fascial infection, it is often followed by systemic toxicity, such as septic shock and multi-organ failure. The aim of this study is to establish reliable data on the treatment of necrotizing fasciitis patients at the topmost referral hospital in West Java, Indonesia. We collected medical record data from January 2015 to December 2021 at Rumah Sakit Umum Pusat Dr. Hasan Sadikin (RSHS), Bandung, Indonesia. We recorded the infection region, bacterial isolates, empirical antibiotics, waiting time for the first surgery, surgical management, length of stay and we analysed the pattern of bacterial isolates, antibiotic use, waiting time for the first surgery, length of stay and mortality. A total of 90 patients' medical records were analysed. We found that the infection was most found in the genitalia and inguinal region (37%). Eighty-five percent of all samples containing gram-negative bacteria. The most used empirical antibiotics were from Cephalosporin class (31%), most of them combined with nitroimidazole (metronidazole) and with quinolones (levofloxacin, ciprofloxacin). Overall mortality rate was 13.3%. Highest mortality rate came from gram-negative bacteria group (14.2%-11 out of 77 patients), patients receiving Ceftriaxone-Metronidazole as empirical antibiotics (28.57%-4 out of 14 patients), patients with no surgery group (37%-3 out of 8 patients), with no mortality came from patients, which were performed debridement followed by fasciotomy/skin graft/flap and amputation. We conclude that the most found bacterial aetiology was Acinetobacter baumanii though it has no significant relation to mortality. We highly recommend early aggressive surgical intervention in reducing mortality rate due to necrotizing fasciitis for source control accompanied by deliberate defect closure and early administration of empirical antibiotics with more susceptibility for gram-negative bacteria, such as Meropenem.

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 > 8 was significantly associated with higher in-hospital mortality (adjusted odds ratio = 1.57; 95% CI: 1.43–2.08; P < .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 > 8 is significantly associated with higher mortality in V vulnificus NF patients.

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.

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.

Diagnostic and Prognostic Value of Laboratory Risk Indicator for Necrotizing Fasciitis Score.

Necrotizing fasciitis (NF) is a lethal soft tissue infection involving skin and subcutaneous tissue with significant morbidity and mortality. To validate the diagnostic and prognostic role of the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) scoring system for NF in patients who present with soft tissue infections. The study was conducted on100 patients who presented with soft tissue infections. Based on the histopathological findings, they were divided into NFand non-necrotizing soft tissue infection groups. Patients were clinically assessed. The lab parameters were assessed andthe LRINECscore was calculated. Patients were stratified based on scoreand grouped into low, intermediate, and high risk. For patients who went into sepsis, the death rate and length of hospital stay, including ICU, were noted based on the scoring system. In our study, the diagnostic role ofLRINEC score ≥ 6 had a sensitivity of 85.7% and specificity of 62.7%, and score ≥ 8 had a sensitivity of 67.3% and specificity of 82.3% with a positive predictive value (PPV) of 78.5 and negative predictive value (NPV) of 72.4, of which 8 is a better cut-off as a diagnostic criterion. The area under the curve was found to be 0.835. To predict the prognostic role, a cut-off value was calculated from the receiver operating characteristic curves of both mortality and sepsis patients in relation to the LRINEC scoreof 9. With the LRINEC score cut-off as 9, with mortality and sepsis as variables, the sensitivity was 50% and 53.3%, specificity was 94.2% and 91.4%, PPV was 78.9% and 72.7%, and NPV was 81.4% and 82%, respectively. The LRINEC score is quick, safe, reproducible, noninvasive, cost-effective, and easily calculated, and has high sensitivity and specificity to predict early diagnosis, and it could be used for risk stratification and prognosis of necrotizing soft tissue infections.

Risk factors and outcomes in patients with severe Necrotizing fasciitis admitted to surgical intensive Care unit: a retrospective cohort study from pakistan.

