Characteristics and differences in necrotizing fasciitis and gas forming myonecrosis: a series of 36 patients

Time Is Fascia: Laboratory and Anamnestic Risk Indicators for Necrotizing Fasciitis

Background: Necrotizing fasciitis is a potentially fatal soft tissue infection in which the timing of surgical intervention significantly affects clinical outcome. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, the Site other than the lower limb, Immunosuppression, Age <60 years, Renal impairment (creatinine >141), and Inflammatory markers (CRP ≥150, WCC >25) (SIARI) score, and procalcitonin levels are intended to aid in the decision-making process to differentiate between necrotizing fasciitis and soft tissue infections. Methods: A retrospective analysis of cases of necrotizing fasciitis and soft tissue infections treated at Klinikum Nürnberg was performed. The two scores as well as procalcitonin levels were tested for their diagnostic value and a new score, the Laboratory and Anamnestic Risk Indicator for Necrotizing Fasciitis (LARINF), was created based on the results. Results: Procalcitonin, LRINEC score, and SIARI score showed insufficient discriminatory ability in our study. The newly created LARINF score combined laboratory parameters of the LRINEC score (hemoglobin and C-reactive protein) with procalcitonin and three comorbidities, resulting in a sensitivity of 84% and a specificity of 75% and the highest area under the receiver operating characteristic (ROC) curve of 0.83. Conclusions: The LARINF score is a novel decision-supporting tool. The decision, in which cases surgical exploration should be initiated, remains a clinical one. However, the score seems to provide an improved basis for identifying a rare clinical picture.

Laboratory Risk Indicator for Necrotizing Fasciitis Score and Patient Outcomes

Context:

The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score helps to diagnose necrotizing soft-tissue infection (NSTI). The LRINEC score has been reported to be associated with poor prognosis, although few studies have evaluated this association.

Aims:

We aimed to describe the characteristics of NSTI and assess whether the LRINEC score was associated with mortality and amputation.

Settings and Design:

We conducted a retrospective observational study from January 2007 to May 2018, in a Japanese tertiary care hospital.

Subjects and Methods:

Patients with NSTI were identified through our hospital database using the discharge diagnosis. We extracted data on patient characteristics, laboratory examinations, microbiological information, treatment, and in-hospital mortality.

Statistical Analysis Used:

We estimated the odds ratios (ORs) and associated 95% confidence intervals (CIs) for in-hospital mortality using logistic regression models.

Results:

We identified 58 patients. The median LRINEC score was 8 (interquartile range [IQR]: 6–9). Forty-four patients (75.9%) scored 6 or more. The eight patients with amputations had a median score of 6 (IQR: 4.5–7.5) versus 8 (IQR: 7–9) for patients who underwent debridement (P = 0.091). Survivors and nonsurvivors had median scores of 8 (IQR: 6–9) and 6 (IQR: 5–8), respectively (P = 0.148). The OR for mortality in patients with liver cirrhosis was 10.5 (95% CI: 1.00–110.36; P = 0.050).

Conclusions:

There was no association between the LRINEC score and patients' outcomes: mortality and amputation. Further studies are warranted to evaluate the utility of the LRINEC score and factors associated with poor prognosis in patients with NSTI.

Clostridial Gas Gangrene - A Rare but Deadly Infection: Case series and Comparison to Other Necrotizing Soft Tissue Infections

Objective

Clostridial gas gangrene (GG) or clostridial myonecrosis is a very rare but life‐threatening necrotizing soft tissue infection (NSTI) caused by anaerobic, spore‐forming, and gas‐producing clostridium subspecies. It is the most rapidly spreading and lethal infection in humans, also affecting muscle tissue. The high mortality, of up to 100%, in clostridial GG is mediated by potent bacterial exotoxins. Necrotizing fasciitis (NF) is an important differential diagnosis, most often caused by group A streptococci, primarily not affecting musculature but the subcutaneous tissue and fascia. In the early stages of the infection, it is difficult to distinguish between GG and NF. Therefore, we compare both infection types, identify relevant differences in initial clinical presentation and later course, and present the results of our patients in a retrospective review.

