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

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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.
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Laboratory risk indicator for necrotising fasciitis
(LRINEC) score for the assessment of early
necrotising fasciitis: a systematic review of the
literature
J Bechar, S Sepehripour, J Hardwicke, G Filobbos
Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
ABSTRACT
INTRODUCTION Early operative debridement of necrotising fasciitis is a major outcome determinant. Identification and diagno-
sis of such patients can be clinically difficult. The Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score first pub-
lished 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.
KEYWORDS
Necrotising fasciitis Score LRINEC Cellulitis
Accepted 14 February 2017
CORRESPONDENCE TO
Janak Bechar, E: janakashwin.bechar@nhs.net
Introduction
Necrotising fasciitis is a rare, potentially life-threatening
infection involving the fascia and subcutaneous tissues. This
can progress to necrosis, leading to a systemic inflammatory
response syndrome (SIRS), shock and even death. Features of
necrotising fasciitis include purpura, subcutaneous bleeding,
bullae, necrosis and gangrene. Mortality from this disease is
up to 40%, with around 500 cases per year.
1,2
Necrotising fas-
ciitis infection is categorised as type 1 (infection from both
aerobic and anaerobic bacteria) and type 2 (group A beta-
haemolytic Streptococcus and Staphylococcus aureus).
3
The high morbidity and mortality associated with necrot-
ising fasciitis has not changed markedly since its description
over 50 years ago.
4,5
Early clinical differentiation between
necrotising fasciitis and cellulitis is important when consid-
ering surgical management. Delayed recognition is a key
factor when considering the high mortality.
6
Imaging modal-
ities such as computed tomography, magnetic resonance
imaging and frozen section biopsy have been previously
used in the discrimination between necrotising fasciitis and
other soft tissue infections but these methods have been lim-
ited by cost and availability.
2,7,8
The Laboratory Risk Indicator for Necrotising Fasciitis
(LRINEC) is a clinical tool first described by Wong C et al.
9
The tool is based on six common serum parameters at the
time of presentation: C-reactive protein (CRP), total white
cell count, haemoglobin, serum sodium, creatinine and glu-
cose (Table 1). An LRINEC of six or greater confers a higher
risk of necrotising fasciitis.
9
The LRINEC scoring system has
been controversial, with papers questioning its role as a
scoring system for prognostic identification.
10,11
Diagnostic scoring has the potential to prevent marked
morbidity and mortality in the accurate diagnosis of necrot-
ising fasciitis. There have been no papers to date offering a
comprehensive review of the literature to reach consensus
regarding the LRINEC score. Our principle objective is to
provide the reader with a critical analysis of the literature
and LRINEC score for future use.
Ann R Coll Surg Engl 2017; 99: 341346 341
REVIEW
Ann R Coll Surg Engl 2017; 99: 341346
doi 10.1308/rcsann.2017.0053
Methods
A systematic review of publications in English was con-
ducted of the following electronic databases: EMBASE,
MEDLINE and the Cochrane Database of Systematic
Reviews. The key words used were (necrotising OR necrotis-
ing) AND (fasciitis) AND (score). The inclusion date range
was 1 January 2004 to 1 June 2015.
Two researchers (JB and GF) independently selected
papers from the databases. Papers were selected through
two levels of screening. The first level entailed the review of
abstracts satisfying the inclusion and exclusion criteria. The
second level of screening involved the review of the articles
in full, with the same application of inclusion and exclusion
criteria. Only studies which passed both the first and second
levels of screening were included in our analysis. Articles
were included if a subgroup of patients fulfilling the
inclusion and exclusion criteria could be extracted. Our pro-
cedure for assessing data within papers was in keeping with
the Preferred Reporting Items for Systematic Reviews and
Meta-analysis criteria.
12
Articles (not letters or case reports)
were included if they met the criteria (Table 2).
Assessment of methodological quality was made accord-
ing to the Consolidated Standards of Reporting Trials.
13
The
methodological quality of non-randomised studies was
assessed using the Methodological Index for Non-Rando-
mised Studies (MINORS) tool.
14
Extracted data (Table 2) were recorded in a Microsoft
Excel® spreadsheet. A Kappa statistic was used to measure
the agreement between reviewers for included articles. We
performed multiple statistical analyses to pooled propor-
tions. All statistical models were produced and presented
using Stats Direct (StatsDirect Ltd, Cheshire, UK). Compari-
sons between groups was made using confidence intervals.
