Cervical Necrotizing Fasciitis--The Value of the Laboratory Risk Indicator for Necrotizing Fasciitis Score as an Indicative Parameter

Wide exposure VS. stab surgical incisions in necrotizing fasciitis of the head and neck: a retrospective analysis of 22 cases

PURPOSE

Necrotizing fasciitis of the head and neck is a rare, rapidly progressing bacterial infection with high mortality. Traditional surgical management involves wide exposure incisions, but minimally invasive stab incisions have emerged as a potential alternative. This study aimed to compare outcomes between wide exposure and stab surgical incisions in the management of head and neck necrotizing fasciitis.

MATERIALS AND METHODS

A retrospective analysis was conducted on 22 patients treated for necrotizing fasciitis of the head and neck between January 2006 and January 2023. Patients were divided into two groups based on the surgical approach: wide exposure incisions (N = 15) and stab surgical incisions (N = 7). Data on mortality, hospital stay, hypertrophic scarring, neck contractures, and tracheostomy tube dependence were collected.

RESULTS

The overall mortality rate was 9.1%, with 6.7% in the wide exposure group and 14.3% in the stab surgical incision group (p > 0.05). Hypertrophic scarring occurred in 59.1% of patients, all of whom underwent wide exposure incisions. Neck contractures were observed in 9.1% of cases, also in the wide exposure group. Tracheostomy was performed in 63.6% of patients, with successful decannulation achieved in 91.7%. The median hospital stay was longer in the stab surgical incision group (p < 0.05), partly due to the need for revision surgeries.

CONCLUSION

Wide exposure incisions remain the standard treatment for necrotizing fasciitis of the head and neck due to their effectiveness in managing extensive tissue necrosis. However, stab surgical incisions offer the advantage of reduced morbidity and functional impairment. These benefits are offset by a slightly higher mortality rate and the potential need for additional interventions. Stab incisions may be a viable option in carefully selected patients, particularly those without extensive comorbidities or advanced disease.

Efficacity of hyperbaric oxygen therapy for necrotizing fasciitis in the maxillofacial region: The review of the literature

Necrotizing fasciitis (NF) is a rare, dangerous, potentially fatal infectious disease of soft tissue. The treatment consists of antibiotic therapy, surgical debridement and subsequent reconstruction. Hyperbaric oxygen (HBO) therapy has been applied in NF patients recently, so our aim was to gather the findings and outcomes for HBO therapy. A PubMed and Google Scholar literature search was conducted regarding the effect of HBO therapy in patients with NF following key words: 'necrotizing fasciitis' AND 'maxillofacial region' OR 'head and neck' AND 'hyperbaric oxygen' OR 'HBO'. A total of 3333 studies have been identified, of which only 16 articles met the inclusion criteria of this review. A conclusion was made, that aggressive combinations of antibiotics and surgical debridement followed by incorporation of HBO therapy, as an adjuvant treatment, in patients with NF and in company by immunoglobulin therapy are showing promising results. In addition, multi-centric studies should be in consideration for further research.

Necrotizing fasciitis and fatal septic shock associated with Streptococcus constellatus

Streptococcus constellatus is usually a benign, commensal bacteria but has increased incidence in blood cultures and abscesses. This pathogenic involvement is most prevalent in individuals with underlying medical conditions, such as solid tumors and type 2 diabetes mellitus, as well as in cases of community-acquired infections. We report a 43-year-old male with a right medial thigh ulcer and necrotic scrotal skin. The wound culture from surgical debridement grew Streptococcus constellatus, and histology was consistent with stage III necrotizing fasciitis. Regardless of etiology, the mortality rate of patients with necrotizing fasciitis is greatly decreased with early intervention and thorough surgical debridement.

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

Objective

Describe features unique to head and neck (H&N) necrotizing fasciitis (NF) compared to other anatomic regions and specify a prognostic score associated with death and descending necrotizing mediastinitis (DNM).

Study Design

Retrospective cohort.

Setting

Tertiary care, level 1 trauma center.