Necrotizing fasciitis (NF) is a debilitating condition that has high mortality and morbidity even in specialized centres. This study aims to determine risk factors in our local population and identify variables that contribute to mortality in the necrotizing fasciitis patients treated in the surgical intensive care unit of a tertiary care hospital. This retrospective cross-sectional study included 39 patients admitted to the surgical ICU from January 1, 2015 to June 30, 2019. They were analyzed for comorbidities, symptoms at presentation, predisposing factors, location of the infection, microbiological analysis and mortality. There were 27 (69.2%) males and 12 (30.8%) females while the age was distributed as 47.44±15 years. Pain was the most frequently reported symptom (89.7%), followed by swelling (79.5%) and tenderness (77%). Significant predisposing factors included trauma in 14 (35.9%) and Intramuscular injections (IM) in 10 (25.6%) patients. On univariate and multiple logistic regression, patients with chronic kidney disease (AOR:1.27, 95% CI: 0-691.22) and ischemic heart (AOR: 1.55, 95% CI: 0.02-153.26) disease had higher odds of mortality than those with no comorbidity. The overall mortality was 12/39 (30.8%). Intramuscular injections without aseptic measures in our local population are a significant predisposing risk factor for severe necrotizing fasciitis. High laboratory risk Indicators for necrotizing fasciitis and acute physiology and chronic health evaluation II scores at admission were associated with increased mortality.

Clinical and Laboratory Parameters for Differential Diagnosis of Necrotizing Faciitis and Cellulitis.

Necrotizing fasciitis (NF) requires surgical intervention and has high morbidity and mortality. Furthermore, it can be confusing with some skin diseases such as cellulitis. We investigated the roles of clinical and laboratory parameters at the time of admission to the hospital in the differential diagnosis of NF and cellulitis patients. Patients with cellulitis and NF located between the nipple level and the knee between January 2018 and January 2021 were included in our retrospective study. The fever, history, complete blood count results, blood biochemistry, C-reactive protein and procalcitonin values of the patients at the time of admission to the emergency department, length of hospital stay, mortality rates, and laboratory risk indicator for necrotizing fasciitis (LRINEC) scores were recorded and evaluated whether there was a difference in both patient groups. A total of 55 patients, including 26 patients in the NF group and 29 patients in the cellulite group, were included in the study. It was observed that patients with NF applied to the hospital statistically earlier, had higher leukocyte, platelet and neutrophil levels, had longer hospital stays and had higher mortality numbers. In high leukocyte, platelet, and neutrophil levels in the case of cellulitis patients, the clinician should follow the patient's clinic course closely and keep NF in mind.

Rational Use of Ceftriaxone in Necrotizing Fasciitis and Mortality Associated with Bloodstream Infection and Hemorrhagic Bullous Lesions.

Necrotizing fasciitis (NF) is an uncommon life-threatening necrotizing skin and soft tissue infection. The formation of hemorrhagic bullae is a special skin sign of NF. The purposes of this study were to investigate the incidence of hemorrhagic bullae formation and bacteremia associated with different organisms, to appraise the appropriate use of ceftriaxone, and to compare the clinical and laboratory risk indicators of NF patients with Gram-positive and Gram-negative infections on the initial examination. Methods: From March 2018 to December 2020, there were seventy-four NF patients with positive monomicrobial bacterial cultures enrolled based on surgical confirmation, and were categorized into two groups: the Gram-positive group and the Gram-negative group. Ceftriaxone susceptibility tests were carried out using the standard disk diffusion technique. Data, such as demographics, clinical outcomes, microbiological results, presentations of hemorrhagic bullae, and laboratory findings, were compared among these two groups. Results: The Gram-negative group included 52 patients, of whom 6 patients died, resulting in a mortality rate of 11.5%. The Gram-positive group included 22 patients and none died. Patients with bacteremia, hemorrhagic bullae, shock, fever, higher segmented forms and banded forms, and lower platelet counts constituted higher proportions in the Gram-negative group than in the Gram-positive group. The multivariate analysis identified six variables for the differentiation of Gram-negative and Gram-positive NF: the presentation of bacteremia, hemorrhagic bullae, shock at first consultation, fever with body temperature &gt; 38.5 °C, band forms &gt; 0%, and segmented forms ≦ 74%. A total of 66 isolates (89.2%) was susceptible to ceftriaxone. Conclusions: Gram-negative NF patients were significantly associated with hemorrhagic bullae presentation, blood stream infection, and mortality. Physicians should be alert to NF patients with the appearance of bacteremia, shock, fever, higher WBC banded and segmented forms, and lower platelet counts at the emergency department, with patients revealed to more likely have Gram-negative infections. Ceftriaxone with/without other appropriate antibiotics under the supervision of infectious doctors appeared to be clinically effective for the treatment of NF and blood stream infections.

