Necrotizing Fasciitis Research Articles

Is Prompt Hyperbaric Oxygen Adjunctive Therapy Able to Reduce Mortality and Amputation in Management of Necrotizing Soft-Tissue Infection?

Background: Necrotizing soft-tissue infection (NSTI) is a rare and serious disease with high morbidity and mortality. Standard therapeutic concepts have included urgent surgical intervention, broad-spectrum antibiotic treatment, and intensive care. Hyperbaric oxygen therapy (HBOT) is used as adjuvant therapy in some centers, but its benefits remain controversial. Methods: A retrospective analysis was conducted in which 98 patients with a clinical diagnosis of NSTI were treated with standard treatments plus HBOT. The clinical outcomes were wound healing, performance status, hospital length, complication rate, recurrence rate, morbidity (amputation rate), and mortality. Primary or secondary outcomes were compared between the time interval of HBOT and the clinical outcomes. Results: The average times from diagnosis of NSTI to initial HBO treatment and from initial surgery to initial HBO treatment were both significantly longer in dead patients than in surviving patients (P = 0.031; P = 0.020). These two time intervals were both significantly longer in amputated patients than in preserved patients (P = 0.031; P = 0.037). Conclusions: Using combined treatment with early surgical debridement combined with HBOT, it is possible to reduce hospital stay, intensive care unit stay, number of debridements, improve complete wound healing rate, and lower amputation and mortality rates among patients with NSTI. The early onset of HBOT soon after diagnosis, especially during critical conditions, is proved to be associated with higher survival and preservation rates.

Clinical Presentation and Treatment Outcomes of Necrotizing Fasciitis: A Prospective Comparative Study of Children and Adults in Sokoto

Abstract Background: Necrotizing fasciitis (NF) is a severe soft tissue infection typified by swiftly spreading necrosis of the fascia and subcutaneous fat with successive necrosis of the skin which affects all age groups. Objective: To compare the clinical presentation and treatment outcome of NF between children and adults. Materials and Methods: A prospective descriptive study of all patients presenting with NF to the (Usmanu Danfodiyo Univrersity Teaching Hospital, Sokoto), from September 2018 to August 2019. Participants were stratified into adults and children for comparison during data analysis. Results: A total of 32 patients were analyzed, 24 (75.0%) were adults. The age range was 2 weeks to 75 years with a median age of 35 years. Necrotic skin patches and skin erythema were the most common cutaneous findings. The lower limb was the most commonly affected region in adults (58.3%), whereas the head and neck and abdominal wall were equally commonly involved in children (37.5%). Children had more multiple isolates than adults, 87.5% compared to 62.5%, respectively, and it was significant (P value 0.04). Escherichia coli and Klebsiella species were both significantly commoner in isolates of children than adults (P value 0.01 and 0.04, respectively). The method of wound coverage was significantly different (P value 0.003) as fewer children required skin grafting. The mortality rate was 6.25%, the two deaths occurred in adults. Conclusion: NF is commoner in adults in our region. The predilection sites of the disease in the two groups differ and healing by secondary intention was more possible in children.

Fournier's Gangrene Surgical Reconstruction: A Systematic Review.

Fournier's gangrene (FG) is a rare form of necrotizing fasciitis of the perineal, genital, or perianal region. It is characterized by an aggressive course and high mortality rate, over 20%. FG demands immediate treatment including resuscitation maneuvers, intravenous antibiotic therapy and early surgical debridement. Background/Objectives: The gold-standard treatment for FG is surgical reconstruction. However, up to date, no precise guidelines exist. Thus, we decided to systematically review the literature, focusing on FG contemporary approaches to reconstructive surgery, aiming to analyze the various reconstructive strategies and their specific indications. Methods: A systematic review was carried out according to the PRISMA statement by searching various databases from April 2014 to April 2024, using the terms ''Fournier Gangrene OR Fournier Gangrene Reconstruction OR Fournier Gangrene Treatment OR Fournier Gangrene Plastic Surgery OR Necrotizing Fasciitis OR Necrotizing Fasciitis AND Reconstruction". The eligibility criteria included original studies aimed at discussing FG reconstruction with at least three clinical cases. Results: The final synthesis included 38 articles, and 576 reconstructions were described. Of these, 77.6% were minimally invasive strategies (direct closure, secondary healing, grafts, and local random flaps), while more invasive reconstructions (loco-regional flaps based on known vascular anatomy) were adopted in 22.4%. No free flaps were reported. Conclusions: FG requires immediate medical interventions including broad-spectrum antibiotic therapy, surgical debridement, adjuvant therapies, and reconstructive surgeries. Taking into account the anatomical characteristics of the inguinal-crural region, skin grafts and local random flaps could offer versatile and effective reconstructions for most FG cases, while the more invasive strategies should be reserved for very few cases. Future research is warranted to define an FG dedicated reconstruction protocol.