Methods

A single-institution database identified 399 confirmed cases of NF between 2006 and 2021, 33 of which involved the H&N. Patients with confirmed H&N NF were sorted into cohorts based on clinical outcomes, with the "poor" outcomes group defined by death and/or DNM.

Results

Thirty-three patients with H&N NF were included. Compared to NF of other regions, patients with H&N NF had a significantly lower mortality rate (6.06% vs 20.8%, p = .041) and significantly lower rates of obesity (27.3% vs 63.7%, p < .001) and hypertension (42.4% vs 60.9%, p = .038). Within the H&N group, there were 2 deaths (6.06%) and 8 cases of DNM (24.2%). Diabetes was associated with poor outcomes (p = .047), as was an abbreviated sequential organ failure assessment score for necrotizing fasciitis (nfSOFA) of 2 or greater (p = .015).

Conclusion

H&N NF is unique among other forms of NF, with a lower mortality rate and lower rates of obesity and hypertension in affected patients. Within the H&N cohort, worse outcomes were associated with diabetes as well as a nfSOFA score of 2 or greater. Timely surgical debridement alongside broad-spectrum antibiotics remains the mainstay of treatment for NF; however, this simple prognostic score may play a role during the early stages of care for patients with H&N NF.

Complications of Severe Odontogenic Infections: A Review

Severe odontogenic infections are routinely treated with little associated morbidity and mortality. Improvements in surgical techniques, antibiotic treatments, and imaging modalities have made associated complications exceedingly rare. A number of complications have been described in the literature including airway obstruction, descending necrotizing mediastinitis, orbital abscess, septic cavernous sinus thrombosis, cerebral abscess, sepsis, necrotizing fasciitis, and Lemierre's syndrome. The purpose of this article is to discuss the pathophysiology of severe odontogenic infections and the risk factors associated with the development of complications. Given the morbidity and mortality of these conditions, it is important to review the clinical features of each and the diagnostic tools that aid in early recognition.

Cervical Necrotizing Fasciitis: An Institutional Experience

Introduction Cervical necrotizing fasciitis is an acute, progressive, and rapidly spreading soft tissue infection affecting the fascial planes of the head and neck region. It has high morbidity and mortality rate. In this study, we have reviewed cervical necrotizing fasciitis cases treated in our department and analyzed the various risk factors, laboratory indices, and treatment modalities that affect the prognosis of this deadly disease. Design and method This is a retrospective review. We have reviewed the medical records and charts of seven patients hospitalized in our institute with the diagnosis of cervical necrotizing fasciitis between 2015 and 2019. Results Of the seven patients, six were male and one was female. The mean age was 49.8 years (range: 38-70 years). Etiology was found to be odontogenic infection in five (71%) cases. The presenting feature in all cases was tender cervical swelling. Intraoperatively, the submandibular triangle was found to be involved in all cases (100%) followed by the carotid triangle in five (71%) cases and the submental triangle in three (42%) cases. The most common comorbidities associated with cervical necrotizing fasciitis were found to be uncontrolled diabetes mellitus and anemia. All patients underwent emergency aggressive surgical debridement and culture-directed broad-spectrum antibiotics (100%). Additional procedures in the form of tracheostomy were required in two (28%) cases and skin grafting in two (28%) cases. One patient in our series developed sepsis with descending mediastinitis. The average hospital stay was 27 days. All the patients survived with no mortality. Conclusion Cervical necrotizing fasciitis should be diagnosed early. Early initiation of broad-spectrum antibiotics and aggressive surgical debridement are the two key management strategies that can improve survival. Strict glycemic control and correction of anemia result in a favorable outcome.

Computed tomography analysis of fascial space involvement demonstrates correlations with laboratory tests, length of hospital stays and admission to the intensive care unit in odontogenic infections

OBJECTIVES

Odontogenic infections are frequent and can spread, leading to complications such as sepsis and the need for admission to an Intensive Care Unit (ICU). The purpose of this study was to perform a computed tomography analysis of the fascial space involvement and correlate with personal data, laboratory tests, length of hospital stays and admission to the ICU in patients with odontogenic infections who required hospitalization.