Methods

Patients diagnosed with GG from 2008 to 2018 in our level one trauma center were identified. Their charts were reviewed retrospectively and data analyzed in terms of demographic information, microbiological and histological results, therapeutic course, outcome, and mortality rates. The laboratory risk indicator for NF (LRINEC) score was applied on the first blood work acquired. Results were compared to those of a second group diagnosed with NF.

Results

Five patients with GG and nine patients with NF were included in the present study. Patients with GG had a mortality rate of 80% compared to 0% in patients with NF. In eight patients with NF, affected limbs could be salvaged; one NF underwent amputation. LRINEC did not show significant differences between the groups; however, C‐reactive protein was significantly increased (P = 0.009) and hemoglobin (Hb) was significantly decreased (P = 0.02) in patients with GG. Interleukin‐6 and procalcitonin levels did not show significant difference. Patients with GG were older (70.2 vs 50 years). Of the isolated bacteria, 86% were sensitive to the initial calculated antibiotic treatment with ampicillin‐sulbactam or imipenem plus metronidazole plus clindamycin.

Conclusion

Both GG and NF need full‐scale surgical, antibiotic, and intensive care treatment, especially within the first days. Among patients with NSTI, those with clostridial GG have a significantly increased mortality risk due to early septic shock caused by clostridial toxins. In the initial stages, clinical differences are hardly detectable. Immediate surgical debridement is the key to successful therapy for NSTI and needs to be performed as early as possible. However, patients should be treated in a center with an experienced interdisciplinary intensive care team based on a predetermined treatment plan.

The EGS grading scale for skin and soft-tissue infections is predictive of poor outcomes: a multicenter validation study

INTRODUCTION

Over the last 5 years, the American Association for the Surgery of Trauma has developed grading scales for emergency general surgery (EGS) diseases. In a previous validation study using diverticulitis, the grading scales were predictive of complications and length of stay. As EGS encompasses diverse diseases, the purpose of this study was to validate the grading scale concept against a different disease process with a higher associated mortality. We hypothesized that the grading scale would be predictive of complications, length of stay, and mortality in skin and soft-tissue infections (STIs).

METHODS

This multi-institutional trial encompassed 12 centers. Data collected included demographic variables, disease characteristics, and outcomes such as mortality, overall complications, and hospital and ICU length of stay. The EGS scale for STI was used to grade each infection and two surgeons graded each case to evaluate inter-rater reliability.

RESULTS

1170 patients were included in this study. Inter-rater reliability was moderate (kappa coefficient 0.472-0.642, with 64-76% agreement). Higher grades (IV and V) corresponded to significantly higher Laboratory Risk Indicator for Necrotizing Fasciitis scores when compared with lower EGS grades. Patients with grade IV and V STI had significantly increased odds of all complications, as well as ICU and overall length of stay. These associations remained significant in logistic regression controlling for age, gender, comorbidities, mental status, and hospital-level volume. Grade V disease was significantly associated with mortality as well.

CONCLUSION

This validation effort demonstrates that grade IV and V STI are significantly predictive of complications, hospital length of stay, and mortality. Though predictive ability does not improve linearly with STI grade, this is consistent with the clinical disease process in which lower grades represent cellulitis and abscess and higher grades are invasive infections. This second validation study confirms the EGS grading scale as predictive, and easily used, in disparate disease processes.

LEVEL OF EVIDENCE

Prognostic/Epidemiologic retrospective multicenter trial, level III.

