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Early diagnosis and management of Necrotizing Fasciitis
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Necrotizing soft tissue infections: Review and current concepts in treatment, systems of care, and outcomes Introduction Necrotizing soft tissue infections (NSTIs) rank among the more difficult disease processes encountered by physicians and surgeons. NSTIs can arise primarily in the dermis and epidermis, but they more commonly affect the deeper layers of adipose tissue, fascia, or muscle. NSTIs are typically caused by toxin-producing bacteria and are characterized clinically by very rapid progression of disease with significant local tissue destruction. Varying amounts of early or late systemic toxicity depend on the strain of bacteria and toxins produced. Once symptomatic, the progression of disease is typically measured in hours; early diagnosis and treatment are crucial to survival. Diagnosis is hindered by the fact that the disease progresses below the surface, and the cutaneous manifestations belie the severity of disease. As the infection disseminates, patients develop pain and signs of systemic toxicity disproportionate to the findings of skin examination, and physicians must maintain a high index of suspicion to rapidly diagnose NSTIs. The standard treatment consists of broad-spectrum antibiotics, wide surgical debridement, and supportive care. Most patients require multiple surgical debridements, and survivors often have large and complex wounds requiring soft tissue coverage and prolonged hospitalizations. Even with optimal treatment, NSTIs portend significant morbidity and have mortality rates of 25%-35% in recent series. In this review, we provide historical context; discuss the epidemiology, etiology, and pathogenesis of disease; summarize the major microbiology; and elaborate the clinical presentation and diagnosis of disease with a special discussion of NSTIs in immune- compromised patients. We then outline the major and novel treatment strategies, organized by phase of treatment and with special emphasis on the importance of multidisciplinary care teams. Finally, we summarize the information on in-hospital outcomes and close with a brief discussion of posthospital and developing information on long-term quality of life and functional outcomes.
Necrotizing fasciitis is a rapidly progressing skin infection characterized by necrosis of the fascia and subcutaneous tissue, accompanied by severe systemic toxicity. The objective of this systematic review was to identify clinical features and investigations that will aid early diagnosis.
A systematic literature search of PubMed was undertaken using the keywords 'necrotising fasciitis', 'necrotising skin infection', 'diagnosis' and 'outcome'. Case series of 50 or more subjects with information on symptoms and signs at initial presentation, investigations and clinical outcome were included.
Nine case series were selected, with a total of 1463 patients. Diabetes mellitus was a co-morbidity in 44·5 per cent of patients. Contact with marine life or ingestion of seafood in patients with liver disease were risk factors in some parts of Asia. The top three early presenting clinical features were: swelling (80·8 per cent), pain (79·0 per cent) and erythema (70·7 per cent). These being non-specific features, initial misdiagnosis was common and occurred in almost three-quarters of patients. Clinical features that helped early diagnosis were: pain out of proportion to the physical findings; failure to improve despite broad-spectrum antibiotics; presence of bullae in the skin; and gas in the soft tissue on plain X-ray (although this occurred in only 24·8 per cent of patients).
A high index of suspicion of necrotizing fasciitis is needed in a patient presenting with cutaneous infection causing swelling, pain and erythema, with co-morbidity of diabetes or liver disease. The presence of bullae, or gas on plain X-ray can be diagnostic. Early surgical exploration is the best approach in the uncertain case.
Necrotising Soft Tissue Infection is a rapidly progressing fatal
disorder, the prognosis of which depends on early diagnosis
and management.
Objective: In this study, our objective was to assess the factors
contributing to mortality due to NSTI.
Methods: A retrospective review of the records of all patients
with NSTI involving fascia, skin or muscle between January 2007
and December 2011, was performed. The atiology, predisposing
factors, risk factors, causative microbiological organisms and
the clinical outcomes associated with mortality were studied.
Statistical Data: Descriptive statistics comprising of proportion(%) presented. Chi–square test was employed to assess the
statistical significance in the distribution of various known risk
factors between the survivors and non–survivors. A ‘p’ value
less than 0.05 was considered significant.
Results: Sixty patients records were reviewed. Fifty-one patients
(85%) were males and nine (15%) were females. Mean age was
46.57 years (+/- 20.60) ranging from 15–83 years. All the patients
were treated by debridement & wide spectrum antibiotics.
Mono-microbial atiology being found in 27 patients (63.3%) and
polymicrobial culture was isolated in 13 patients (36.7%), with
E-coli and staphylococci being the most common organisms
to be isolated. In most patients, multiple debridements were
done. The overall mortality rate was estimated to be 25%. Age,
aatiology, diabetes mellitus, hypoalbuminemia, alcohol, site of
infection, bacteriology etc. were the risk factors associated with
mortality, that were evaluated. Diabetes mellitus was the most
common associated risk factor found in 32 patients (53.3%),
though not statistically significant. Increasing age (>50 years,
p value = 0.016), raised Serum Creatinine (>1.2mg/dl, p-value
= 0.023) and delayed surgical intervention(>24 hours p value=
0.006) were the risk factors associated with Mortality in NSTI
that were statistically significant.
Conclusion: Despite the use of appropriate antibiotic treatment,
aggressive debridement & resuscitation, NSTI still leads to a
high mortality & morbidity. In this series, there is high mortality
associated with increasing age, raised serum creatinine and
delayed surgical intervention. The mortality rate (25%) is
comparable with other studies.