Association between Insurance Status and Outcomes of Hospitalizations for Necrotizing Soft Tissue Infections.

Background: Lack of insurance is associated with poorer outcomes in hospitalized patients. However, few studies have explored this association in hospitalizations for necrotizing soft tissue infections (NSTIs). This study examined the impact of insurance status on the outcome of NSTI admissions. Methods: All adult hospitalizations for necrotizing fasciitis, gas gangrene, and Fournier gangrene between 2016 and 2018 were examined using the Nationwide Inpatient Sample database. Insurance status was categorized as insured (including Medicare, Medicaid, and Private, including Health maintenance organization (HMO) or uninsured (Self-pay). Outcome measures included mortality rates, limb loss, length of hospital stay, prolonged hospital stay, and critical care admissions. Statistical analysis included weighted sample analysis, chi-square tests, multivariate regression analysis, and negative binomial regression modeling. Results: Approximately 29,705 adult hospitalizations for NSTIs were analyzed. Of these, 57.4% (17,065) were due to necrotizing fasciitis, 22% (6,545) to gas gangrene, and 20.5% (6,095) to Fournier gangrene. Approximately 9.7% (2,875) were uninsured, whereas 70% (26,780) had insurance coverage. Among the insured, Medicare covered 39.6% (10,605), Medicaid 29% (7,775), and private insurance 31.4% (8,400). After adjustments, Medicare insurance was associated with greater odds of mortality (adjusted odds ratio [aOR]: 1.81; 95% confidence interval [CI]: 1.33-2.47; p = 0.001). Medicaid insurance was associated with increased odds of amputation (aOR: 1.81; 95% CI: 1.33-2.47; p < 0.001), whereas private insurance was associated with lower odds of amputation (aOR: 0.70; 95% CI: 0.51-0.97; p = 0.030). Medicaid insurance was associated with greater odds of prolonged hospital stay (aOR: 1.34; 95% CI: 1.09-1.64; p < 0.001). No significant association was observed between the lack of insurance or self-pay and the odds of primary or secondary outcomes. Conclusion: Medicare insurance was correlated with greater odds of mortality, whereas Medicaid insurance was associated with increased odds of amputation and longer hospital stay. Uninsured status was not associated with significant differences in NSTI outcomes.

Gender and Racial Differences in the Provision of Palliative Care Services Among Critically ill Necrotizing Fasciitis and Septic Shock Geriatric Patients: Analysis of a Nationwide Database in the United States.

Introduction: Necrotizing fasciitis (NF) and sepsis shock (SS) are both severe and life-threatening conditions requiring specialized care, including palliative care (PC), to optimize comfort. However, data on the utilization of PC in this population, including racial and gender differences, are limited. Methods: We used the National Inpatient Sample (NIS) database from 2016 to 2020 to extract data on patients with NF and SS as well as PC utilization. Chi-squared tests and multivariate linear regression models were utilized to analyze relationships between categorical and continuous variables, respectively. Multivariable logistic regression was used to determine adjusted odds ratios (aORs) and 95% confidence intervals (CI) for various outcomes among various gender and racial groups. Mann-Kendall trend test was used to assess mortality trends over time. Results: Among the 11,260 patients with NF and SS, 2,645 received PC whereas 8,615 did not. Female patients had significantly higher odds of receiving PC versus males (aOR: 1.42, 95% CI 1.27-1.58). No significant racial differences in PC utilization were observed. Patients receiving PC had higher odds of in-hospital mortality (aOR: 1.18, 95% CI 1.03-1.35). No significant trend in in-hospital deaths was observed over the study period. PC was associated with significantly shorter length-of-stay and lower costs. Conclusion: Our study provides comprehensive insights, and identifies gender differences in PC utilization in NF and SS patients. Further research must aim to refine delivery strategies and address potential differences in PC.

