Necrotizing Fasciitis Patients Research Articles

Necrotizing fasciitis of the extremities: a prospective study

Necrotizing fasciitis is a rapidly progressive infection and is a necrosis of the fascia and surrounding tissues. Despite recent advances in its management, outcomes have not improved and mortality rate is still high. Between September 2007 and August 2009, we prospectively studied twenty-four histopathologically proven necrotizing fasciitis patients to assess the prognostic factors that indicate the outcome. Mortality rate was 20.8%. Twelve patients (50%) improved, while seven patients (29.2%) were complicated by limb loss. Mortality rates related to upper and lower limb involvement were similar (20% vs. 22.2%). The rates of gangrene and amputation in patients with diabetes mellitus were significantly higher than other comorbidities. Patients with gram-positive infections had significantly lower rates of amputation (15.4% vs. 54.5%, P = 0.04). Mean band cell count and serum potassium level were significantly higher in the nonsurvivors same as leukocyte count in the patients with gangrene, while serum sodium level was significantly lower in nonsurvivors. We conclude that hyponatremia, hyperkalemia, and increased band cells in the peripheral blood of patients may be useful parameters in distinguishing life-threatening necrotizing fasciitis; hence, we recommended lower threshold to amputation during surgery for this group of patients.

Clinical and Microbiological Spectrum of Necrotizing Fasciitis in Surgical Patients at a Philippine University Medical Centre

The study describes the clinical characteristics, bacteriology and risk factors for mortality of patients with necrotizing fasciitis (NF), seen in a university medical centre. The medical charts of NF patients admitted to the institution from January 2004 to July 2007 were retrieved and reviewed retrospectively. The majority of the 67 patients included in the study presented with localized nonspecific inflammatory manifestations: tenderness (94%), warmth (86%), oedema (76%), skin necrosis (75%), and ulceration (68%). Diabetes mellitus (22%) was the most common predisposing medical condition. The most frequent isolates were Escherichia coli (44%), Acinetobacter baumannii (19%), Staphylococcus aureus (15%) and Enterococcus faecium (15%). Overall mortality rate was 36%. Risk factors significantly associated with mortality were truncal involvement (p = 0.034), leukocytosis (p = 0.038), acidosis (p = 0.001), hypoalbuminaemia (p = 0.004), hypocalcaemia (p = 0.000) and hyponatraemia (p = 0.023). Logistic regression analysis revealed acidosis [p < 0.05, odds ratio (OR) = 9] and hypoalbuminaemia (p < 0.05, OR = 14) as significant independent risk factors for mortality. The identified risk factors can inform clinicians of increased mortality risks for certain patients with NF. They should serve as a trigger for more aggressive surgical and critical care, and antimicrobial therapy for these patients.

Hospital epidemiology of emergent cervical necrotizing fasciitis

Background:Necrotizing fasciitis (NF) is a surgical emergency. It is a rapidly progressing infection of the fascia and subcutaneous tissue and could be fatal if not diagnosed early and treated properly. NF is common in the groin, abdomen, and extremities but rare in the neck and the head. Cervical necrotizing fasciitis (CNF) is an aggressive infection of the neck and the head, with devastating complications such as airway obstruction, pneumonia, pulmonary abscess, jugular venous thrombophlebitis, mediastinitis, and septic shock associated with high mortality.Aim:To assess the presentation, comorbidities, type of infection, severity of disease, and intensive care outcome of CNF.Methods:Medical records of the patients treated for NF in the surgical intensive care unit (SICU) from January 1995 to February 2005 were reviewed retrospectively.Results:Out of 94 patients with NF, 5 (5.3%) had CNF. Four patients were male. The mean age of our patients was 41.2 ± 14.8 years. Sixty percent of patients had an operative procedure as the predisposing factor and 80% of patients received nonsteroidal anti-inflammatory drugs (NSAIDs). The only comorbidity associated was diabetes mellitus (DM) in 3 patients (60%). Sixty percent of the cases had type1 NF. Mean sequential organ failure assessment (SOFA) score on admission to the ICU was 8.8 ± 3.6. All patients had undergone debridement at least two times. During the initial 24 h our patients received 5.8 ± 3.0 l of fluid, 2.0 ± 1.4 units of packed red blood cells (PRBC), 4.8 ± 3.6 units of fresh frozen plasma (FFP), and 3.0 ± 4.5 units of platelet concentrate. The mean number of days patients were intubated was 5.2 ± 5.1 days and the mean ICU stay was 6.4 ± 5.2 days. Sixty percent of cases had multiorgan dysfunction (MODS) and one patient died, resulting in a mortality rate of 20%.Conclusion:According to our study, CNF represents around 5% of NF patients. CNF was higher among male patients and in patients with history NSAIDs and dental surgeries. Type 1 NF was more common and DM was the only comorbid condition seen in this limited number of patients. The low mortality may be due to the early diagnosis and aggressive surgical treatment combined with optimal supportive intensive care management.