METHODS

Patients with odontogenic infections admitted between June 2017 and May 2018 were prospectively evaluated. The fascial spaces involved were studied using computed tomography with contrast. The possible correlations of tomographic findings with comorbidities, nutritional status, the causative tooth, laboratory tests, length of hospital stays and admission to the ICU were analyzed.

RESULTS

We identified 66 cases of odontogenic infections which were admitted in the period analyzed. The involvement of primary spaces (86.7%) predominated, followed by secondary ones (8.7%), and cervical (4.6%). The most frequently involved fascial spaces were submandibular (27.1%), buccal (20.8%), sublingual (18.3%), submental (16.7%), and others (17.1%). There were significant differences between laboratory tests (p < 0.001), mean hospital stays (p < 0.001), and admissions to the ICU (p < 0.001) depending on the number of fascial spaces involved. There was no influence of comorbidities, nutritional status, or causative tooth on fascial space involvement.

CONCLUSION

There was a relationship between greater involvement of fascial spaces assessed by computed tomography and higher values of laboratory tests, more extended hospitalization stays and admission to the ICU.

LEVEL OF EVIDENCE

Level 2b.

Cavernous Sinus Involvement and Near Miss Mediastinitis following Mandibular Tooth Infection Treated during the COVID-19 Pandemic: Clinical Diagnosis and Treatment

Odontogenic infections represent a frequent condition that in some cases, if not treated promptly, can spread quickly to the rest of the body and turn into life-threatening infections. In this work, the case is reported of a 59-year-old woman, diabetic and overweight, who presented to the Odontostomatology and Otolaryngology Section of the Policlinic of Bari with mandibular tooth infection that had developed into a deep neck space infection leading to the involvement of cavernous sinuses and near mediastinum. The diagnosis, the surgical drainage of the phlegmon and removal of infection foci, appropriate control of the airways, and a correct antibiotic therapy made it possible to avoid a potentially fatal condition. Prompt management and early diagnosis of deep space neck infections, such as phlegmon and/or necrotizing fasciitis, with the auxilium of CT scans and tools such as LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis), NLR (Neutrophil-to-Lymphocyte Ratio), and LRINECxNLR scores (Laboratory Risk Indicator for Necrotizing Fasciitis and Neutrophil to Lymphocyte Ratio), are advised to evade delays and complications that could potentially worsen the patient’s outcome.

Application of the laboratory risk indicator for necrotizing fasciitis score to the head and neck: a systematic review and meta-analysis

BACKGROUND

Recent studies have attempted to verify the predictive capability of the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) for cervical necrotizing fasciitis (CNF).

METHODS

The two authors independently reviewed six databases (PubMed, Cochrane, Embase, Web of Science, SCOPUS and Google Scholar databases were searched). Seven cohort studies were included in the analysis. Sensitivity and specificity were determined by extracting items from binary classification from each paper. The diagnostic accuracy of the included studies was evaluated using QUADAS ver. 2.

RESULTS

The diagnostic odds ratio (OR) of LRINEC for CNF with the cutoff value of 6 was 13.9952 (95% CI, 3.8537; 50.8255, I²  = 76.7%). The area under the SROC curve was 0.842, suggesting acceptable diagnostic accuracy. The correlation between sensitivity and false positive rate was 0.055, indicating that it was not heterogeneous. The sensitivity, specificity, and negative predictive values were 0.7503 ([0.4637; 0.9126], I²  = 79.1%), 0.8455 ([0.7084; 0.9250], I²  = 96.0%) and 0.9829 ([0.9089; 0.9970], I²  = 93.7%), respectively. In the comparison of subgroups according to a LRINEC score (6-8, and), the cutoff value of 6 showed moderate sensitivity (75%) and high specificity (85%) and greater diagnostic power than other cutoff values.

CONCLUSIONS

LRINEC is a useful adjunctive tool for predicting CNF in patients with a soft tissue infection. In addition, a more accurate diagnosis is possible by using the LRINEC score with a cutoff value of 6.