496 Necrotising Fasciitis Within a Single Centre: A 5 Year Retrospective Review

Abstract Aim Necrotising Fasciitis (NF) is a rapidly progressing soft tissue infection that necessitates prompt diagnosis and management. This study examined NF cases over a 5-year period at Bradford Royal Infirmary and those referred from local hospitals to enhance patient care and outcomes. Method Cases coded as “Necrotising Fasciitis” between April 2018 and January 2023 were retrospectively reviewed using electronic records. These encompassed patients transferred for plastic surgery input and those admitted under various specialties. Data on risk factors, admission details, surgical interventions, microbiology results, and outcomes were collected. Microbiology results included histology, tissue, swabs and blood cultures if sent. Results A total of 50 cases were identified - 33 male and 17 female patients with a mean age of 53 (range of 25-93). The mean Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score was 8.6 prior to debridement. Of the 13 cases with histological confirmation, 2 were calculated as low risk and 2 as intermediate. Tissue cultures showed 21 cases with E. Coli and/or Mixed Anaerobes (Type 1) and 8 with Group A Strep and/or Staph Aureus (Type 2). 4 cases did not require debridement, while others needed an average of 2.3 debridements. 23 of the 45 patients required reconstruction by the local plastics team. 37 patients of the total 50 were discharged, 3 self-discharged and 10 died acutely (22.2% mortality rate). Conclusions While the LRINEC score is a valuable indicator for NF, histology demonstrates its limitations. It is an adjunct, not a substitute, to clinical diagnosis, ensuring accurate management and preventing misdiagnosis.

Necrotizing Soft Tissue Infection Following a Closed Distal Radius Fracture: A Case Report and Literature Review.

Necrotizing soft tissue infections (NSTIs), characterized by extensive soft tissue destruction, are rare but life-threatening. We present a case of a NSTI in a healthy 65-year-old woman following a closed distal radius fracture. The patient presented with severe pain, fever, and lethargy 4 days after her index injury, with physical examination of the right upper limb revealing erythema and swelling to the mid-humeral level and blisters of the fingers and hand. Multiple surgical debridements were required to control the infection, which was caused by Streptococcus pyogenes. This case highlights the rapid progression and devastating consequences of NSTI, which can occur even in the setting of closed injuries in patients without comorbidities. Prompt diagnosis, early surgical intervention, and appropriate antimicrobial therapy are crucial in managing this pathology.Level of Evidence: Level 5.

Successful Management of Necrotizing Fasciitis of Perianal Region due to Kobiraji Maltreatment for Hemorrhoids

Necrotizing fasciitis (NF), an invasive soft-tissue infection that affects the fascia superficially and spreads quickly along subcutaneous tissue. It is a medical- surgical emergency. The patient may have symptoms that are not consistent with the clinical findings, such as a temperature, evidence of local inflammation, and acute pain. Patients typically present at a later stage, but because there are few cutaneous signs in the early stages, diagnosis might be difficult. Thus, a high index of suspicion plays a crucial role in the NF diagnosis. Furthermore, intraoperative diagnosis frequently serves as a confirmation. The cornerstones of the treatment include analgesia, hydration and electrolyte control, intravenous antibiotics and prompt surgical debridement. JAFMC Bangladesh, Vol 19, No 2 (December) 2023: 42-46

Enhancing Early Detection of Necrotizing Soft Tissue Infections: The Role of the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) Score.