Necrotizing Fasciitis of the Lower Limb – A Prospective Study of Prognostic Factors Affecting Mortality

Necrotizing fasciitis is a life and limb threatening soft tissue infection with a high mortality rate. This study tries to identify the possible risk factors that contribute to mortality in patients with necrotizing fasciitis involving a lower limb. We prospectively reviewed 41 patients that presented with necrotizing fasciitis of the lower limb over a period of one year. Results show that the mortality rate for necrotizing fasciitis of the lower limb is quite high at 19.5%. Comparison among necrotizing fasciitis patients reveals that higher mortality rate is seen among those patients with advanced age and those presented with initial high pre-operative creatinine levels. Sex, pre-morbid diabetes mellitus, duration from initial symptoms to presentation for treatment and presence of streptococcus group A were not associated with an increased mortality rate. Neither were admission vital signs, subcutaneous gas on radiograph, prior antibiotic treatment on admission or clinical note of bullae formation.

Surgical considerations in pediatric necrotizing fasciitis

Background:Necrotizing fasciitis (NF) is a serious infection of soft tissues. This paper presents experience with pediatric NF and suitability of conservative surgery in its management.Materials and Methods:In this retrospective study, 70 patients of NF were managed during the study period of eight years. The study was divided into two time periods- first period (June 1998 to June 2001- group 1) and second period (June 2001 to June 2006- group 2). The parameters studied were age, sex, site of involvement and treatment. The treatment included intravenous antibiotics, supportive therapy and either aggressive (group 1) or conservative surgery (group 2).Results:Age of presentation ranged from 10 days to 11 years. Male to female ratio was 1.69:1. Back was the commonest site to be involved. Culture reports were polymicrobial in 70% with predominance of Staphylococcus species. Predisposing factors included malnourishment, boils, scratch injury, intravenous cannulation and injections. Conservative surgery had better outcome in terms of hospital stay, complications and cost of treatment.Conclusion:NF is a serious and disease which requires immediate and all out attention. Early diagnosis, aggressive supportive treatment and conservative surgery improve survival.

Necrotizing Fasciitis Occurred in the Abdominal Wall Associated with Advanced Gallbladder Cancer: Report of a Case

We describe herein a case of necrotizing fasciitis (NF) concurred with stageIVA gallbladder cancer (GBC) successfully treated by two–step surgical procedures. A 55–year–old Japanese woman complaining of abdominal pain was admitted to our hospital. Examinations showed NF concurred with advanced GBC. After the debridement of necrotic tissues by aggressive surgical intervention, we waited for the NF wound to heal. Subsequently we performed a right extended hepatectomy with removal of a portion of the common bile duct and partial resection of diaphragma for GBC, and skin flap plasty for the scar of NF. This patient is still alive with no signs of recurrence more than three years after primary operation. We believe that inflammation caused by advanced GBC led to NF, and to our knowledge, similar cases have never been reported. This case suggests that complete infection control of NF prior to radical operation for malignancies should be considered to treat patients of NF accompanied by malignancy.

Necrotizing Fasciitis: A Complication of Percutaneous Coronary Revascularization

Percutaneous coronary revascularization is rarely complicated by infection. Necrotizing fasciitis (NF) is a severe, deep-seated, potentially life-threatening infection of fascia and subcutaneous tissues. We report herein 2 cases of NF in patients undergoing percutaneous transluminal coronary revascularization for treatment of acute coronary syndrome. These are the first 2 reported cases of NF associated with percutaneous coronary revascularization.