The characteristics of oro-cervical necrotizing fasciitis-Comparison with severe cellulitis of oro-cervical region and necrotizing fasciitis of other body regions

Background

Necrotizing fasciitis (NF) is an acute and life-threatening soft-tissue infection however rarely seen in oro-cervical region. Therefore, the details of oro-cervical NF (OCNF) are not well known. The purpose of this study was to investigate the characteristics of OCNF by comparing it with severe cellulitis of oro-cervical region (OCSC) or NF of other body regions (e.g., limb, perineum, and trunk) (BNF), respectively.

Materials and methods

At first, various risk factors for OCNF in oro-cervical severe infection (OCSI; composed of OCNF and OCSC), including neutrophil-to-lymphocyte ratio (NLR) and Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, were investigated by univariate and multivariate analyses. Next, the differences between OCNF and BNF, including inflammatory markers and mortality, were investigated.

Results

In the present study, 14 out of 231 OCSI patients had OCNF. Multivariate analyses of OCSI patients showed that NLR ≥15.3 and LRINEC score ≥6 points were significantly related to OCNF. During the same period, 17 patients had BNF. The OCNF group had significantly higher inflammatory markers than the BNF group when diagnosis, but significantly lower clinical stages at the time and mortality as outcomes.

Conclusion

We found that compared to BNF, OCNF can be detected at lower clinical stage by using indexes, such as NLR and LRINEC score, besides clinical findings, which may help contributing to patient’s relief.

Early diagnosis of craniofacial necrotising fasciitis: Analysis of clinical risk factors

Necrotising fasciitis (NF) is a rapidly progressing fatal disease. Craniofacial necrotising fasciitis (CNF) is limited to the region above the mandibular margin, and early diagnosis is particularly difficult in the absence of related studies. Ten-year data of patients with craniofacial infection were collected from four separate hospitals. Based on the diagnostic criteria, patients were classified into abscess and CNF. The risk factors for early diagnosis were analysed by comparing the two groups. Simple abscess was found in 176 patients, and CNF was detected in 25 patients. The risk factors associated with CNF include old age, presence of odontogenic infection, elevated white blood cell count (WBC), increased C-reactive protein (CRP), high levels of creatinine (Cr) and glucose (Glu) and low levels of haemoglobin (Hb) and albumin (Alb). In addition, fever above 38°C and sinusitis at the time of admission and progressive sepsis after admission were also risk factors. Among the statistically significant risk factors, low Alb level showed the greatest association with CNF progression. Appropriate management of CNF via early diagnosis and extensive surgical intervention based on identified risk factors can reduce the mortality rate, complications and unnecessary medical expenses. Clinical question/level of evidence: Diagnostic, III.

New laboratory predictive tools in deep neck space infections

Introduction

Deep neck space infections (DNSIs) are a group of infective suppurative diseases involving deep neck spaces and cervical fascia. Necrotising and septic evolutions are rare, but severe complications can dramatically affect the prognosis and should be promptly managed. Clinical examination often has low sensitivity, although instrumental diagnosis may delay te treatment. We investigated two laboratory tools, LRINEC (Laboratory Risk Indicator for the Necrotizing fasciitis) and NLR (neutrophil to lymphocyte ratio), in the expectation to find a rapidly available predictive indicator that may help in distinguishing necrotising complications and/or systemic septic involvement.

Methods

A retrospective observational cohort study was performed on 118 patients who had underwent surgical treatment for DNSIs at our Surgical Unit. LRINEC, NLR and the product LRINEC x NLR were calculated.

Results

Statistical analysis showed that these scores may have utility in rapidly predicting the risk of necrotising fasciitis and systemic involvement at an early diagnostic stage.

Conclusions

Further studies with a larger cohort may be necessary in order to increase the sensitivity and specificity.

Comparison of death and survival cervical necrotizing fasciits cases

BACKGROUND

Cervical Necrotizing Fasciitis (CNF) is associated with a high mortality rate. The occurrence of mediastinitis with CNF may increase mortality up to 70%.

AIMS

We aimed to identify the differences between surviving and deceased cases.