Background There is great variation in the etiology, predisposing organisms, incidence, clinical characteristics, severity, and consequences of skin and/or subcutaneous tissue infections. Extensive necrosis of the subcutaneous tissues and fascia is a characteristic of necrotizing soft tissue infections, which are frequently deadly. To change the course of treatment, this study highlights the need to find a tool that can quickly and accurately identify patients with necrotizing fasciitis (NF) and assist in making an early treatment decision. Methodology A prospective evaluation of 30 individuals with soft tissue infections was conducted using the laboratory risk indicator for necrotizing fasciitis (LRINEC). The patients were classified as low, intermediate, and high risk for the start of NF based on their LRINEC score. To assess the importance of the LRINEC score in forecasting the start of NF and its clinical consequences, patients in each group underwent appropriate management and statistical analysis. Results This study included 28 males (93.3%) and two females (6.7%). The associated p-value, recorded as 0.039, signifies statistical significance in the observed area under the receiver operating characteristic (ROC) curve. The p-value in risk categorization was found to be 0.296, which suggests that LRINEC helps in risk categorization with 100% sensitivity when used as a screening tool. Conclusion The early detection of necrotizing soft tissue infections, such as NF, is vital. The LRINEC score, based on routine lab tests, accurately distinguishes these infections. With high sensitivity and significant p-values, it helps stratify patients, guiding timely interventions and saving lives.

Management of Unilateral Buccal Necrotizing Fasciitis Superimposed with Submandibular Abscess At Colli Dextra in a Type 2 Diabetes Mellitus patient : A Case Report

Background: Necrotizing fasciitis (NF) is a relatively rare infectious disease of soft tissues that is characterized by necrosis of subcutaneous tissue and fascia and can even extend to involve the skin and muscles, with the main spread through odontogenic infections. One of the main comorbidities of necrotizing fasciitis is diabetes mellitus. Proper case management is needed because NF can result in severe morbidity and mortality if not treated at an early stage. Study Objective: This case report aims to report the management of patients with buccal necrotizing fasciitis complicated by submandibular abscesses with comorbid type 2 diabetes mellitus. Case Presentation: A 60-year-old woman came to RSHS complaining of swelling on her right cheek 20 days before hospital admission, which further extended to the jaw and neck area. Swelling on the patient's face did not improve after antibiotic treatment, and continued to enlarge to a size of 10x8x7 cm and 8x6x5 cm. The patient has a history of type 2 diabetes mellitus and controlled hypertension. The patient is diagnosed as necrotizing fasciitis and submandibular abscess. Patients are given antibiotic treatment and performed pus-tapping, necrotomy debridement, and tooth extraction. Conclusion : Necrotizing fasciitis involving the facial (especially buccal) area is rare, with the main cause being odontogenic, peritonsillar, or sinugenic. The main management includes debridement, reconstructive measures, and administration of antibiotics. Extensive tissue involvement, and poly-comorbid conditions can worsen the prognosis of necrotizing fasciitis. Keywords : Abscess, Buccal, Colli dextra, Necrotizing fasciitis, Submandibular

NECROTIZING FACICIT AFTER HEMOROIDECTOMY

Necrotizing fasciitis (NF); is a progressive soft tissue infection involving the lower extremities and perianal region, extending from the skin to the fascia. Although it is frequently seen in the elderly, it can be seen in all age groups with concomitant diseases, previous surgery history, and immune system disorders. NF, which develops as a result of rapid tissue invasion, can cause serious morbidity and mortality if early diagnosis and early surgical debridement are not performed. Therefore, NF should be suspected if pain, fever, and septic markers are disproportionate to the lesion in the clinic. The most important step in the treatment of NF is early surgical debridement and initiation of appropriate antibiotics. In addition to these treatments, various wound care treatments can also be applied. We tried to explain the process from diagnosis to discharge in a patient who developed NF after hemorrhoidectomy in terms of treatment management.

Prognostic Factors in Necrotizing Fasciitis: Insights from a Two-Decade, Two-Center Study Involving 209 Cases.