Necrotising soft tissue infection (NSTI) presents unique challenges in diagnosis and management. The key to a successful outcome is a high index of suspicion in appropriate clinical settings. Type II NSTI tends to occur on an extremity in younger, healthier patients with a history of known trauma, and to be monomicrobial. Type I NSTI tends to occur on the trunk of older, less healthy patients without an obvious history of trauma, and tends to be polymicrobial. Other, rarer types exist as well. The pathophysiology of both types involves superantigen acticivty, as well as a number of microbial byproducts which collectively decrease the viscosity of pus, facilitating its spread along deep tissue planes and ultimately causing diffuse deep thrombosis and aggressive systemic sepsis. The most important physical finding is tenderness to palpation beyond the area of redness, and the lack of crepitus should not be seen as a reassuring sign. Suspected cases should undergo early surgical exploration for diagnosis, which may be performed at bedside through a small incision. Most imaging techniques are not sufficiently specific to warrant a delay in surgical exploration. The Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) shows promise as a tool for excluding suspected cases. Successful outcomes in cases of NSTI require early and aggressive serial debridement and a multidisciplinary critical care approach.
Necrotizing fasciitis (NF), a life-threatening rare infection of the soft tissues, is a medical and surgical emergency. It is characterized by subtle, rapid onset of spreading inflammation and necrosis starting from the fascia, muscles, and subcutaneous fat, with subsequent necrosis of the overlying skin. Once suspected, immediate and extensive radical debridement of necrotic tissues is mandatory. Appropriate antibiotics and intensive general support avoid massive systemic diffusion of the infective process and are the key for successful treatment. However, early diagnosis is missed or delayed in 85% to 100% of cases in large published series: because of the lack of specific clinical features in the initial stage of the disease, it is often underestimated or confused with cellulitis or abscess. Mortality rates are still high and have shown no tendency to decrease in the last 100 years. Unfortunately, the prevalence of the disease is such that physicians rarely become sufficiently confident with NF to be able to proceed with rapid diagnosis and management. This review covers the literature published in MEDLINE in the period 1970 to December 31, 2010. Particular attention is given to the clinical and laboratory elements to be considered for diagnosis. A wide variety of diagnostic tools have been described to facilitate and hasten the diagnosis of NF, but the most important tool for early diagnosis still remains a high index of clinical suspicion.
The authors evaluate in a retrospective fashion the factors influencing outcome in a large group of patients presenting with necrotizing soft tissue infections, and, based on this analysis, propose a plan for optimal care of such patients.
In many smaller series of patients with necrotizing soft tissue infections, similar analyses of risk factors for mortality have been performed, producing conflicting conclusions regarding optimal care. In particular, debate exists regarding the impact of concurrent physiologic derangements, type and extent of infection, and the role of hyperbaric oxygen in treatment.
A retrospective chart review of 198 consecutive patients with documented necrotizing soft tissue infections, treated at a single institution during an 8-year period, was conducted. Using a model for logistic regression analysis, characteristics of each patient and his/her clinical course were tested for impact on outcome.
The mortality rate among the 198 patients was 25.3%. The most common sites of origin of infection were the perineum (Fournier's disease; 36% of cases) and the foot (in diabetics; 15.2%). By logistic regression analysis, risk factors for death included age, female gender, extent of infection, delay in first debridement, elevated serum creatinine level, elevated blood lactate level, and degree of organ system dysfunction at admission. Diabetes mellitus did not predispose patients to death, except in conjunction with renal dysfunction or peripheral vascular disease. Myonecrosis, noted in 41.4% of the patients who underwent surgery, did not influence mortality.
Necrotizing soft tissue infections represent a group of highly lethal infections best treated by early and repeated extensive debridement and broad-spectrum antibiotics. Hyperbaric oxygen appears to offer the advantage of early wound closure. Certain markers predict those individuals at increased risk for multiple-organ failure and death and therefore assist in deciding allocation of intensive care resources.
Twenty-one consecutive patients with streptococcal toxic shock syndrome (TSS) between December 1994 and April 1995 were treated
with a median dose of 2 g of intravenous immunoglobulin (IVIG)/kg (cases) and were compared with 32 patients with streptococcal
TSS between 1992 and 1995 who did not receive IVIG therapy (controls). The outcome measure was 30-day survival. Patient plasma
was tested for its ability to inhibit T cell activation induced by the infecting strain. The proportion of cases with 30-day
survival was higher than that of the controls with 30-day survival (67% vs. 34%, respectively; P = .02). Multivariate analysis revealed that IVIG administration and a lower Acute Physiology and Chronic Health Evaluation
II score were associated with survival; the odds ratio for survival associated with IVIG therapy was 8.1 (95% confidence interval,
1.6–45; P = .009). IVIG therapy enhanced the ability of patient plasma to neutralize bacterial mitogenicity and reduced T cell production
of interleukin-6 and tumor necrosis factor α. IVIG may be an effective adjunctive therapy for streptococcal TSS, possibly
because of its ability to neutralize bacterial exotoxins.
Acute necrotising fasciitis is a life-threatening condition, which requires urgent surgical intervention. Surgical debridement is invariably associated with large areas of tissue loss.
We present a 58-year old woman with a past history of cervical carcinoma who presented with necrotising fasciitis of the perineum and upper thighs with associated pubic bone osteomyelitis. Following extensive debridement, a Vacuum Assisted Closure (VAC) system was applied to the large residual defect to facilitate skin graft application and optimise wound healing.
This case demonstrates the successful management of a complex and potentially lethal wound of the perineum with debridement, skin grafting and the VAC system.
Much has been written in the medical literature of all countries engaged in the World War bearing on various phases of acute bacterial gangrene produced by anaerobic organisms. But almost no attention has been given to another group of cases characterized by a rapidly developing gangrenous process from which only the hemolytic streptococcus can be recovered with regularity. These two groups differ from one another quite widely in several important respects, both clinically and pathologically. The latter is a clear cut clinical entity which can readily be recognized and whose clinical course and bacteriologic findings can be fairly well predicted.