A case of streptococcus necrotizing fasciitis secondary to acute tonsillitis and review of literatures

Necrotizing fasciitis, officially named by Wilson in 1952, was a rare potentially life-threatening necrotizing soft tissue infections disease. The main lesions showed subcutaneous fat and fascia layer in progressive necrosis, generally not involving muscles. It was characterized by acute onset, rapid progress, and dangerous condition, often accompanied by systemic toxin shock, which was a relatively rare clinical acute critical disease with high mortality rate. Necrotizing fasciitis is a rare but clinical critical disease. The overall incidence of necrotizing fasciitis is approximately 0.04 cases per 1000 persons in the United States, the 30-day mortality is 27%, and necrotizing fasciitis–related mortality in Asian region is about 28%. Streptococcus pyogenes (group A streptococcus) are human-specific pathogens that can cause upper respiratory tract infection such as tonsillitis, associated with post-infection diseases such as rheumatic fever, and also can induce severe invasive diseases such as necrotizing fasciitis and streptococcus toxin shock syndrome. This article reports a case of streptococcus necrotizing fasciitis secondary to suppurative tonsillitis, which was seldom reported before and our successful management with delayed debridement. This study was anonymous and was approved by the local Research Ethics Committee. Informed consent was obtained from the patient.

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.].

Laboratory risk indicator for necrotising fasciitis (LRINEC) score for the assessment of early necrotising fasciitis: a systematic review of the literature

Introduction Early operative debridement of necrotising fasciitis is a major outcome determinant. Identification and diagnosis of such patients can be clinically difficult. The Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score first published in 2004 is based on routinely performed parameters and offers a method for identifying early cases. No literature review has yet been performed on the application of such a score. Methods A systematic review of English-language literature was performed from 2004 to 2014 to identify articles reporting use of LRINEC score and the incidence of necrotising fasciitis. We performed a critical review of PubMed, Medline and Embase in line with the PRISMA statement. A meta-analysis was performed with a random effects model and 95% confidence interval. Suitable correlation coefficient and receiver operating characteristic (ROC) curves were also calculated. Results After application of inclusion criteria, 16 studies with 846 patients were included. The mean LRINEC score in patients with necrotising fasciitis was 6.06. Two papers reported LRINEC score in patients without necrotising fasciitis with a mean 2.45. All six studies with a reported coefficient of variance were < 1; Pearson correlation coefficient was r = 0.637 (P = 0.011). An ROC curve showed an area under the curve of 0.927. Conclusions The LRINEC score is a useful clinical determinant in the diagnosis and surgical treatment of patients with necrotising fasciitis, with a statistically positive correlation between LRINEC score and a true diagnosis of necrotising fasciitis.

Review of 58 patients with necrotizing fasciitis in the Netherlands

Background

Necrotizing fasciitis is a rare, life threatening soft tissue infection, primarily involving the fascia and subcutaneous tissue. In a large cohort of patients presenting with Necrotizing fasciitis in the Netherlands we analysed all available data to determine the causative pathogens and describe clinical management and outcome.

Methods

We conducted a retrospective, multicentre cohort study of patients with a necrotizing fasciitis between January 2003 and December 2013 in an university medical hospital and three teaching hospitals in the Netherlands. We only included patients who stayed at the Intensive Care Unit for at least one day.

Results

Fifty-eight patients were included. The mortality rate among those patients was 29.3 %. The central part of the body was affected in 28 patients (48.3 %) and in 21 patients (36.2 %) one of the extremities. Most common comorbidity was cardio vascular diseases in 39.7 %. Thirty-nine patients (67.2 %) were operated within 24 h after presentation. We found a type 1 necrotizing fasciitis in 35 patients (60.3 %) and a type 2 in 23 patients (39.7 %).

Conclusions

Our study, which is the largest study in Europe, reaffirmed that Necrotizing fasciitis is a life threatening disease with a high mortality. Early diagnosis and adequate treatment are necessary to improve the clinical outcome. Clinical awareness off necrotizing fasciitis remains pivotal.

Laboratory Risk Indicators for Necrotizing Fasciitis and Associations with Mortality

OBJECTIVES

Necrotizing fasciitis (NF) is rare but life threatening soft tissue infection characterized by a necrotizing process of the subcutaneous tissues and fascial planes. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score has been verified as a useful diagnostic tool for detecting necrotizing fasciitis. A certain LRINEC score might also be associated with mortality. The aims of this study are to determine risk factors affecting the prognosis and to evaluate the prognostic value of the LRINEC score in NF.