Prognostic Role of Subsequent Thrombocytopenia in Necrotizing Fasciitis Without Liver Disease.

Necrotizing fasciitis (NF) is a life-threatening disease with a fulminant presentation. Although early diagnosis can be aided by combining physical examination, the Laboratory Risk Indicator for Necrotizing Fasciitis score, and computed tomography, a mortality rate of 30% is still reported. In the modern times, an economical and efficient biomarker for predicting mortality in NF patients is still lacking. Platelet count is typically measured in routine blood tests and aids in predicting disease severity. We aimed to clarify the role of platelet count as a predictive factor for aspects of prognosis, such as mortality and surgical outcomes, in patients with NF. We identified 285 patients with NF between 2018 and 2020 in a single medical center in southern Taiwan. Medical records were collected for the evaluation of patients with thrombocytopenia. Univariate and multivariate analyses were performed for different outcomes. We included 115 patients with confirmed diagnoses of NF. Twelve patients died with a mortality rate of 10.4%. Patients with thrombocytopenia exhibited a higher mortality rate (20.9% vs 4.2%, P = 0.006), more shock episodes (51.2% vs 11.1%, P < 0.001), higher intensive care unit admission rate (46.5% vs 13.9%, P < 0.001), and longer hospital length of stay (37.49 ± 24.12 days vs 28.82 ± 14.63 days, P = 0.037) than those without thrombocytopenia. All patients infected with Vibrio species exhibited thrombocytopenia. In multivariate analysis, independent risk factors for mortality were thrombocytopenia (odds ratio, 4.57; 95% confidence interval, 1.08-19.25) and single gram-negative bacterial culture from the wound (odds ratio 6.88; 95% confidence interval, 1.58-29.96). In patients with NF and subsequent thrombocytopenia, a higher mortality rate, greater numbers of shock episodes, higher demand for intensive care unit, and longer hospital length of stay were observed than in those without thrombocytopenia. In patients with NF, platelet count is a valuable and economic indicator of prognosis. Once thrombocytopenia developed in patients with necrotizing fasciitis, aggressive antibiotic treatment and surgical management are required to improve the chances of recovery.

Utility of the Lactate/Albumin Ratio as a Predictor for Mortality in Necrotizing Fasciitis Patients.

Background The lactate/albumin (L/A) ratio has been proposed as a prognostic marker because the ratio is associated with multiple organ failure and mortality in critically ill patients. We aimed to investigate the clinical utility of the L/A ratio as a good prognostic indicator of mortality in a cohort of necrotizing fasciitis patients. Method This retrospective study was conducted in two tertiary hospitals in Taiwan between 2015 and 2020. We reviewed adult patients with measured serum lactate and albumin on the emergency department (ED) arrival to evaluate the prognostic performance of the lactate and lactate/albumin (L/A) ratio for outcome prediction. Result Of the 262 NF patients, 20 (7.63%) died in the hospital. The area under the receiver operating characteristic curve (AUROC) value of the L/A ratio (0.76, 95% confidence interval [CI] 0.69–0.81, P < 0.01) was higher than lactate alone (0.71, 95% CI 0.65–0.74 P < 0.01) for predicting in-hospital mortality. The optimal cutoff of the L/A ratio was 1.61. The AUROC value of the L/A ratio was better than lactate alone regardless of normal lactate level. The cutoff of L/A ratio and hypoalbuminemia showed further discriminative value for in-hospital mortality even in patients with normal lactate levels. Conclusion The prognostic performance of the L/A ratio was superior to a single measurement of lactate for predicting in-hospital mortality and intensive care unit (ICU) lengths in necrotizing fasciitis patients. Aggressive intervention and intensive care were necessary for high-risk NF patients upon ED arrival.