On questioning other medical men in China, I have learned that the disease is fairly common and has a rather wide distribution in that part of the Orient; but little has been written on the subject. A review of the general medical literature indicates that the condition is relatively rare
Background:
Invasive group A Streptococcus (GAS) infections cause significant morbidity and mortality. We report the epidemiology and trends of invasive GAS over 8 years of surveillance.
Methods:
From January 2005 through December 2012, we collected data from the Centers for Disease Control and Prevention's Active Bacterial Core surveillance (ABCs), a population-based network of 10 geographically diverse U.S. sites (2012 population, 32.8 million). We defined invasive GAS as isolation of GAS from a normally sterile site or from a wound in a patient with necrotizing fasciitis (NF) or streptococcal toxic shock syndrome (STSS). Available isolates were emm typed. We calculated rates and made age- and race-adjusted national projections using census data.
Results:
We identified 9557 cases (3.8 cases per 100,000 persons per year) with 1116 deaths (case-fatality ratio [CFR]: 11.7%). CFRs for septic shock, STSS and NF were 45%, 38%, and 29%, respectively. Annual incidence was highest among persons aged ≥65 years (9.4 per 100,000), persons aged <1 year (5.3), and blacks (4.7). National rates remained steady over 8 years of surveillance. Factors independently associated with death included increasing age, residence in a nursing home, recent surgery, septic shock, NF, meningitis, isolated bacteremia, pneumonia, emm type 1 or 3, and underlying chronic illness or immunosuppression. An estimated 10,649-13,434 cases of invasive GAS infections occur in the U.S. annually, resulting in 1,136-1,607 deaths. emm types in a 30-valent M-protein vaccine accounted for 91% of isolates.
Conclusions:
The burden of invasive GAS infection in the U.S. remains substantial. Vaccines under development could have a considerable public health impact.
Twenty-one consecutive patients with streptococcal toxic shock syndrome (TSS) between December 1994 and April 1995 were treated with a median dose of 2 g of intravenous immunoglobulin (IVIG)/kg (cases) and were compared with 32 patients with streptococcal TSS between 1992 and 1995 who did not receive IVIG therapy (controls). The outcome measure was 30-day survival. Patient plasma was tested for its ability to inhibit T cell activation induced by the infecting strain. The proportion of cases with 30-day survival was higher than that of the controls with 30-day survival (67% vs. 34%, respectively; p = .02). Multivariate analysis revealed that IVIG administration and a lower Acute Physiology and Chronic Health Evaluation II score were associated with survival; the odds ratio for survival associated with IVIG therapy was 8.1 (95% confidence interval, 1.6-45; P = .009). IVIG therapy enhanced the ability of patient plasma to neutralize bacterial mitogenicity and reduced T cell production of interleukin-6 and tumor necrosis factor α. IVIG may be an effective adjunctive therapy for streptococcal TSS, possibly because of its ability to neutralize bacterial exotoxins.
Background:
The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score has been verified as a useful diagnostic tool for detecting necrotizing fasciitis (NF). Its application, however, is mainly for NF types I and II. The practical relevance of the LRINEC score for Vibro vulnificus-related skin and soft tissue infection (SSTI) was hardly ever investigated. The aim of this study was to assess the applicability of the LRINEC scoring system and to identify NF-predicting factors in patients with V. vulnificus-caused SSTI.
Methods:
A retrospective study was conducted, enrolling 125 consecutive patients diagnosed with V. vulnificus-related SSTI who were admitted to a teaching hospital between January 2003 and December 2011. Demographics, laboratory data, comorbidities, treatment, and outcomes were collected for each patient and extracted for analysis. Logistic regression and receiver operating characteristic curve analyses were performed.
Results:
The mean (SD) age of the 125 patients was 63.0 (10.9) years; 58% of the patients were male. The mean (SD) LRINEC score at admission was 2.4 (1.9) points. Of the 125 patents, 72 (58%) had NF. Multivariate analysis revealed that the presence of hemorrhagic bullous lesions (p = 0.002) and higher LRINEC scores at admission (p < 0.0001) were significantly associated with the presence of NF. In addition, the area under the receiver operating characteristic curve for the LRINEC scoring model for detecting NF was 0.783 (p < 0.0001). An optimal cutoff LRINEC score of 2 or greater had a sensitivity of 71%, a specificity of 83%, and a positive predictive value of 85%, with an 11.9-fold increased risk for the presence of NF (p < 0.0001).
Conclusion:
We have demonstrated that the LRINEC score and hemorrhagic bullous/blistering lesions are significant predictors of NF in patients with V. vulnificus-related SSTI. V. vulnificus-infected patients having hemorrhagic bullous/blistering lesions or with an LRINEC score of 2 or greater should be thoughtfully evaluated for the presence of NF.
Level of evidence:
Diagnostic test study, level II.
Objectives/hypothesis:
Cervical necrotizing fasciitis (CNF) is challenging to diagnose and associated with high morbidity and mortality. The objective of this study is to evaluate the utility of two laboratory-based diagnostic tools for distinguishing necrotizing from non-necrotizing infection when specifically applied to neck infection.
Study design:
Retrospective review.
Methods:
We reviewed 17 consecutive cases of CNF and 70 cases of non-necrotizing neck infection (cellulitis, phlegmon, abscess) occurring at our institution over a 10.75-year period. Cervical necrotizing fasciitis was confirmed by operative report documentation. Patient demographics, presenting characteristics, and outcomes were recorded.
Results:
Use of white blood cell count and serum sodium levels to predict cervical necrotizing fasciitis had a sensitivity of 24% (95% confidence interval [CI], 0.078-0.502), specificity of 81% (95% CI, 0.688-0.889), positive predictive value of 23% (95% CI, 0.054-0.401), and negative predictive value of 81% (95% CI, 0.769-0.857). A Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score of ≥ 6 had a sensitivity of 56% (95% CI, 0.227-0.847), specificity of 60% (95% CI, 0.274-0.863), positive predictive value of 25% (95% CI, 0.072-0.433), and negative predictive value of 85% (95% CI, 0.733-0.962).