Further values were compared using means, standard devia-
tions, Pearson Correlation coefficient (r), two-tailed student
T test, two-tailed single-sample T test and receiver operator
curve (ROC) plots. The threshold for significance was P<
0.05.
Results
The literature search identified 77 articles. After the applica-
tion of inclusion and exclusion criteria at the first and sec-
ond level of screening, 16 articles were included in the final
analysis (Kappa 0.72; Fig 1).
9,1619,2131
The mean MINORS
score for comparative studies was 8.6 and 7.0 for non-com-
parative studies.
A total of 846 patients was included from the selected
papers (range 7209). The continents of origin were Europe
for nine papers, Asia for five papers, North America for one
paper and Oceania for one paper. The mean number of
years of study was 6.5 years (range 115 years). The mean
LRINEC score for patients with necrotising fasciitis was 6.06.
The mean LRINEC score for patients without necrotising
fasciitis was 2.45. The Pearson correlation coefficient
Table 1 The Laboratory Risk Indicator for Necrotising
Fasciitis
Parameter Range Score
a
Hb (g/dl) >13.5 0
1113.5 1
<11 2
White cells (10^9/L) <15 0
1525 1
>25 2
Sodium (mmol/L) <135 2
Creatinine (μmol/L) >141 2
Glucose >10 1
C-reactive protein >150 4
a
Score 5 = <50% risk (low); 67 = intermediate risk; 8=
>75% risk (high).
Table 2 Inclusion and exclusion criteria
Criterion Inclusion Exclusion
Population Human Non-human
Adults (>18yrs) Non-tissue infection/NF
Soft tissue infection Non-English
Any country of origin Review articles
Full article Conference proceedings
Intervention LRINEC score No LRINEC score
Comparator LRINEC score to necrotising fasciitis and soft-tissue infections
Outcomes Confirmed necrotising fasciitis Necrotising fasciitis not confirmed
Study design Any clinical study
a
Non-clinical study
a
Comparative or non-comparative, randomised or non-randomised
342 Ann R Coll Surg Engl 2017; 99: 341346
BECHAR SEPEHRIPOUR HARDWICKE FILOBBOS LABORATORY RISK INDICATOR FOR NECROTISING FASCIITIS
(LRINEC) SCORE FOR THE ASSESSMENT OF EARLY NECROTISING
FASCIITIS: A SYSTEMATIC REVIEW OF THE LITERATURE
between LRINEC score and positive diagnosis of necrotising
fasciitis was r= 0.637 (P= 0.01). A two-tailed student T test
was used to compare patients with a positive diagnosis of
necrotising fasciitis and patients with a negative diagnosis. A
two-tailed analysis was chosen to accommodate patients
with LRINEC scores at the extremes of the range. This
revealed t= 2.98 (P= 0.01). A two-tailed single-sample T test
was used to determine the value at which the LRINEC score
was statistically significant in patients with necrotising fas-
ciitis; with an LRINEC score of 6, t= 0.14 (P= 0.44). An LRI-
NEC score of 7.1 was significant (t=1.93, P= 0.03). Figure 2
illustrates an ROC curve for patients with and without
necrotising fasciitis with calculated LRINEC scores. The fit-
ted ROC area was 0.927. Figure 3 shows a forest plot of
papers for LRINEC means, with score range and confidence
intervals where indicated.
Discussion
It has been suggested that the LRINEC score is capable of
detecting early cases of necrotising fasciitis among patients
with severe soft tissue infections. Wong et al. suggest a LRI-
NEC threshold of 6 for patients with a suspicion of necrot-
ising fasciitis and a score of 8 for patients with a strong
prediction for the disease.
9
The importance of adopting an
Articles identified through database
searching
(n = 77)
IdentificationScreeningEligibilityIncluded
No duplicates
Titles and abstracts screened
(n = 77)
Full texts assessed for eligibility
(n = 22)
Studies included for data extraction
(n = 16)
Full articles excluded (n = 3)
Non-extractable data (3)
Abstracts excluded with reasons (n = 74)
case reports (2)
letters (1)
No LRINEC (52)
Figure 1 Search strategy for inclusion and exclusion of articles into the systematic review.