Necrotizing fasciitis (NF) is a critical disease with high morbidity and mortality rates that poses significant challenges in diagnosis and treatment. Prognostic factors for the clinical course of NF remain unclear and are currently under research. This study aims to identify such factors in a large cohort of patients which represents a major comprehensive investigation of prognostic factors for NF. Retrospective analysis was conducted on necrotizing fasciitis cases from 2003 to 2023 at two German hospitals. Data included demographics, comorbidities, laboratory findings, infection site, causative microorganisms and outcomes. Statistical analysis involved t-tests, chi-square tests, and ROC analysis. A total of 209 patients were included, with a mortality rate of 18%. Patients were categorized into survivors (n = 171) and non-survivors (n = 38). Non-survivors were significantly older (68.9 ± 13.9 years vs. 55.9 ± 14.3 years; p < 0.01) and exhibited a higher prevalence of peripheral vascular diseases, cancer, and heart, liver, or renal insufficiency. Laboratory findings and scoring results also varied significantly between the two groups. The ROC curve analysis identified age as a predictor of mortality, with an optimal cut-off value of 68.5 years (sensitivity: 60.5%, specificity: 81.9%). Higher age was associated with increased mortality risk. The patient's age stands out as the primary predictive element for mortality in necrotizing fasciitis. Additionally, we advocate for employing the Laboratory and Anamnestic Risk Indicator for Necrotizing Fasciitis (LARINF-score), which holds substantial prognostic significance and is straightforward to calculate. Considering our findings, crafting a clinical algorithm or scoring mechanism to forecast mortality in NF would be a promising target for future research.

Treating necrotizing skin and soft-tissue infections.

Treating necrotizing skin and soft-tissue infections.

Real-time identification of life-threatening necrotizing soft-tissue infections using indocyanine green fluorescence imaging.

Necrotizing soft-tissue infections (NSTIs) are life-threatening infections with a cumulative case fatality rate of 21%. The initial presentation of an NSTI is non-specific, frequently leading to misdiagnosis and delays in care. No current strategies yield an accurate, real-time diagnosis of an NSTI. A first-in-kind, observational, clinical pilot study tested the hypothesis that measurable fluorescence signal voids occur in NSTI-affected tissues following intravenous administration and imaging of perfusion-based indocyanine green (ICG) fluorescence. This hypothesis is based on the established knowledge that NSTI is associated with local microvascular thrombosis. Adult patients presenting to the Emergency Department of a tertiary care medical center at high risk for NSTI were prospectively enrolled and imaged with a commercial fluorescence imager. Single-frame fluorescence snapshot and first-pass perfusion kinetic parameters-ingress slope (IS), time-to-peak (TTP) intensity, and maximum fluorescence intensity (IMAX)-were quantified using a dynamic contrast-enhanced fluorescence imaging technique. Clinical variables (comorbidities, blood laboratory values), fluorescence parameters, and fluorescence signal-to-background ratios (SBRs) were compared to final infection diagnosis. Fourteen patients were enrolled and imaged (six NSTI, six cellulitis, one diabetes mellitus-associated gangrene, and one osteomyelitis). Clinical variables demonstrated no statistically significant differences between NSTI and non-NSTI patient groups (). All NSTI cases exhibited prominent fluorescence signal voids in affected tissues, including tissue features not visible to the naked eye. All cellulitis cases exhibited a hyperemic response with increased fluorescence and no distinct signal voids. Median lesion-to-background tissue SBRs based on snapshot, IS, TTP, and IMAX parameter maps ranged from 3.2 to 9.1, 2.2 to 33.8, 1.0 to 7.5, and 1.5 to 12.7, respectively, for the NSTI patient group. All fluorescence parameters except TTP demonstrated statistically significant differences between NSTI and cellulitis patient groups (). Real-time, accurate discrimination of NSTIs compared with non-necrotizing infections may be possible with perfusion-based ICG fluorescence imaging.

Prospective derivation and validation of a NECROtizing Soft tissue InfectionS (NECROSIS) score: An EAST multicenter trial.

Although several risk indices have been developed to aid in the diagnosis of NSTIs, these instruments suffer from varying levels of reproducibility and failure to incorporate key clinical variables in model development. The objective of this study was to derive and validate a clinical risk index score - NECROSIS - for identifying NSTIs in emergency general surgery (EGS) patients being evaluated for severe skin and soft tissue infections. We performed a prospective study across 16 sites in the US of adult EGS patients with suspected NSTIs over a 30-month period. Variables analyzed included demographics, admission vitals and labs, physical exam, radiographic, and operative findings. The main outcome measure was the presence of NSTI diagnosed clinically at the time of surgery. Multivariate analysis was performed to identify independent predictors for the presence of NSTI using the Hosmer-Lemeshow test and the Akaike information criteria. Of 362 patients, 297 (82%) were diagnosed with a NSTI. Overall mortality was 12.3%. Multivariate analysis identified 3 independent predictors for NSTI: systolic blood pressure ≤ 120 mmHg, violaceous skin, and WBC ≥15 (x103/uL). Multivariate modelling demonstrated Hosmer-Lemeshow goodness of fit (p = 0.9) with a c-statistic for the prediction curve of 0.75. Test characteristics of the NECROSIS score were similar between the derivation and validation cohorts. NECROSIS is a simple and potentially useful clinical index score for identifying at-risk EGS patients with NSTIs. Future validation studies are warranted. Diagnostic Tests or Criteria, Level III.