Conclusions:
Neither the LRINEC score nor the use of admission white blood cell count and sodium level were useful for distinguishing cervical necrotizing fasciitis from non-necrotizing neck infection.
Necrotising soft tissue infection (NSTI) is a deadly disease associated with a significant risk of mortality and long-term disability from limb and tissue loss. The aim of this study was to determine the effect of hyperbaric oxygen (HBO(2)) therapy on mortality, complication rate, discharge status/location, hospital length of stay and inflation-adjusted hospitalisation cost in patients with NSTI.
This was a retrospective study of 45,913 patients in the Nationwide Inpatient Sample (NIS) from 1988 to 2009.
A total of 405 patients received HBO(2) therapy. The patients with NSTI who received HBO(2) therapy had a lower mortality (4.5 vs. 9.4 %, p = 0.001). After adjusting for predictors and confounders, patients who received HBO(2) therapy had a statistically significantly lower risk of dying (odds ratio (OR) 0.49, 95 % confidence interval (CI) 0.29-0.83), higher hospitalisation cost (US45,464, p = 0.02) and longer length of stay (LOS) (14.3 days vs. 10.7 days, p < 0.001).
This retrospective analysis of HBO(2) therapy in NSTI showed that despite the higher hospitalisation cost and longer length of stay, the statistically significant reduction in mortality supports the use of HBO(2) therapy in NSTI.
Necrotizing fasciitis (NF), a life-threatening soft tissue infection, requires early diagnosis, prompt and repeated surgical intervention, and broad-spectrum antibiotic therapy. The aim of this study was to identify the independent predictors of mortality among patients with NF in Taiwan.
We retrospectively reviewed the medical records of all patients who were admitted to Chi-Mei Medical Center, Tainan, Taiwan, with a diagnosis of NF. The definitive diagnosis was confirmed by the surgical findings, including (1) dishwater or foul-smelling discharge, (2) presence of necrotic fascia or lack of fascial bleeding, and (3) lack of resistance of normally adherent muscular fascia to blunt dissection. To identify factors associated with mortality, variables including personal history and comorbidities, clinical symptoms and signs, laboratory data, and microbiological data were compared between survivors and nonsurvivors.
From January 2003 to December 2009, 472 patients treated for NF were included in the study. The overall mortality was 12.1% (n = 57) and the 30-day mortality was 11.0% (n = 52). Multivariate analysis revealed eight independent predictors of mortality for NF including liver cirrhosis, soft tissue air, Aeromonas infection, age older than 60 years, band polymorphonuclear neutrophils >10%, activated partial thromboplastin time >60 s, bacteremia, and serum creatinine >2 mg/dL.
We identified eight independent predictors of mortality that provided useful information on the severity of NF and guidance for treatment. Prospective studies are required to examine the fitness and sufficiency of these variables as effective predictors of NF mortality.
Fournier's gangrene (FG) is a rapidly developing necrotizing fasciitis that originates in genital and perineal region. The mortality rate is high and requires prompt diagnosis, antibiotic treatment and extensive necrosectomy with derivative colostomy. Vacuum Assisted Closure (VAC) is a wound care system of paramount importance in the treatment of complex wounds, including the perineum.
We evaluated 6 cases of FG (males, mean age: 54.6 yrs) of the last 3 years (February 2008-August 2010). All patients were diabetics. We used intravenous antibiotic treatment and early surgical debridement with colostomy, followed by immediate positioning of a VAC device (NP 125-200 mmHg). The dressing changes were done every 3-4 days. Hyperbaric oxygen therapy (HBOT) was given only to one patient. Microbiological etiology was assessed by multiple cultures to tailor the antimicrobial treatment.
The VAC therapy reduces the number of dressings and the hospital length of stay (LOS), in agreement with the literature; in one of the cases a secondary reconstructive surgical intervention was possible. The colostomy was reversed in all patients within 3 months.
Negative pressure is a time saving device, reducing days of hospitalization, patient's discomfort and number of medications. The possibility of a early reconstructive surgery improves significantly quality of life.
Necrotizing fasciitis (NF) is a necrotizing soft tissue infection that can cause rapid local tissue destruction, necrosis and life-threatening severe sepsis. Predisposing conditions for NF include diabetes, malignancy, alcohol abuse, and chronic liver and kidney diseases. NF is classified into two categories (types 1 and 2) based on causative microorganisms. The initial clinical picture of NF mimics that of cellulitis or erysipelas, including fever, pain, tenderness, swelling and erythema. The cardinal manifestations of NF are severe pain at onset out of proportion to local findings, hemorrhagic bullae and/or vital sign abnormality. In such cases, NF should be strongly suspected and immediate surgical intervention should be considered, along with broad-spectrum antimicrobials and general supportive measures, regardless of the findings of imaging tests.
Necrotising fasciitis (NF) is situated with myositis and myonecrosis at the severe end of a spectrum of skin and soft tissue infections but is far removed from erisepelas, impetigo and cellulitis. Inexperienced clinicians are easily misled by the protean manifestations of infection, especially exotoxin or superantigen mediated consequences from streptococcal NF. Early clinical suspicion and surgery are key to improving survival, and patients with NF need integrated multidisciplinary management, adjusted to the infecting organism(s), the site of infection, and the effects from any toxins produced. A multiparametric approach, incorporating various clinical and laboratory parameters, can aid aggressive management. This review describes the diagnosis and management of the major types of NF, emphasising important aetiological clues from the history and the appropriate usage of diagnostic investigations. The potential benefits of controversial therapeutic approaches, including hyperbaric oxygen and intravenous immunoglobulin, are discussed.