1.0
ROC Curve
0.5
0.0
0.0 0.5
False positive fraction
True positive fraction
1.0
Figure 2 Receiver operating characteristic (ROC) curve of
LRINEC scores for patients with and without necrotising
fasciitis; blue line = fitted ROC curve; grey line = 95%
confidence interval of fitted ROC curve.
Ann R Coll Surg Engl 2017; 99: 341346 343
BECHAR SEPEHRIPOUR HARDWICKE FILOBBOS LABORATORY RISK INDICATOR FOR NECROTISING FASCIITIS
(LRINEC) SCORE FOR THE ASSESSMENT OF EARLY NECROTISING
FASCIITIS: A SYSTEMATIC REVIEW OF THE LITERATURE
evidence-based approach for the diagnosis of necrotising
fasciitis has the potential to lead to early diagnosis, surgical
intervention and improved morbidity and mortality. Mortal-
ity rates vary widely, from over 50% to as low as 8.6%,
15
with
the low mortality figures being attributed to a low compara-
tive patient age (less than 62 years) in some studies. The
average LRINEC score reported in our study was 6.06, over
the threshold of 6 reported by Wong et al.
9
The score also
varied markedly for the part of the body affected with necrot-
ising fasciitis, with limbs scoring 6, groin 6.8 and chest/trunk
7.3.
The number of studies that reported an LRINEC score in
patients without necrotising fasciitis were comparatively
few, with only Chao et al.
16
and Holland et al.
17
reporting
scores of 1.1 and 3.8, respectively. Chao et al. reported the
use of the LRINEC score uniquely in patients with necrotis-
ing fasciitis and soft tissue infection with the atypical micro-
organism Vibrio vulnificus. The retrospective study
examined 125 consecutive patients with this microorganism
over 8 years. The LRINEC score in soft tissue infections
(necrotising fasciitis negative) may have been biased owing
to the atypical nature of this organism. The paper by Holland
et al.
17
retrospectively examined 28 patients with the
possibility of a necrotising fasciitis diagnosis on admission.
Of these, 17 were found to have severe soft tissue infections
with a low LRINEC of 3.8. The small numbers of both of
these patient groups for a negative necrotising fasciitis LRI-
NEC score lends to a perceived low sensitivity. Of the 16
studies included in this review, only four detailed a coeffi-
cient of variance ranging from 0.2 described by Citak et al.
18
to 0.7 by Chao et al.
16
This suggests a small range of LRINEC
scores for a given patient with necrotising fasciitis. Only two
papers demonstrated a range of LRINEC scores with confi-
dence intervals (Fig 3).
Swain et al.
19
retrospectively studied patients with necrot-
ising fasciitis over a five-year period, recruiting 15 patients
with the disease between 2006 and 2011. Of these patients,
the mean LRINEC score varied for patients who survived
and those who died. The LRINEC score was comparatively
higher for patients who died (LRINEC 9) versus those who
survived (LRINEC 6.5) with necrotising fasciitis. The paper
also examined the comorbidities associated with necrotising
fasciitis. The authors found the highest associated comor-
bidities were diabetes, hypertension, obesity and
hypercholesterolaemia.
19
Avinash M
Mean LRINEC score in published papers
Backhaus M
Chao W
Citak M
Glass G
Hodgins N
Holland M
Lee L
Mizokami F
Swain R
Tilcorn D
1 2 3 4 5 6 7 8 9 10 11
Figure 3 Forest plot for papers included in the study.
344 Ann R Coll Surg Engl 2017; 99: 341346
BECHAR SEPEHRIPOUR HARDWICKE FILOBBOS LABORATORY RISK INDICATOR FOR NECROTISING FASCIITIS
(LRINEC) SCORE FOR THE ASSESSMENT OF EARLY NECROTISING
FASCIITIS: A SYSTEMATIC REVIEW OF THE LITERATURE
The LRINEC score examines six laboratory-based param-
eters but makes no consideration for patient age, comorbid-
ities, clinical observations and other blood parameters (e.g.
lactate) as do other scoring systems such as APACHE II and
GLASGOW scoring in pancreatitis. Other perceived
criticisms of the LRINEC score are the relatively small
cohort used to devise the score, an over-reliance on non-
specific CRP (given a maximal score of 4 compared with
other parameters). Borschitz et al.