Identifying necrotizing soft tissue infection using infectious fluid analysis and clinical parameters based on machine learning algorithms

BackgroundDetermining the presence of necrotizing soft tissue infection (NSTI) poses a significant hurdle. As of late, there has been a notable increase in the application of artificial intelligence (AI) machine learning techniques in identifying diseases, a shift that can be attributed to their exceptional efficiency, unbiased nature, and high precision. MethodsInformation was gathered from a cohort of 13 patients suffering from NSTI, alongside 12 patients with cellulitis. The construction of NSTI diagnostic machine learning models utilized four different algorithms, specifically random forest, k-nearest neighbors (KNN), support vector machine (SVM), and logistic regression. These models were constructed based on 28 distinctive attributes identified through statistical examination. Following this, the diagnostic efficiency of each algorithms was evaluated. A novel random forest model, streamlined for clinical use, was later developed by focusing on 6 attributes that had the most pronounced influence on the accuracy of our initial random forest model. ResultsThe following data was noted regarding the sensitivity and specificity of the four NSTI diagnostic models:logistic regression displayed 78.2 % and 83.7 %, KNN presented 79.1 % and 87.1 %, SVM showed 83.5 % and 86.3 %, and random forest exhibited 89.6 % and 92.9 %, respectively. In comparison, lactate levels in fluid demonstrated 100 % sensitivity and 76.9 % specificity at an optimal cut-off point of 69.6 mg/dL. Among all four machine learning models, random forest outperformed the others and also showed better results than fluid lactate. A newly constructed random forest model, created using 6 of the 13 identified features, displayed promising results in diagnosing NSTI, having a sensitivity and specificity of 90.2 % and 92.2 %, respectively. ConclusionsDeveloping a diagnostic model for NSTI employing the random forest algorithm has resulted in a diagnostic technique that is more efficient, cost-effective, and expedient. This approach could provide healthcare practitioners with the tools to identify and manage NSTI with greater efficacy.

Can The Systemic Immune-Inflammation Index (SII) and Charlson Comorbidity Index (CCI) be used to predict mortality in patients with necrotizing fasciitis?

This study aimed to determine the impact of mortality and morbidity indices on the diagnosis and prognosis of patients suffering from necrotizing fasciitis. A retrospective analysis was performed on 41 patients (26 females, 15 males) with necrotizing fasciitis (NF). The SII (Systemic Immune-Inflammation Index) was computed using the formula SII = (P × N)/L, where P, N, and L measure the counts of peripheral platelets, neutrophils, and lymphocytes, respectively. This study evaluated the clinicopathological characteristics and follow-up information to assess the comparative effectiveness of SII, CCI (Charlson Comorbidity Index), and LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) scores as mortality and morbidity indices for patients with NF. The optimal cut-off for SII was determined to be 455. The SII value in the group with mortality was significantly higher compared to the group without mortality (p < 0.05). The CCI value in the group with mortality was significantly higher than the group without mortality (p < 0.05). The SII and CCI values were found to be effective in distinguishing between patients who suffered mortality and those who did not. SII is a powerful tool for predicting mortality in patients with necrotizing fasciitis (NF). The SII index provides a novel, easily accessible, and inexpensive indicator for monitoring the progress and predicting the survival of patients with NF.

The microbiological profile of necrotising fasciitis at a secondary level hospital in Gauteng.