Early recognition of necrotizing fasciitis (NF) can be difficult, but is important as infections progress rapidly and have significant mortality. The aim of this study of patients with NF was to determine the clinical characteristics at presentation, causative pathogens and subsequent clinical outcome.
We retrospectively reviewed consecutive patients with NF presenting to Middlemore Hospital from January 2000 to June 2006.
Eighty-two patients were evaluated: 56% male, mean age 54.9 years (standard deviation 18.5), 40% Pacific Islanders. The site of infection was the lower limb in 46 (56%) patients, upper limb in 12 (15%) patients and perineum in 13 (16%) patients. Twenty-two (27%) patients were taking non-steroidal anti-inflammatory drugs, 29 (35%) had diabetes mellitus, 25 (30%) had gout and 17 (21%) had congestive heart failure. Forty-nine (60%) patients had a surgical procedure within 24 h of admission. Streptococcus pyogenes was isolated from tissue or blood cultures in 33 (40%) patients and 26 (32%) patients had polymicrobial infection. Twenty-five (30%) patients died, 17 (68%) within 72 h of admission. Independent predictors of mortality include congestive heart failure (P = 0.033) and a history of gout (P = 0.037).
NF remains an important disease in our community with significant morbidity and mortality. Pacific Islanders were disproportionately represented. Early diagnosis of NF can be difficult and requires a high index of suspicion in all patients presenting with cellulitis or unexplained sepsis. Congestive heart failure and gout are independent predictors of mortality and patients with these conditions and sepsis need early assessment with more aggressive hospital triaging.
The high morbidity and mortality of necrotizing fasciitis (NF) supports the need for epidemiological studies to characterize the disease and identify patient factors associated with adverse outcomes. A multi-site medical record review of patients diagnosed with NF was performed (n=80, mortality 15%). Variables collected were hypothesized to have association with adverse outcomes from NF, and multivariable analysis was used to detect any such association in this population. Select factors associated with mortality included evidence of underlying conditions (P=0.002), advanced age (P=0.04), young age (P=0.03), and evidence of sepsis (P=0.006). Select factors associated with amputation included diabetes mellitus (P=0.006), evidence of underlying conditions (P=0.03), and cutaneous gangrene noted on admission (P=0.006). These findings demonstrate the important association of NF and extremes of age with mortality and morbidity and support the value of early suspicion with prompt diagnosis and treatment in order to prevent adverse outcomes since the associated risk factors are not immediately modifiable.
Necrotizing fasciitis is a life-threatening soft-tissue infection. It is useful to know the etiology of this disease in each community and region because this information can facilitate early diagnosis and treatment. We reviewed medical records of 217 consecutive patients with necrotizing fasciitis in South Korea. Etiologic organisms were documented in 171 (78.8%) patients. Gram-negative marine bacteria were the most common organisms (68.4%). Seasonal variation in incidence occurred during warmer periods. Liver cirrhosis and alcoholism were common underlying illnesses. Gastrointestinal symptoms were more common in persons infected with gram-negative marine bacteria (56.4% versus 29.6%). Gram-negative bacteria were the predominant pathogens in multiple site involvement. Acute Physiology and Chronic Health Evaluation II scores, marine bacteria, and medical treatment without surgery affected mortality. When necrotic areas included less than three extremities, fasciotomy improved the survival rate. In coastal areas, gram-negative marine bacteria are the most common pathogens associated with necrotizing fasciitis. Fasciotomy can improve survival of patients with necrotic areas that involve less than three sites in necrotizing fasciitis.
The authors present a case of an extensive fulminant necrotizing fasciitis of the left flank, thigh, and lower parts of the leg treated with debridement, split-thickness skin grafting, and a giant negative pressure wound dressing covering 0.53 m( 2) or 18% of the body surface. To the authors' knowledge, this is the largest split-thickness grafted body surface successfully treated with negative pressure wound dressing documented in the literature.
Twenty-eight cases of necrotizing fasciitis (NF) were treated in 27 patients. Most commonly these infections were caused by perineal disease, operative procedures, and cutaneous ulcers. Associated chronic diseases were present in 21 patients. Postoperative fasciitis occurred when prophylactic antibiotics were omitted or used inappropriately during clean-contaminated or contaminated procedures and when primary skin closure was done in the presence of intra-abdominal contamination. All but four infections were polymicrobial. The overall mortality rate was 73% (20 of 27). Death was due to persistent would sepsis in nine, systemic septic complications despite apparent local control of the infection in nine, and myocardial infarction in two patients. Five of seven survivors had NF limited to one region (leg, perineum, or abdomen). Only 2 of 15 patients survived when more than one debridement was necessary to control ongoing wound necrosis. Eleven of 12 patients who had a delay in treatment for more than 12 hours died. These results suggest that prompt recognition and treatment of NF are essential for survival. The presence of chronic debilitating diseases may contribute to the uncontrollable nature of both local and systemic infection, further emphasizing the need for early diagnosis. Postoperative fasciitis is potentially preventable by strict adherence to the principles for management of contaminated procedures.
The authors determined the risk factors of mortality in patients with necrotizing soft-tissue infections (NSTIs) and examined the incidence and mortality from NSTI secondary to Streptococcus pyogenes.
All patients with NSTIs who were treated between January 1989 and June 1994 were analyzed for presentation, etiology, factors important in pathogenesis and treatment, and mortality.