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.

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.

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.

Analysis on the diagnosis and treatment of necrotizing fasciitis complicated with sepsis

To recognize the characteristics of necrotizing fasciitis patients complicated with sepsis and summarize the experience the treatment. A retrospective study was conducted. The clinical data of 57 patients with necrotizing fasciitis complicated with sepsis admitted to Guangdong Provincial People's Hospital from July 2009 to December 2019 was analyzed by collecting such factors as gender, age, complications, infection sites, pathogens, surgery information, treatment options and outcome. The patients were divided into debridement group (n = 14) and control group (n = 43) according to whether the debridement was completed within 48 hours of admission, and the mortality during hospitalization between the two groups was compared. A telephone follow-up had been done to record the long-term outcome of these patients. Among 57 patients with necrotizing fasciitis complicated with sepsis, there were 43 males and 14 females with the average age of (57.9±12.1) years old. Most of the underlying diseases were diabetes mellitus (70.17%), other diseases included hypertension (8.77%), tumor chemotherapy (7.02%), liver disease (hepatitis, cirrhosis, 7.02%), coronary artery heart disease (3.51%), systemic lupus erythematosus (3.51%), etc. Most of the infection site was lower limbs (71.93%). There were 78 pathogens cultured in 57 patients, in which 52 were non-drug resistant bacteria (66.67%), and 26 were drug resistant bacteria (33.33%). There were 40 Gram positive (G+) bacteria (51.28%), 29 Gram negative (G-) bacteria (37.18%), 8 fungi (10.26%) and 1 mixed bacteria (1.28%). Finally, of 57 patients, 46 patients were cured, and 11 patients died with hospital mortality of 19.30%. Among 57 patients, the hospital mortality in the debridement group was significantly lower than that in the control group [0% (0/14) vs. 25.58% (11/43), P < 0.05]. Among the 46 cured patients, 11 had accepted amputations, accounting for 23.91%. In December 2020, 43 patients who were cured (3 patients were lost to follow-up) were followed up by telephone. Twenty-three patients were completely self-care, 9 patients were partly self-care, 8 patients were completely unable to take care of themselves, and 3 patients died. Necrotizing fasciitis with sepsis mostly occurs in people with weakened immunity, and has a high mortality and disability rate. Early identification and active surgical debridement may be the key to improve the treatment effect.

The combined score of quick SOFA and the charlson comorbidity index could be a poor prognostic indicator for in-hospital mortality among patients with necrotizing fasciitis

IntroductionWhile necrotizing fasciitis (NF) is a rare but rapidly progressive devastating soft tissue infectious disease showing a high in-hospital mortality rate of 20–30%, there are no evidence-based predictive tools. Patients and methodsFor the purpose of examining which predictive tools could correctly reflect the severity and prognosis of NF, we retrospectively reviewed all patients who were diagnosed with NF at our institute. The disease severity was evaluated by quick SOFA (qSOFA), SOFA score, SIRS score, APACHE II score, LRINEC score and the combined score of qSOFA and CCI. ResultsA total of 27 patients were enrolled in this study. The median age was 68 years (range 39–96 years). With respect to the predictive values for in-hospital mortality among NF patients, the area under the ROC curve for qSOFA, SOFA score, APACHE II score, the combined score of qSOFA and CCI were 0.653 (p = 0.192), 0.588 (p = 0.12), 0.709 (p = 0.075) and 0.782 (p = 0.016) respectively.A univariate analysis showed that the combined score of qSOFA and CCI≥5 and the initial treatment failure were poor prognostic indicators for the in-hospital death among NF patients. The appropriate cut-offs of qSOFA and CCI were based on the Youden Index. ConclusionWe concluded that the combined score of qSOFA and CCI could reflect the severity and prognosis of NF for in-hospital death.