Correlates of length of stay, cost of care, and mortality among patients hospitalized for necrotizing fasciitis

Several previous studies of necrotizing fasciitis (NF) have been single-institution investigations suffering from small samples sizes. This study of 216 NF patients hospitalized in Florida, USA, during 2001 was designed to identify risk factors for length of stay (LOS), total patient charges (TC), and mortality, using a statewide database. Robust gamma mixed regression was used to determine the predictors of LOS and TC while simultaneously accounting for outliers and the clustering of patients in 87 hospitals. Relative risks (RR) for hospital mortality were calculated using binomial regression. The NF hospitalization rate in Florida was 1.3/100,000. The median TC was US$54,533 and cumulative charges for all 216 patients were nearly US$20 million. Patients aged > or =44 years at the time of admission were five times as likely to expire in the hospital than patients who were aged < or =43 years (adjusted RR 5.08, P=0.03). Unexpectedly, diabetes was associated with a 61% reduction in the risk of hospital mortality (adjusted RR 0.39, P=0.04). Age > or =44 years was the most powerful predictor of prolonged LOS, elevated TC, and an increased risk of hospital mortality in patients suffering from NF.

Necrotizing fasciitis: A decade of surgical intensive care experience

Necrotizing fasciitis is a rare disease, potentially limb and life-threatening infection of fascia, subcutaneous tissue with occasionally muscular involvement. Necrotizing faciitis is a surgical emergency with high morbidity and mortality. Aim: Aim of this study was to analyze presentation, microbiology, surgical, resuscitative management and outcome of this devastating soft tissue infection. Materials and Methods: The medical records of necrotizing fasciitis patients treated in surgical intensive care unit (SICU) of our hospital from Jan 1995 to Feb 2005 were reviewed retrospectively. Results: Ninety-four patients with necrotizing fasciitis were treated in the surgical intensive care unit during the review period. Necrotizing fasciitis accounted for 1.15% of total admissions to our SICU. The mean age of our patients was 48.6 years, 75.5% of the cases were male. Diabetes mellitus was the most common comorbid disease (56.4%), 24.5% patients had hypertension, 14.9% patients had coronary artery disease, 9.6% had renal disease and 6.4% cases were obese. History of operation (11.7%) was most common predisposing factor in our patients. All patients had leucocytosis at admission to the hospital. Mean duration of symptoms was 3.4 days. Mean number of surgical debridement was 2.1, mean sequential organ failure assessment (SOFA) score at admission to SICU was 8.6, 56.38% cases were type 1 necrotizing fasciitis and 43.61% had type 2 infection. Streptococci were most common bacteria isolated (52.1%), commonest regions of the body affected by necrotizing fasciitis were the leg and the foot. Mean intubated days and intensive care unit (ICU) stay were 4.8 and 7.6 days respectively. Mean fluid, blood, fresh frozen plasma and platelets concentrate received in first 24 hours were 4.8 liters, 2.0 units, 3.9 units and 1.6 units respectively. Most commonly used antibiotics were piperacillin with tazobactum and clindamycin. Common complication was ventricular tachycardia (6.4). 46.8% patients had multi organ dysfunction, 15 of them died giving a mortality of 16% in this study. Conclusion: Necrotizing fasciitis is more common in males, diabetes mellitus was the most common comorbid disease, type 1-necrotizing fasciitis was more common and the most common regions of the body affected by necrotizing fasciitis were the leg and the foot.

A case series of patients with black tar heroin-associated necrotizing fasciitis

In 2000, a series of cases of necrotizing fasciitis (NF) among injection users of black tar heroin was observed in our Emergency Department (ED). The description of these cases characterizes the ED presentation of NF, focusing on the sensitivity of physical signs and ED diagnostic tests. All cases of pathologically determined NF in 2000 were prospectively and retrospectively identified and analyzed. Among the 20 patients identified, 20% had fever and 80% were tachycardic in the ED. Most patients, 95%, had elevated white blood cell counts (mean = 37.1 + 23.4 k/ul), 79% had elevated lactate levels, 47% were hyponatremic, and 33% had soft tissue gas on radiograph. Thirty-seven percent of blood cultures and 75% of surgical wound cultures were positive, revealing a variety of organisms. Although tachycardia, leukocytosis, and elevated lactate levels are common in NF patients, fever and soft tissue gas are not. Tests and traditional teaching regarding the “classic” findings of NF should be amended to reflect differences seen in the setting of injection drug use with black tar heroin.