20
conducted an observa-
tional study which recruited 29 patients with necrotising fas-
ciitis and 59 matched comparators. Of the additional
parameters, patients with necrotising fasciitis compared
with control have statistically increased pain. Patients with
renal failure and chronic venous insufficiency also showed a
higher risk of diagnosis for necrotising fasciitis. The authors
suggested an addition of several parameters (Table 3). Fur-
ther studies need to be performed to validate the additional
parameters suggested by Borschitz et al.
20
This may take the
form of a prospective comparative study, with all patients
with suspected cellulitis, abscess and necrotising fasciitis
being enrolled with timed follow-up to resolution. This
would elucidate the scores apparent better sensitivity and
specificity as compared with the standard LRINEC score.
Conclusion
The LRINEC score is a useful adjunct in the clinical diagno-
sis of necrotising fasciitis with a statistically positive correla-
tion. The score, however, is amenable to further
development, with the possible addition of clinical perime-
ters such as pain, pyrexia and comorbidities.
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Table 3 Modified Laboratory Risk Indicator for Necrotising
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Parameters Range Score
a
Laboratory
C-reactive protein >150 mg/dl 4
Total white cell count <15 × 106/mm
3
0
Total white cell count 1525 × 106/mm
3
1
Total white cell count >25 × 106/mm
3
2
Erthrocyte count <4 × 10^6/μl1
Haemoglobin >13.5 g/dl 0
Haemoglobin 1113.5 g/dl 1
Haemoglobin <11 g/dl 2
Creatinine <135 mmol/L 2
Fibrinogen levels >750 mg/dl 2
Clinical
Pain Mild/none 0
Intermediate 1
Strong 2
Fever 37.5°C 0
37.6-37.9°C 1
38°C 2
Tachycardia >100 beats/minute 1
Signs of acute renal injury No 0
Yes 1
a
8 = strong suspicion for necrotising fasciitis 67 = suspicion;
no suspicion
Ann R Coll Surg Engl 2017; 99: 341346 345
BECHAR SEPEHRIPOUR HARDWICKE FILOBBOS LABORATORY RISK INDICATOR FOR NECROTISING FASCIITIS
(LRINEC) SCORE FOR THE ASSESSMENT OF EARLY NECROTISING
FASCIITIS: A SYSTEMATIC REVIEW OF THE LITERATURE
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346 Ann R Coll Surg Engl 2017; 99: 341346
BECHAR SEPEHRIPOUR HARDWICKE FILOBBOS LABORATORY RISK INDICATOR FOR NECROTISING FASCIITIS
(LRINEC) SCORE FOR THE ASSESSMENT OF EARLY NECROTISING
FASCIITIS: A SYSTEMATIC REVIEW OF THE LITERATURE
... A leukemoid reaction is described as a white blood cell value more than 50,000 cells/mL associated with an increase in immature forms of neutrophils [4]. Clinically it is diagnosed only after excluding malignant hematological disorder, CML or CNL. ...
... MRI and CT scan can be used to differentiate from equivocal findings. There is no lab parameter specific for necrotising fasciitis identified till date, but there has been a proposition of a Laboratory Risk Indicator for Necrotizing Fasciitis score (LRINEC) to categorise the risk of the same [4]. Treatment includes a course of IV antibiotics. ...
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Necrotizing fasciitis is infrequently encountered but highly fatal group of infections. It is a infection of any of the three layers of soft tissue compartments which includes the dermis, subcutaneous tissue, superficial fascia,deep fascia or the muscle along with necrotising changes. During the initial stages it might be tricky to differentiate cellulitis and other infections of the superficial skin from necrotising fasciitis leading to an delay in the diagnosis. Prompt diagnosis and management can reduce mortality .This case report highlights a previously unreported presentation of necrotising fasciitis of breast in the form of leukemoid reaction encountered in the rural central India following COVID-19 infection. Case Study Popat et al.; JPRI, 33(62B): 217-222, 2021; Article no.JPRI.79576 218
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... Chest and leg X-rays were normal. The patient was diagnosed with NF of the left leg with an LRINEC score of 8 [5]. ...