Sixty-five patients were identified with NSTIs secondary to postoperative wound complications (18), trauma (15), cutaneous disease (15), idiopathic causes (10), perirectal abscesses (3), strangulated hernias (2), and subcutaneous injections (2). Necrotizing soft-tissue infections were polymicrobial in 45 patients (69%). S. pyogenes was isolated in only 17% of the NSTIs, but accounted for 53% of monomicrobial infections. Eight of ten idiopathic infections were caused by a single bacterium (p = 0.0005), whereas 82% of postoperative infections were polymicrobial. An average of 3.3 operative debridements per patient and amputation in 12 patients were necessary to control infection. The overall mortality was 29%; mortality from S. pyogenes infection was only 18%. The average time from admission to operation was 90 hours in nonsurvivors versus 25 hours in survivors (p = 0.0002). Other risk factors previously associated with the development of NSTIs did not affect mortality.
Early debridement of NSTI was associated with a significant decrease in mortality. S. pyogenes infection was the most common cause of monomicrobial NSTI, but was not associated with an increased mortality.
Necrotizing fasciitis is a soft tissue gangrenous infection that is optimally treated by early diagnosis, radical surgical debridement of all involved necrotic tissue, broad spectrum antibiotics, and aggressive nutritional support. The early clinical diagnosis of an area of necrotizing fasciitis is difficult and frequently unreliable. We are reporting a series of cases in which an early, accurate diagnosis of necrotizing fasciitis was established by a frozen section tissue biopsy obtained at the bedside.
Over a 15-year period, a consecutive series of 43 patients had a bedside biopsy under local anesthesia with immediate frozen section evaluation. All patients were seen in the hospital or emergency room for treatment of an inflammatory process.
These 43 patients had bedside biopsy and frozen section evaluation of an inflammatory process. Twelve patients were found to have necrotizing fasciitis. These patients were treated with immediate surgical debridement of all gross necrotic tissue, broad spectrum antibiotics, and adequate nutritional support. All of them survived. No cases of infectious gangrene occurred in the group of patients whose biopsy did not reveal necrotizing fasciitis.
Frozen section tissue biopsy is a useful adjunct in establishing an early, accurate diagnosis of infectious gangrene.
Although there is much consensus, certain controversies exist regarding the management of Fournier's gangrene. Method: Publications in English on Fournier's gangrene from January 1950 to September 1999 were obtained through the Medline database and relevant reference lists in publications. It was possible to identify 1726 cases for study. Data extracted for review included country of reported cases, number of patients in each report and relevant clinical features.
Fournier's gangrene occurs worldwide. However, its definition has generated considerable controversy as efforts are made to refine the original description in the light of increasingly understood aetiological factors. Attempts to classify the disease into primary and secondary forms have not been successful. The basic pathological process, necrotizing fasciitis, has been identified in the perineum of women and children, although the disease afflicts the male more often than the female. Most reported cases have occurred in the USA and Canada. The major sources of sepsis are the local skin, colon, anus and rectum, and the lower urinary tract. Colonic, anal and rectal sources carry the worst prognosis. Diabetes mellitus is important in aetiological terms. Rare causes include vasectomy and circumcision. Investigations are essential to define the cause of an episode but not for the diagnosis of the disease. Early aggressive treatment of Fournier's gangrene and underlying conditions is essential. Hyperbaric oxygen and honey are treatment modalities yet to be universally adopted. Risk of death, 16 per cent overall in this series, is related to the patient's condition at presentation.
Controversies over the definition of Fournier's gangrene persist but these do not affect the treatment options. The diagnosis is made on clinical grounds. The occurrence of the disease in women is under-reported and may go unrecognized by some clinicians. Some treatment options, such as hyperbaric oxygenation and radical excision, remain controversial.
Learning objectives:
After studying the article, the participant should be able to: 1. Describe the most common bacteriology of necrotizing fasciitis and purpura fulminans. 2. Describe the "finger test" in the diagnosis of necrotizing fasciitis. 3. Discuss the three presentation patterns of necrotizing fasciitis. 4. Discuss the pathophysiology of acute infectious purpura fulminans. 5. Discuss the treatment strategies for necrotizing fasciitis and purpura fulminans, including the use of artificial skin substitutes. Necrotizing fasciitis and purpura fulminans are two destructive processes that involve skin and soft tissues. The plastic and reconstructive surgeon may frequently be called on for assistance in the diagnosis, treatment, and/or reconstruction of patients with these conditions. Understanding the natural history and unique characteristics of these processes is essential for effective surgical management and favorable patient outcome. A comprehensive review of the literature pertaining to these two conditions is presented, outlining the different pathophysiologies, the patterns of presentation, and the treatment strategies necessary for successful management of these massive infectious soft-tissue diseases.
To study the clinical profile and outcome of patients with necrotising soft-tissue infections.
Prospective study.
Teaching hospital, India.
75 patients (54 male and 21 female), mean age 40 years (range 8 months-85 years).
Patients were uniformly managed by initial resuscitation, debridement, topical wound care, systemic antibiotics, and enteral hyperalimentation.
Morbidity and mortality.
Aetiology of the infections included major and minor trauma, minor skin infections and postoperative infections. 22 patients were diabetic. The extremities were involved in 57 patients, the trunk in 26 and the perineum in 21. 68 presented with local tenderness (91%), 74 with oedema (99%), 54 with erythema (72%), 55 with ulceration (73%), and 54 with a purulent or serous discharge (72%). beta-haemolytic streptococci were isolated from only 10 patients. Staphylococcus aureus was the most common bacteria isolated (n = 30, 46%) followed by Bacteroides fragilis and anaerobic cocci (n = 22, 34% each). Cultures grew fungi in 9 patients. 20 patients died giving a mortality of 27%. Jaundice and serum albumin were the only factors to have a significant influence on mortality.
Necrotising soft tissue infections are potentially fatal. Early recognition and prompt aggressive debridement are the keys to successful management.