Necrotizing fasciitis: management and outcome.

To observe the various clinical presentations of necrotizing fasciitis and evaluate their management and outcome. An observational descriptive study. Surgical-c unit of Khyber Teaching Hospital, Peshawar, from July 2001 to June 2002. The study included 20 patients of necrotizing fasciitis treated during this period. Age, gender, clinical presentation and predisposing factors were recorded. Pus was cultured and the isolated organism and their sensitivity identified. Management included broad-spectrum antibiotics, extensive and frequent debridements along with supportive measures. Common age group was 21-40 years with a male predominance. eight patients had necrotizing fasciitis of inguinoscrotal and perineal region, while 6 each had abdomen and 6 with necrotizing fasciitis of the limbs involvement. Factors predisposing to infection were diabetes in 5 patients, abscess in 6, trauma in 3 and surgery in 3 patients, while no specific cause was found in 3 cases. Escherichia (E. coli), Bacteroids, Enterococci and Streptococci were the commonest organisms isolated. All were sensitive to a combination of piperacillin and ampicillin. Debridements were done 1-5 times in most cases. Fifteen patients (75%) had complete recovery, 2 (10%) went to other hospitals on their own, 2 (10%) patients expired while one patient was referred to the plastic surgery unit. Necrotizing fasciitis has multiple etiology and predisposing factors. The bacteriology is poly microbial. Early presentation and diagnosis, supportive measures, broad-spectrum antibiotics, prompt and aggressive surgical debridements remains the cornerstone of management.

Streptococcus pyogenes prtFII, but not sfbI, sfbII or fbp54, is represented more frequently among invasive-disease isolates of tropical Australia.

Streptococcus pyogenes (group A streptococcus) strains may express several distinct fibronectin-binding proteins (FBPs) which are considered as major streptococcal adhesins. Of the FBPs, SfbI was shown in vitro to promote internalization of the bacterium into host cells and has been implicated in persistence. In the tropical Northern Territory, where group 4 streptococcal infection is common, multiple genotypes of the organism were found among isolates from invasive disease cases and no dominant strains were observed. To determine whether any FBPs is associated with invasive disease propensity of S. pyogenes, we have screened streptococcal isolates from bacteraemic and necrotizing fasciitis patients and isolates from uncomplicated infections for genetic endowment of 4 FBPs. No difference was observed in the distribution of sfbII, fbp54 and sfbI between the blood isolates and isolates from uncomplicated infection. We conclude that the presence of sfbI does not appear to promote invasive diseases, despite its association with persistence. We also show a higher proportion of group A streptococcus strains isolated from invasive disease cases possess prtFII when compared to strains isolated from non-invasive disease cases. We suggest that S. pyogenes may recruit different FBPs for different purposes.

Necrotizing Fasciitis: A Fourteen-Year Retrospective Study of 163 Consecutive Patients

This review was prompted by continued public and professional interest of necrotizing fasciitis as well as worldwide increases in the incidence of streptococcal invasive infections. Our objective was to outline the clinical course of necrotizing fasciitis and delineate factors relating to mortality among 163 diagnosed patients. Over 14 years patients diagnosed with necrotizing fasciitis were reviewed for patient history, comorbid conditions, and progression of clinical course. A logistic regression model was used to identify factors increasing mortality risk among necrotizing fasciitis patients. Nearly 17 per cent of the patients showed no identifiable antecedent trauma. Seventy-one per cent of tissue culture-positive patients (145) had multibacterial infections. Although no streptococcal species were recovered from one-third of these culture-positive patients there was an increase in mortality noted with beta-Streptococcus infections. Ninety-six per cent of the patient deaths were correlated with variables organized into the following categories: 1) patient history (intravenous drug use and age <1 or >60 years), 2) comorbid conditions (cancer, renal disease, and congestive heart failure), 3) characteristics of clinical course (trunk involvement, positive blood cultures, peripheral vascular disease, and positive cultures for beta-streptococcus or anaerobic bacteria), and 4) quantitative timeline of clinical course (time: injury to diagnosis, diagnosis to treatment). Mortality is correlated to patient history, comorbid conditions, and progression of clinical course. Necrotizing fasciitis can occur idiopathically and is generally a polymicrobial infection that sometimes occurs in the absence of streptococci. Clearly the mortality and morbidity associated with necrotizing fasciitis can be decreased with clinical awareness, early diagnosis, adequate surgical debridement, and intensive supportive care.