METHODS

Twenty-five patients with necrotizing fasciitis treated in Samsun Education and Research Hospital between January 2008 and April 2013 were enrolled in the study. Surviving and non-surviving patient groups were compared regarding demographic data, co-morbidity, predisposing factors, causative agents, number of debridements and LRINEC score.

RESULTS

Mean age was 55.6±16.79 years (min: 17-max: 84), and the female/male ratio was 16/9. Mortality was observed in 6 (24%) patients. The most frequent comorbid diseases were diabetes mellitus (52) and peripheral circulatory disorders (24%), and the most frequent etiologies were cutaneous (32%) and perianal abscess (20%). Pseudomonas aeruginosa infection was higher in the non-surviving group (p=0.006). The mean number of debridements and LRINEC score were higher in the non-surviving group than in the surviving group (p=0.003 and p=0.003, respectively).

CONCLUSIONS

Pseudomans aeruginosa infection and multiple debridements are related with mortality. The LRINEC score might help predict mortality in NF.

Fulminant Necrotizing Fasciitis of the Thigh, Following an Infection of the Sacro-iliac Joint in an Immunosuppressed, Young Woman

Necrotizing soft tissue infection of an extremity is a rare but life-threatening disease. The disease is an infection that involves the soft tissue layer and is characterized by rapidly spreading inflammation (especially of the fascial planes and the surrounding tissues) with a high mortality. Early diagnosis is essential for the outcome of the patients. Radical surgical debridement is the treatment of choice. The predisposing factors are immunosuppression, diabetes mellitus and drug abuse. This report presents a case of necrotizing fasciitis in the thigh, following an abscess of the sacro-iliac joint, as a rare complication in a young, immunosuppressed woman. The patient's history revealed intravenous drug abuse and hepatitis C. After immediate diagnosis by magnetic resonance imaging, radical surgical debridement was required and performed. Prior to soft tissue coverage with a split skin graft, five additional sequential debridements were necessary. During her hospital stay, the patient experienced further cerebral and pulmonary septic embolisms and an infection of the elbow. Six months after admission, the patient was discharged in good condition to a rehabilitation center. Necrotizing fasciitis is a life-threatening complication following an abscess of the sacro-iliac joint. Physicians must be vigilant to inflammatory signs and pain in immunosuppressed patients. An abscess of the sacro-iliac joint is rare, but complications of an untreated abscess can be fatal in these patients.

The Prediction Predicament: Rethinking Necrotizing Soft Tissue Infections Mortality

BACKGROUND

Our study sought to identify independent risk factors predisposing patients with necrotizing soft tissue infections (NSTIs) to mortality from among laboratory values, demographic data, and microbiologic findings in a small population. To this end, a retrospective review was conducted of the medical records of all patients with NSTI who had been treated at our institution from 2003 to 2012 (n=134).

METHODS

Baseline demographics and comorbidities, clinical and laboratory values, hospital course, and the microbiologic characteristics of surgical incision cultures were recorded. Each variable was tested for association with survival status and all associated variables with p<0.15 were included in a logistic regression model to seek factors associated independently with mortality.

RESULTS

Surprisingly, no demographic or pre-existing condition proved to be a predictor of mortality. Two laboratory values had an inverse correlation to mortality: High C-reactive protein (CRP) and highest recorded CRP. Of surgical incisions that grew bacteria in culture, 33.6% were polymicrobial. Mortality rates were highest with Enterococcus-containing polymicrobial infections (50%), followed by those containing Pseudomonas (40%), and Streptococcus spp. (27%). Understanding why so many studies across the literature, now including our own, find such disparate results for correlation of NSTI mortality with patient data may lie in the fundamentally dynamic nature of the organisms involved.