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Background Necrotizing fasciitis (NF) is a rare and life-threatening form of infection involving rapidly spreading inflammation and extensive necrosis of the skin, subcutaneous tissue, and superficial fascia. Case presentation This study reported two cases of NF in a 56-year-old female and a 38-year-old male who demonstrated typical signs and symptoms of necrotizing fasciitis. Both presented to the hospital with skin necrosis in the lower extremity, sepsis shock, and multiorgan failure. Based on the clinical presentation, physical examination, and additional examination, a diagnosis of necrotizing fasciitis was made. The LRINEC score was used to distinguish NF from other soft tissue infections. Both patients were treated with empirical antibiotics, surgical debridement and planned to be amputated, but the patients were hemodynamically unstable and passed away before the amputation proceeded. Discussion Delay in the diagnosis of NF increases the risk of mortality and the use of the LRINEC score is very helpful in decision making for health workers. Conclusion The key to the management of NF is early diagnosis, debridement, removal of necrotic tissue, amputation, and use of empirical antibiotics.
... Ein Zeitverlust für die spätere Therapie sollte jedoch unbedingt vermieden werden. Bei unklarer Diagnose ist eine Probeinzision mit Biopsien für die Mikrobiologie und Pathologie zur Diagnostik zu entnehmen [1]. Oft findet sich auf der nekrotischen Faszie auch eine gräulich-trübe Flüssigkeit, das sog. ...
... However, although the LRINEC score is a useful tool for the diagnosis of an NSTI, its validity for predicting the prognosis has not been proven. 13) Furthermore, its use is limited when competing inflammation is present, because such a condition might cause similar laboratory derangements. As the LRINEC score alone does not accurately represent the patient's comprehensive clinical condition, we decided to include some factors including time from diagnosis to surgery, comorbidities, microbiological features, and the patient's hemodynamic status at the time of visiting the emergency room in the analysis of patients with NSTIs. ...
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Background: Emergent diagnosis and treatment are important for the survival of patients with necrotizing soft-tissue infections (NSTIs). Death is the most catastrophic outcome, but limb loss is also one of the most important complications that can have a significant impact on the rest of the patient's life. The purpose of this study was to identify predictive factors for limb loss caused by NSTIs. Methods: The data of patients at our center who were diagnosed with NSTIs from May 2003 to January 2019 were analyzed retrospectively. The inclusion criteria were patients with a definite diagnosis of NSTI involving the upper or lower limb. A total of 49 patient records were analyzed in terms of demography, laboratory data, microbiological causes, treatment, and final outcome. Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) scores at initial admission were also collected as laboratory data. Final outcomes were classified into survival with limb salvage and survival with limb loss. Results: The limb loss rate was 20.4% (10/49) in our study. On comparison between the limb salvage group and the limb loss group, independent risk factors of limb loss were as follows: presence of hypotension at admission (odds ratio [OR], 8.2; 95% confidence interval [CI], 1.7-38.3; p = 0.008); LRINEC score ≥ 9 (OR, 5.8; 95% CI, 1.3-25.6; p = 0.012), and glucose level > 300 mg/dL (OR, 4.5; 95% CI, 0.9-21.9; p = 0.041). Various microbiological organisms were isolated; the most prevalent specimen was streptococci (32.6%), followed by staphylococci (26.5%). Poor outcomes including limb loss and mortality had no correlation with microbiological organisms. Conclusions: For patients with NSTIs, the presence of hypotension at admission, a high glucose level (> 300 mg/dL), and a high LRINEC score (> 9) were independent risk factors for limb loss.
... In addition, the LRINEC score is an adjunct biochemical tool that may assist clinicians to identify and stratify the risk of NF in patients with suspected soft tissue infection [8]. The average LRINEC score of all NF patients in our study was 5.9, and it was comparable to that of a systematic review (6.06) [17]. ...
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The purpose of this study was to determine the impact of coronavirus disease 2019 (COVID-19) on the delayed presentation of necrotising fasciitis (NF). A retrospective study was conducted of adult patients (≥16 years old) diagnosed with NF at a hospital from 2017 to 2020. A quantitative comparative analysis for the COVID-19 group and control group between 2017 and 2019. Structured interviews were conducted to examine the impact of COVID-19 on patients. There were 6 patients in the COVID-19 group and 10 patients in the control group. The COVID-19 group had a longer mean onset of symptoms till hospital presentation of 4.1 days and a longer mean operative time. The COVID-19 group was more likely to be admitted to intensive care unit. Three patients in the COVID-19 group did not survive compared to survival in the counterparts. Participant responses indicated the COVID-19 pandemic did not prevent them from presenting to ED.