Necrotizing fasciitis is a life-threatening soft-tissue infection primarily involving the superficial fascia. The present report describes the clinical presentation and microbiological characteristics of this condition as well as the determinants of mortality associated with this uncommon surgical emergency.
The medical records of eighty-nine consecutive patients who had been admitted to our institution for necrotizing fasciitis from January 1997 to August 2002 were reviewed retrospectively.
The paucity of cutaneous findings early in the course of the disease makes the diagnosis difficult, and only thirteen of the eighty-nine patients had a diagnosis of necrotizing fasciitis at the time of admission. Preadmission treatment with antibiotics modified the initial clinical picture and often masked the severity of the underlying infection. Polymicrobial synergistic infection was the most common cause (forty-eight patients; 53.9%), with streptococci and enterobacteriaceae being the most common isolates. Group-A streptococcus was the most common cause of monomicrobial necrotizing fasciitis. The most common associated comorbidity was diabetes mellitus (sixty-three patients; 70.8%). Advanced age, two or more associated comorbidities, and a delay in surgery of more than twenty-four hours adversely affected the outcome. Multivariate analysis showed that only a delay in surgery of more than twenty-four hours was correlated with increased mortality (p < 0.05; relative risk = 9.4).
Early operative débridement was demonstrated to reduce mortality among patients with this condition. A high index of suspicion is important in view of the paucity of specific cutaneous findings early in the course of the disease.
Early operative debridement is a major determinant of outcome in necrotizing fasciitis. However, early recognition is difficult clinically. We aimed to develop a novel diagnostic scoring system for distinguishing necrotizing fasciitis from other soft tissue infections based on laboratory tests routinely performed for the evaluation of severe soft tissue infections: the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score.
Retrospective observational study of patients divided into a developmental cohort (n = 314) and validation cohort (n = 140)
Two teaching tertiary care hospitals.
One hundred forty-five patients with necrotizing fasciitis and 309 patients with severe cellulitis or abscesses admitted to the participating hospitals.
None.
The developmental cohort consisted of 89 consecutive patients admitted for necrotizing fasciitis. Control patients (n = 225) were randomly selected from patients admitted with severe cellulitis or abscesses during the same period. Hematologic and biochemical results done on admission were converted into categorical variables for analysis. Univariate and multivariate logistic regression was used to select significant predictors. Total white cell count, hemoglobin, sodium, glucose, serum creatinine, and C-reactive protein were selected. The LRINEC score was constructed by converting into integer the regression coefficients of independently predictive factors in the multiple logistic regression model for diagnosing necrotizing fasciitis. The cutoff value for the LRINEC score was 6 points with a positive predictive value of 92.0% and negative predictive value of 96.0%. Model performance was very good (Hosmer-Lemeshow statistic, p =.910); area under the receiver operating characteristic curve was 0.980 and 0.976 in the developmental and validation cohorts, respectively.
The LRINEC score is a robust score capable of detecting even clinically early cases of necrotizing fasciitis. The variables used are routinely measured to assess severe soft tissue infections. Patients with a LRINEC score of > or = 6 should be carefully evaluated for the presence of necrotizing fasciitis.
Necrotizing soft-tissue infections (NSTIs) are highly lethal. They are frequent enough that general and specialty physicians
will likely have to be involved with the management of at least 1 patient with NSTI during their practice, but they are infrequent
enough that familiarity with the disease will seldom be achieved. Establishing the diagnosis of NSTI can be the main challenge
in treating patients with NSTI, and knowledge of all available tools is key for early and accurate diagnosis. The laboratory
risk indicator for necrotizing fasciitis score can be helpful for distinguishing between cases of cellulitis, which should
respond to medical management alone, and NSTI, which requires operative debridement in addition to antimicrobial therapy.
Imaging studies are less helpful. The mainstay of treatment is early and complete surgical debridement, combined with antimicrobial
therapy, close monitoring, and physiologic support. Novel therapeutic strategies, including hyperbaric oxygen and intravenous
immunoglobulin, have been described, but their effect is controversial. Identification of patients at high risk of mortality
is essential for selection of patients that may benefit from future novel treatments and for development and comparison of
future trials.
Necrotizing fasciitis is a severe soft-tissue infection characterized by a fulminant course and high mortality. Early recognition is difficult as the disease is often clinically indistinguishable from cellulitis and other soft-tissue infections early in its evolution. Our aim was to study the manifestations of the cutaneous signs of necrotizing fasciitis as the disease evolves.
This was a retrospective study on patients with necrotizing fasciitis at a single institution. Their charts were reviewed to document the daily cutaneous changes from the time of presentation (day 0) through to day 4 from presentation.
Twenty-two patients were identified. At initial assessment (day 0), almost all patients presented with erythema, tenderness, warm skin, and swelling. Blistering occurred in 41% of patients at presentation whereas late signs such as skin crepitus, necrosis, and anesthesia were infrequently seen (0-5%). As time elapsed, more patients had blistering (77% had blisters at day 4) and eventually the late signs of necrotizing fasciitis characterized by skin crepitus, necrosis, and anesthesia (9-36%) were seen. A clinical staging system was developed based on our observations. Stage migration from early to late stage necrotizing fasciitis was evident with majority of patients in stage 1 at day 0 (59%), whereas by day 4, majority had developed into stage 3 (68%).
This study has demonstrated the continuum of cutaneous manifestations as necrotizing fasciitis evolves. This will help in the early recognition and intervention of this devastating condition.