CONCLUSIONS

This study suggests that no single factor present on admission is a robust predictor of outcome; it is likely that survival in NSTI is predicated upon a complex interaction of multiple host and microbial factors that do not lend themselves to reduction into a simple formula. It is also abundantly clear that the well-established principles of NSTI surgery should continue to be followed in all cases, with an emphasis on early debridement, irrespective of apparent severity of initial presentation.

Clinical predictors for severe sepsis in patients with necrotizing fasciitis: an observational cohort study in northern Thailand

Background

Necrotizing fasciitis (NF) is a life-threatening infection of skin and fascia. Its progress is extremely fast, with extensive necrosis. Delay in treatment, with subsequent huge soft tissue loss and associated severe sepsis, remains a major cause of death in the management of NF.

Objective

The aim of this study was to explore clinical characteristics that may be used to predict severe sepsis in patients with NF, in the context of routine clinical practice in northern Thailand.

Methods

A retrospective observational cohort study was conducted. The patient cohort in this study consisted of all patients who were diagnosed with NF by surgical or pathological confirmation. The follow-up period started with the admission date and ended with the discharge date. The clinical variables were collected from patients registered at three provincial hospitals in northern Thailand from 2009 to 2012. The clinical predictors for severe sepsis were analyzed using multivariable risk regression.

Results

A total of 1,452 patients were diagnosed with NF, either with severe sepsis (n=237 [16.3%]) or without severe sepsis (n=1,215 [83.7%]). From the multivariable analysis, female sex (relative risk [RR] =1.51; 95% confidence interval [CI] =1.04–2.20), diabetes mellitus (RR =1.40; 95% CI =1.25–1.58), chronic heart disease (RR =1.31; 95% CI =1.15–1.49), hemorrhagic bleb (RR =1.47; 95% CI =1.32–1.63), skin necrosis (RR =1.45; 95% CI =1.34–1.57), and serum protein <6 g/dL (RR =2.67; 95% CI =1.60–4.47) were all predictive factors for severe sepsis.

Conclusion

The clinical predictors for severe sepsis in patients with suspicion of NF included female sex, diabetes mellitus, chronic heart disease, hemorrhagic bleb, skin necrosis, and serum protein <6 d/dL. The risk ratio was much higher in patients with total protein less than 6 g/dL, which is associated with malnutrition. Therefore, provision of sufficient nutritional support and close monitoring for these clinical predictors may be beneficial to reduce morbidity and mortality.

Necrotizing soft tissue infections after injection therapy: Higher mortality and worse outcome compared to other entry mechanisms

OBJECTIVES

Necrotizing Soft Tissue Infections represent a rare entity of infection associated with a high mortality. The aim of this retrospective study was to analyze patients with an iatrogenic etiology of injection or infiltration to compare the outcome with other etiologies.

METHODS

The study group consisted of 21 patients treated with a Necrotizing Fasciitis caused by injection or infiltration. Risk factors and outcome were compared to 134 patients with a Necrotizing Fasciitis caused by other entry mechanisms.

RESULTS

Overall mortality in our study group was 14 of 21 (67%) with an amputation rate of 11 of 15 (73%) if an extremity was involved. The survival rate was significantly worse after injection or infiltration (p < 0.001) as was the amputation rate (p = 0.013), the percentage of patients requiring intensive care (100% vs. 83%, p = 0.038) and vasopressors (81% vs. 54%, p = 0.02). Injection or infiltration therapy proved to be the strongest prognostic factor (p = 0.003) besides the known risk factors obesity (0.007) and renal insufficiency (0.025).

CONCLUSIONS

Our results demonstrate that patients with a Necrotizing Soft Tissue Infection after injection or infiltration therapy have a significantly worse prognosis.

Necrotizing fasciitis: risk factors of mortality

BACKGROUND

Necrotizing fasciitis (NF) is a serious infection of skin and soft tissues that rapidly progresses along the deep fascia. It becomes a fatal soft tissue infection with high mortality rate if treatment is delayed. Early diagnosis for emergency surgical debridement and broad-spectrum antibiotic therapy were the optimal treatments to reduce the mortality rate of NF.