METHODS

The present study was conducted retrospectively by scanning the files of 16 patients between the ages of 19-71 who were diagnosed with CNF. Patients were divided into two groups as the surviving patient group (SPG) and the deceased patient group (DPG). Both groups were compared in terms of age, gender, Laboratory Risk Indicator for Necrotizing Fasciitis (LRİNEC) score, duration of symptom onset to hospital admission, use of antibiotherapy prior to admission, duration of hospitalization, presence of diabetes mellitus (DM), presence of dental etiology, mediastinitis, and respiratory distress at the time of admission.

RESULTS

Diabetes mellitus was the most common comorbid disease. 5 out of 7 deceased patients had DM. Dental events were the most common etiology. Rapid surgical debridement and airway management was the first treatment method. The most frequently isolated species in the culture was Streptococcus. 6 of 11 patients who developed mediastinitis deceased at the end of the process.

CONCLUSION

Dental pathologies mostly play a role in the etiology. It is obvious that dentists, another occupational group that frequently encounters this patient group, have a critical role in this process. Therefore, precise attention should be given to dental problems in patients with diabetes, and hospitalization and initiation of broad-spectrum antibiotherapy should be considered in case of suspicion of deep neck infection.

Early detecting cervical necrotizing fasciitis from deep neck infections: a study of 550 patients

PURPOSE

The aim of this retrospective review study is to evaluate Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score as an indicative parameter in early detecting cervical necrotizing fasciitis (CNF) from deep neck infections (DNI).

METHODS

We reviewed 12 cases of CNF and 538 cases of non-necrotizing deep neck infection hospitalized in our hospital over the last decade. Cervical necrotizing fasciitis was histologically confirmed.

RESULTS

Using an LRINEC score of 6 as a cutoff sensitivity was calculated at 100% (95% CI 99.9-100) and specificity 72.5% (95% CI 72.4-72.6). Negative predicted value (NPV) was 100% and positive predicted value (PPV) was 7.5%. C-reactive protein (CRP), white blood count (WBC), and glucose (Glu) levels have a higher correlation. Haemoglobin (Hb), sodium (Na), and creatinine (Cr) do not seem to have a big impact in our study.

CONCLUSION

LRINEC score proves to be a useful "rule-out" tool that works on the safe side with high sensitivity and poor specificity. WBC, CRP, and Glu seem to be the most significant variables of the LRINEC score. Hb, Na, and Cr make the score safer. Decision for surgery must be based on medical history, clinical symptoms and signs, imaging findings, and laboratory tests and not according to the LRINEC score itself.

Management and postoperative use of double-cannula irrigation-drainage tube in cervical necrotizing fasciitis: a Chinese single-institution experience of 46 patients

PURPOSE

This study aimed to analyze a Chinese institution's experience with managing cervical necrotizing fasciitis (CNF) and observe the effects of a new therapeutic approach for postoperative drainage system.

METHODS

A retrospective study was established including a total of 46 CNF patients who underwent surgical debridement between April 2006 and April 2018. Analyses of demographic data, etiology, comorbidity, microbiology, complications, treatment methods, duration of treatment, and treatment outcomes were obtained.

RESULTS

There were 16 kinds of microbes cultured in 29 patients. Diabetic patients were more commonly infected by microbes (P < 0.05). There was a significant reduction in the number of operative time (P < 0.05) and length of hospitalization (P < 0.01) with postoperative therapy of double-cannula irrigation-drainage (DCID) system.

CONCLUSION

CNF management includes controlling for comorbidities especially glycemic control and reasonable utilization of antibiotics and aggressive postoperative therapy. DCID system can effectively reduce operative frequency and duration of hospitalization.

Necrotizing Soft Tissue Infection: Diagnostic Accuracy of Physical Examination, Imaging, and LRINEC Score: A Systematic Review and Meta-Analysis

OBJECTIVE

We sought to summarize accuracy of physical examination, imaging, and Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score in diagnosis of necrotizing soft tissue infection (NSTI) in adults with a soft tissue infection clinically concerning for NSTI.

SUMMARY OF BACKGROUND DATA

NSTI is a life-threatening diagnosis. Delay to diagnosis and surgical management is associated with increased mortality.