To characterize the Emergency Department (ED) presentation of necrotizing soft tissue infections (NSTI) and identify severity markers. Procedures: Retrospective chart review of pathologically diagnosed NSTIs presenting to an urban ED from 1990-2001. Cases were identified from a surgical database, ICD-9 search and prospectively. Five Emergency Physicians (EPs) abstracted data using a standardized form. Severe NSTI was defined by any of the following: death, amputation, intensive care unit (ICU) stay >24 h, >300 cm(2) debrided. Severe and non-severe cases were compared using chi-square, Fisher's exact, and multivariate logistic regression testing.
The 122 cases were characterized by: injection drug use, 80%; fever, 44%; systolic blood pressure (BP) <100 mm Hg, 21%; white blood cell count (WBC) >20 x 10(9)/L, 43%; median time to operation, 8.4 h; mortality, 16%. The managing EP suspected NSTI in 59%. A systolic BP <100 mm Hg, BUN >18 mg/dL, radiographic soft tissue gas, admission to a non-surgical service and clostridial species were independently associated with severe NSTI.
Pathologically defined NSTIs have a wide spectrum of ED presentations and early diagnosis remains difficult.
Necrotizing fasciitis is an uncommon and life-threatening soft tissue infection with high mortality. Though early aggressive surgical intervention is important for improving survival, the impact of mortality from different microorganisms remains uncertain. Our study aims to identify the association of mortality and different microorganisms, and the positive and negative predictors of mortality in patients with necrotizing fasciitis.
This retrospective cohort study enrolled patients admitted via the emergency department (ED) with discharged diagnosis of necrotizing fasciitis (International Classification of Diseases, Ninth Revision, code 72886). Multivariate logistic regression analysis was used to identify microbiological, clinical, and biochemical variables independently associated with the mortality of necrotizing fasciitis.
Multivariate logistic regression analysis showed that Vibrio infection, Aeromonas infection, hypotension, malignancy, and band form 10% or greater were significantly associated with increase of mortality (P < .05). They were considered as positive predictors of mortality. The presence of hemorrhagic bullae, however, was significantly associated with decrease of mortality (P < .05). It was considered as negative predictor of mortality.
Aeromonas infection, Vibrio infection, cancer, hypotension, and band form white blood cell count greater than 10% are independent positive predictors of mortality in patients with necrotizing fasciitis. Streptococcal and staphylococcal infections, in contrast, are not predictors of mortality. The presence of hemorrhagic bullae is an independent negative predictor of mortality. Further study should focus on the accuracy of these factors.
United States Sanitary Commission Surgical memoirs of the War of the Rebellion Hurd and Houghton; 1871 Investigation upon the nature, causes and treatment of hospital gangrene as prevailed in the Confederate armies 1861–1865 Fournier's gangrene: a review of 1726 cases
- J Jones
Jones J. United States Sanitary Commission. Surgical memoirs of the War of the Rebellion. New York, NY: Hurd and Houghton;
1871. Investigation upon the nature, causes and treatment of hospital gangrene as prevailed in the Confederate armies 1861–1865;
pp. 142–580.
[5].
N. Eke, " Fournier's gangrene: a review of 1726 cases, " BJS, 2000:87(6):718–28.
[6].
Laboratory indicators for early detection and surgical treatment of vibrio necrotising fasciitis
- Yh Tsai
- Rww Hsu
- Kc Huang
- Tj Huang
Tsai YH, Hsu RWW, Huang KC, Huang TJ. Laboratory indicators for early detection and surgical treatment of vibrio necrotising
fasciitis. Clin Orthop Relat Res 2010;468(8):2230–37.
- B Wilson
- Necrotizing Fasciitis
Wilson B. Necrotizing fasciitis. Am Surg. 1952 Apr;18(4):416-31.
[4].
Necrotizing fasciitis
- B Wilson
Wilson B. Necrotizing fasciitis. Am Surg. 1952 Apr;18(4):416-31.
United States Sanitary Commission. Surgical memoirs of the War of the Rebellion
- J Jones
Jones J. United States Sanitary Commission. Surgical memoirs of the War of the Rebellion. New York, NY: Hurd and Houghton;
Hyperbaric oxygen therapy in necrotising soft tissue infections: a study of patients in the United States Nationwide Inpatient Sample
- C R Soh
- R Pietrobon
- J J Freiberger
- S T Chew
- D Rajgor
- M Gandhi
Soh CR, Pietrobon R, Freiberger JJ, Chew ST, Rajgor D, Gandhi M et al. Hyperbaric oxygen therapy in necrotising soft tissue
infections: a study of patients in the United States Nationwide Inpatient Sample. Intensive Care Med. 2012 Jul;38(7):1143-51. doi:
10.1007/s00134-012-2558-4. Epub 2012 Apr 20.
Diagnosis and management of necrotizing faciitis: a multiparametric approach
- M S Morgan
Morgan MS. Diagnosis and management of necrotizing faciitis: a multiparametric approach. J Hosp Infect. 2010 Aug;75(4):249-57.
doi: 10.1016/j.jhin.2010.01.028. Epub 2010 Jun 9
Independent predictors of mortality for necrotizing fasciitis: a retrospective analysis in a single institution
- K F Huang
- M H Hung
- Y S Lin
- C L Lu
- C Liu
- C C Chen
Huang KF, Hung MH, Lin YS, Lu CL, Liu C, Chen CC et al. Independent predictors of mortality for necrotizing fasciitis: a
retrospective analysis in a single institution. J Trauma. 2011 Aug;71(2):467-73; discussion 473. doi: 10.1186/1477-7819-6-67
Laboratory indicators for early detection and surgical treatment of vibrio necrotising fasciitis
- Y H Tsai
- Rww Hsu
- K C Huang
- T J Huang
Tsai YH, Hsu RWW, Huang KC, Huang TJ. Laboratory indicators for early detection and surgical treatment of vibrio necrotising
fasciitis. Clin Orthop Relat Res 2010;468(8):2230-37.