A simple model to help distinguish necrotizing fasciitis from nonnecrotizing soft tissue infection

Background: Necrotizing fasciitis (NF) has been associated with certain “hard” clinical signs (hypotension, crepitance, skin necrosis, bullae, and gas on x-ray), but these may not always be present. Using results of a previous study, we developed a simple model to serve as an adjunctive tool in diagnosing NF (admission WBC > 15.4 × 10 9/L or serum sodium [Na] < 135 mmol/L) and determined its ability to distinguish between patients with NF and nonnecrotizing soft tissue infection (non-NF). Study Design: A retrospective review was conducted of consecutive NF (n = 31) and non-NF patients (n = 328) treated at a single institution during an 11-month period. Comparison of admission vital signs, physical examination findings, radiology results, and number of patients meeting model criteria was performed. Results: Ninety percent of NF patients and 24% of non-NF patients met model criteria (p < 0.0001). The model had a sensitivity of 90%, a specificity of 76%, a positive predictive value of 26%, and a negative predictive value of 99% for diagnosing NF. Nineteen (61%) NF patients had no “hard” signs of NF; the model correctly classified 18 (95%) of these patients. Conclusions: Admission WBC greater than 15.4 × 10 9/L and serum Na less than 135 mmol/L are useful parameters that may help to distinguish NF from non-NF infection, particularly when classic “hard” signs of NF are absent.

Objective criteria may assist in distinguishing necrotizing fasciitis from nonnecrotizing soft tissue infection

Background: Optimal treatment of necrotizing fasciitis (NF) requires rapid diagnosis. The purpose of the study was to identify objective admission measurements that help differentiate NF from nonnecrotizing (non-NF) infection and, among NF patients, to identify admission factors that predict mortality.Methods: Twenty-one NF cases were paired with matched non-NF controls. Statistical comparison of admission vital signs, laboratory values, and radiographic studies was performed.Results: On multivariate analysis, admission white blood cell count (WBC) >14 × 109/L, serum sodium <135 mmol/L, and blood urea nitrogen (BUN) >15 mg/dL separated NF from non-NF patients. Mortality for NF patients was predicted by admission WBC >30 × 109/L. Mortality was also significantly increased for patients transferred from an outside institution prior to definitive therapy.Conclusions: Objective admission criteria (elevated WBC and BUN and decreased serum sodium) can assist in distinguishing NF from non-NF infections. The best objective predictor of mortality in NF patients is marked elevation of admission WBC.

Early recognition of neonatal abdominal wall necrotizing fasciitis

Necrotizing fasciitis (NF) of the abdominal wall occurring in newborns is associated with a 50% mortality rate. Improved survival requires early diagnosis followed by aggressive surgical débridement. During a 10-year period, we treated 7 infants who developed NF. During the same period, 32 infants were admitted with omphalitis that did not progress to NF. The patients with omphalitis and those with NF were compared. Tachycardia, abnormal white blood cell counts, induration, and violaceous skin discoloration were seen exclusively in the NF patients. Polymicrobial infections were documented in 28% of the omphalitis patients and 86% of the NF patients. All omphalitis patients survived, whereas 5 of 7 (71%) NF patients died. Adjuvant hyperbaric oxygen therapy was used for 4 infants with NF, 2 of whom survived (50%). NF is a highly morbid disease, that can be distinguished from other infant abdominal wall infections by the skin changes, white blood cell counts, heart rate, and microbiologic results. Prompt diagnosis of NF improves survival when combined with aggressive surgical débridement.