METHODS

We searched 6 databases from inception through November 2017. We included English-language studies reporting diagnostic accuracy of testing or LRINEC Score. Outcome was NSTI confirmed by surgery or histopathology. Two reviewers screened all citations and extracted data independently. Summary measures were obtained from the Hierarchical Summary Receiver Operating Characteristic model.

RESULTS

From 2,290 citations, we included 23 studies (n = 5982). Of physical examination signs, pooled sensitivity and specificity for fever was 46.0% and 77.0% respectively, for hemorrhagic bullae 25.2% and 95.8%, and for hypotension 21.0% and 97.7%. Computed tomography (CT) had sensitivity of 88.5% and specificity of 93.3%, while plain radiography had sensitivity of 48.9% and specificity of 94.0%. Finally, LRINEC ≥ 6 had sensitivity of 68.2% and specificity of 84.8%, while LRINEC ≥ 8 had sensitivity of 40.8% and specificity of 94.9%.

CONCLUSIONS

Absence of any 1 physical examination feature (eg, fever or hypotension) is not sufficient to rule-out NSTI. CT is superior to plain radiography. LRINEC had poor sensitivity, and should not be used to rule-out NSTI. Given the poor sensitivity of these tests, a high clinical suspicion warrants early surgical consultation for definitive diagnosis and management.

A Systematic Review of the Laboratory Risk Indicator for Necrotizing Fasciitis Score and Its Utility in Orthopedics for Diagnosing Necrotizing Fasciitis in Adults

Given its association with trauma and surgery, necrotizing fasciitis is a disease orthopedists are likely to encounter. The laboratory risk indicator for necrotizing fasciitis score is an adjunct diagnostic test designed to help diagnose early necrotizing fasciitis infections, but studies evaluating the scoring system have reported conflicting results. The purpose of this systematic review was to provide clarity on the laboratory risk indicator for necrotizing fasciitis score's capabilities and when it is best used. [Orthopedics. 2019; 42(3):e288-e294.].

Initial Nutritional Status and Clinical Outcomes in Patients with Deep Neck Infection

OBJECTIVES

The current study aims to determine the correlation between nutritional status upon presentation and disease severity, as well as treatment and survival outcomes.

METHODS

Patients who were diagnosed with deep neck infection, underwent at least one surgical drainage/debridement, and had more than 1 week of hospitalization at a tertiary medical center from 2007 to 2015 were retrospectively included. Thereafter, initial serum albumin, C-reactive protein (CRP), and body mass index (BMI) were reviewed.

RESULTS

A total of 135 patients were included in the final analysis. Accordingly, the proportion of patients with simultaneous mediastinitis (21.0%), necrotizing fasciitis (12.9%), disease extent >1 cervical level (72.6%), mean CRP (22.4 mg/dL), mean length of hospitalization (25.0 days), and mean 1-week follow-up CRP (7.2 mg/dL) was significantly higher in the hypoalbuminemia group (initial serum albumin <3.0 g/dL) than in the normoalbuminemia group (all P<0.05). No significant correlations had been observed according to BMI status. After adjusting for age and Charlson comorbidity index, odds ratios for the following outcomes were calculated in patients initially presenting with hypoalbuminemia: simultaneous mediastinitis (3.07), necrotizing fasciitis (7.89), disease extent >1 cervical level (2.12), initial serum CRP over 20 mg/dL (3.79), hospitalization of more than 14 days (4.10), 1-week follow-up CRP over 5 mg/dL (3.78), and increased duration for an over 50% decrease in initial CRP (2.70) (all P<0.05). Although intravascular albumin replenishment decreased the proportion of patients with hypoalbuminemia after 2 weeks (P<0.05), it did not significantly predict better treatment outcomes.

CONCLUSION

Among the markers reflecting an individual's nutritional state, an initial serum albumin of less than 3.0 g/dL was an independent serologic marker predicting increased disease severity and complications in patients with deep neck infection.