Necrotising fasciitis (NF) is a fulminant soft tissue infection that requires timely diagnosis, urgent surgical debridement, and appropriate antimicrobial therapy. The choice of empiric antimicrobial therapy depends on the microorganisms cultured and the antimicrobial resistance profile of the institution. Necrotising fasciitis has not been studied in our setting. The aim of the study was to audit the microbiological profile of NF and antimicrobial susceptibility profile. This was a retrospective study in a secondary level hospital from the period of 2014-2020. The patients' demographic data, clinical features, location of infection, comorbidities, laboratory and microbiological profiles were analysed. There were 53 patients during 2014-2020 with median age of 45.5 (38.5-56.0) years. The majority of the patients were males (35 [66.04%]), had no comorbidities (25 [47.17%]), and the lower limb was the most common anatomic site (17 [32.08%]). Type II (monomicrobial) NF was the predominant type (31 [58.49%]). Staphylococcus aureus was the most prevalent Gram-positive bacteria (18 [38%]) and Escherichia coli, the main species isolated in the Gram-negative bacteria (14 [36%]) with susceptibility to cloxacillin (94%) and amoxicillin and/or clavulanic acid (92%), respectively. Staphylococcus aureus and Escherichia coli were the most common bacteria with low rate of antimicrobial resistance. Amoxicillin and/or clavulanic acid and an adjunctive clindamycin are appropriate antimicrobial therapy for empiric treatment for NF in our setting. Amoxicillin and/or clavulanic acid and an adjunctive clindamycin can be used as an empiric treatment for NF.

Role of Procalcitonin for Early Discrimination Between Necrotizing Fasciitis and Cellulitis of the Extremities.

Introduction Necrotizing fasciitis (NF) is a grave and life-threatening infection of the soft tissues. It is defined by the gradual necrosis of the fascia and subcutaneous tissue, which spreads along the fascial planes. Cellulitis, a prevalent skin infection, has led to suggestions that procalcitonin could serve as a diagnostic tool to distinguish it from other inflammatory skin conditions that resemble cellulitis. The study aims to assess the procalcitonin (PCT) levels in individuals with NF and cellulitis and determine its effectiveness in early differentiation between these two conditions. Methods After obtaining clearance from the institutional ethical committee, the study was conducted in the Department of General Surgery, Sri Devaraj Urs Medical College, over six months. Informed consent was obtained from all 30 patients included in this study. The study compared PCT levels in patients diagnosed with NF and cellulitis. Statistical analysis was performed using SPSS version 22 software (IBM Corp., Armonk, NY, USA). Results The mean age of subjects was 53.23 ± 8.78 years. Among patients, 21 (70%) were diagnosed with cellulitis and 9 (30%) were diagnosed with NF. The mean PCT levels were 0.34 ± 0.32 and 4.89 ± 1.98 among the cellulitis and NF groups, respectively. There was a significant difference (p<0.05). PCT had a sensitivity of 100% and a specificity of 100%, in differentiating cellulitis and necrotizing fasciitis. Conclusion PCT levels were notably elevated in cases of NFcompared to cellulitis. Despite the study's limited sample size, it represents the first report highlighting the value of PCT as an early diagnostic tool for identifying necrotizing fasciitis.

Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Sepsis Associated with Acute Necrotizing Soft Tissue Infections: The NASTI-HAT Case Series

Abstract Necrotizing soft tissue infections (NSTIs) are surgical emergencies often presenting with concomitant sepsis. The use of intravenous hydrocortisone, vitamin C (ascorbic acid), and thiamine (HAT) has been proposed as beneficial in treating sepsis. To our knowledge, no study has focused exclusively on its use in NSTIs. This study aimed to evaluate use of HAT among patients with NSTIs and included patients from a single Midwestern regional burn center. Patients diagnosed with sepsis or septic shock secondary to an NSTI were randomized and received either intravenous HAT or placebo. The primary outcome was hospital survival. Secondary outcomes included vasopressor therapy duration, renal replacement therapy need, intensive care unit length of stay, serum procalcitonin and sequential organ failure assessment (SOFA) change in the first 72 h, number of wound-related surgeries, and wound classification at hospital discharge. While our study started as a randomized controlled trial, due to low enrollment it was transitioned to a case series. Of the 10 patients enrolled, half received HAT therapy. No significant difference was found between the treatment and placebo groups. Future larger, multicenter studies may help better elucidate the role of intravenous HAT therapy in patients with NSTIs.