OBJECTIVE

The aim of this study was to identify risk factors that increased the mortality rate in patients with NF under routine clinical practices.

METHODS

A retrospective cohort study was performed at three general hospitals located in northern Thailand. All medical records of patients with surgically confirmed NF treated between January 2009 and December 2012 were reviewed. Clinical predictors for mortality were analyzed using multivariable risk regression analysis.

RESULTS

Of a total of 1,504 patients with a diagnosis of NF, 19.3% (n=290) died in hospital and 80.7% (n=1,214) survived. From multivariable analysis, being female (risk ratio [RR] =1.37, 95% confidence interval [CI] =1.01-1.84); age >60 (RR=1.39, 95% CI =1.25-1.53); having chronic heart disease (RR=1.64, 95% CI=1.18-2.28), cirrhosis (RR =2.36, 95% CI=1.70-3.27), skin necrosis (RR =1.22, 95% CI=1.15-1.28), pulse rate >130/min (RR =2.26, 95% CI=1.79-2.85), systolic BP <90 mmHg (RR =2.05, 95% CI =1.44-2.91), and serum creatinine ≥1.6 mg/dL (RR=3.06, 95% CI=2.08-4.50) were risk factors for mortality.

CONCLUSION

Prognostic factors for mortality in NF patients included being female; age >60; or having chronic heart disease, cirrhosis, skin necrosis, pulse rate >130/min, systolic BP <90 mmHg, and serum creatinine ≥1.6 mg/dL. Thus, disease progression to mortality may occur in such patients presenting one of these risk factors. Further examination or close monitoring for systemic involvement may be advantageous to reduce morbidity and mortality.

Avoidance of total abdominal wall loss despite torso soft tissue clostridial myonecrosis: a case report

INTRODUCTION

Clostridial necrotizing soft tissue infections are often fatal. Myonecrosis of the torso is a particularly lethal combination given the classic need for radical debridement of the abdominal and thoracic walls, and therefore total exposure of the intraperitoneal and intrathoracic viscera. This case is unusual do to our ability to preserve anatomical separation between the viscera and the atmosphere.

CASE PRESENTATION

We present a 42-year-old Caucasian man with obesity and diabetes who developed clostridial myonecrosis of his right torso following a mesenteric lymph node biopsy. This required an aggressive debridement (sparing subcutaneous flaps and internal oblique aponeurosis) followed by reconstruction of his right hemi-torso with a biologic prosthesis to prevent subsequent hernia formation.

CONCLUSION

Although basic principles associated with radical debridement were maintained, a full thickness torso wall resection was avoided. This provided reconstruction advantages that included endogenous subcutaneous flap coverage, separation of the peritoneal cavity by the internal oblique aponeurosis, and prevention of a subsequent hernia below the arcuate line. This technique would be of interest to any surgeon or clinician who treats patients with life-threatening torso soft tissue infections.

Necrotizing Fasciitis: Diagnostic Challenges in a Mute Bedridden Patient with Atypical Laboratory Parameters

A 27-year-old mute bedridden patient required parenteral corticosteroids and antibiotics, and hospitalization for an acute respiratory illness. After 2 days, staff noted a ~0.3 cm blister on the patient's right heel. Within 19 hours, blistering increased and the foot became partly gangrenous. The patient developed high fever (40.3°C), and leukocytosis (count: 13 × 10⁹/L; was 6.5 × 10⁹/L ten days earlier). Necrotizing fasciitis (NF) was diagnosed and treated with emergency leg amputation. Histopathology revealed necrosis of fascia, muscle, subcutaneous tissue, and skin. In bedridden patients, corticosteroids may particularly facilitate serious infections, and initial NF blistering may be mistaken for pressure ulcers. Vigilant and frequent whole body monitoring is necessary for all patients incapable of verbalizing their symptoms.