Early Enteral Nutrition is Associated with Reduced Morbidity in Critically Ill Soft Tissue Patients

Soft tissue diseases including necrotizing soft tissue infections are associated with high mortality and morbidity with hospital-acquired infection rates up to 76 per cent. Critically ill patients with soft tissue infections have increased metabolic requirements; however, the effect of early nutrition on inhospital morbidity including nosocomial infection rates remains unclear. We hypothesized that enteral nutrition within 48 hours of intensive care unit admission would be associated with fewer hospital-acquired infections. We conducted a retrospective review of patients with soft tissue infection requiring intensive care unit admission for >72 hours from January 2013 through December 2014 to a high-volume, dedicated soft tissue service. Variables were compared using chisquared, Student's t test, linear regression, and binary logistic regression analysis. Eighty-five patients met inclusion criteria; 80 per cent started enteral nutrition within 48 hours. Twenty-six per cent had a hospital-acquired infection postadmission requiring treatment. Patients started on enteral nutrition within 48 hours had fewer ventilator days (mean 5 vs 12) and shorter hospital length of stay (mean 18 vs 40 days) when adjusted for age, gender, and confounding variables present on admission. Patients receiving early nutrition also had fewer hospital-acquired infections (18 vs 59%) when adjusted for confounding factors (aOR 0.15, P = 0.045). No significant difference in mortality (13.2% early vs 5.9% late, P = 0.4) or for inhospital morbidity when evaluating percentage of goal calories or protein received or time to goal tube feed rate was found. Early enteral feeding is associated with reduced inhospital morbidity in critically ill soft tissue patients, including fewer hospital-acquired infections and ventilator days, and shorter total length of stay.

Necrotizing fasciitis: case series and review of the literature on clinical and medico-legal diagnostic challenges

Necrotizing fasciitis (NF) is a life-threatening infection of soft tissues spreading along the fasciae to the surrounding musculature, subcutaneous fat and overlying skin areas that can rapidly lead to septic shock and death. Due to the pandemic increase of medical malpractice lawsuits, above all in Western countries, the forensic pathologist is frequently asked to investigate post-mortem cases of NF in order to determine the cause of death and to identify any related negligence and/or medical error. Herein, we review the medical literature dealing with cases of NF in a post-mortem setting, present a case series of seven NF fatalities and discuss the main ante-mortem and post-mortem diagnostic challenges of both clinical and forensic interests. In particular, we address the following issues: (1) origin of soft tissue infections, (2) micro-organisms involved, (3) time of progression of the infection to NF, (4) clinical and histological staging of NF and (5) pros and cons of clinical and laboratory scores, specific forensic issues related to the reconstruction of the ideal medical conduct and the evaluation of the causal value/link of any eventual medical error.

Association between cytokine response, the LRINEC score and outcome in patients with necrotising soft tissue infection: a multicentre, prospective study

Early assessment of necrotising soft tissue infection (NSTI) is challenging. Analysis of inflammatory markers could provide important information about disease severity and guide decision making. For this purpose, we investigated the association between cytokine levels and the Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC)-score, disease severity and mortality in NSTI patients. In 159 patients, plasma was analysed for IL-1β, IL-6, IL-10 and TNF-α upon admission. The severity of NSTI was assessed by SAPS, SOFA score, septic shock, microbial aetiology, renal replacement therapy and amputation. We found no significant difference in cytokine levels according to a LRINEC- score above or below 6 (IL-1β: 3.0 vs. 1.3; IL-6: 607 vs. 289; IL-10: 38.4 vs. 38.8; TNF-α: 15.1 vs. 7.8 pg/mL, P > 0.05). Patients with β-haemolytic streptococcal infection had higher level of particularly IL-6. There was no difference in mortality between patients with a LRINEC-score above or below 6. In the adjusted analysis assessing 30-day mortality, the association was strongest for IL-1β (OR 3.86 [95% CI, 1.43-10.40], P = 0.008) and IL-10 (4.80 [1.67-13.78], P = 0.004). In conclusion, we found no significant association between the LRINEC-score and cytokine levels on admission. IL-6 was consistently associated with disease severity, whereas IL-1β had the strongest association with 30-day mortality.