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Necrotizing fasciitis is a rare and severe infectious disease that is often fatal and is characterized by the extensive necrosis of subcutaneous tissue and fascial planes. A number of clinical parameters have been intensively investigated to diagnose and assess the severity and prognosis of necrotizing fasciitis. Since it currently remains unclear whether these parameters are also abnormal before disease onset, the present study investigated this issue. We retrospectively recruited 38 patients, including 12 and 26 patients with necrotizing fasciitis and cellulitis, respectively. The results of routine blood examinations were collected at disease onset and also at baseline, which was defined as the time point before disease onset. No significant differences were observed in age or sex between the necrotizing fasciitis and cellulitis groups. However, significant differences were noted in the levels of hemoglobin, lymphocyte count, platelet count, neutrophil‐to‐lymphocyte ratio, sodium, creatinine, albumin, D‐dimer, and Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score at disease onset. Significant differences were also observed in the levels of hemoglobin, lymphocyte count, monocyte count, platelet count, creatinine, D‐dimer, and LRINEC score at baseline. Hemoglobin, platelet count, C‐reactive protein, creatinine, albumin, and D‐dimer levels were already abnormal at baseline in the necrotizing fasciitis group. In conclusion, the present results revealed precritical abnormalities in routine blood parameters in patients with necrotizing fasciitis. Therefore, individuals predisposed to necrotizing soft tissue infection may be identified prior to disease onset.
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Background Necrotizing fasciitis (NF) is a life-threatening condition requiring urgent attention. It is clinically difficult to diagnose, linked to severe systemic toxicity, and has poor prognosis. In 2001, Andreasen and coworkers described the “Finger test” for the diagnosis of NF. Subsequent studies have suggested early recognition and management of NF. In this study, we compare the LRINEC—Laboratory Risk Indicator for Necrotizing Fasciitis—scoring system with the “Finger test” and histopathological examination for diagnosis of NF. Results In our study, LRINEC scoring system and Finger test are statistically significant in the diagnosis of NF. Males are more frequently affected, and the most common organism causing NF is Staphylococcus. Histopathology remained the gold standard for diagnosis of NF, while LRINEC score and Finger test were good diagnostic tools for early diagnosis, with sensitivities of 83.33 and 86.11%, respectively. Conclusion LRINEC laboratory-based scoring system is easy and reliable diagnostic tool though histopathology remains the gold standard. There is statistically significant correlation between histopathology and laboratory criteria. LRINEC test is independently better than bedside Finger test alone or combined LRINEC and bedside Finger test.
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Necrotising soft tissue infection (NSTI) is a rare but life threatening diagnosis. Geographic, economic and social variances influence presentation and prognosis. As the current literature does not reflect a UK metropolitan population, we conducted a retrospective chart review to establish pertinent features relevant to our practice. Patients with histologically confirmed diagnoses of NSTI presenting to two London teaching hospitals between January 2007 and July 2013 were included in the study. Features of presentation, surgical and medical management, microbiological findings and outcome were evaluated. Twenty-four patients with histologically confirmed NSTI were included. Two age clusters were identified, with means of 46 years (standard deviation [SD]: 10 years) and 80 years (SD: 6 years). Pain, erythema and sepsis were common findings. Hypertension, hypercholesterolaemia and type II diabetes mellitus were common co-morbidities. A third of younger patients had human immunodeficiency virus or hepatitis C, with a quarter dependent on drugs and/or alcohol. The mean Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score was 5.8 (SD: 3.3). The lower extremities, groin and perineum were common sites of infection. Fourteen patients required inotropic support and seventeen required transfusions. The median number of surgical procedures was 5 (range: 1-17). Group A Streptococcus was the most frequently identified pathogen. Five patients died. Being elderly, female sex and failure to use clindamycin as a first-line antibiotic were associated with significantly higher mortality. In contrast to other recent series, group A streptococcal monomicrobial NSTI remains the most common presentation in our population. Survival is anticipated in young patients, regardless of premorbid status. Elderly patients have a poor prognosis. The negative predictive value of the LRINEC score is questioned. Use of clindamycin as a first-line antibiotic is supported.
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Necrotising Fasciitis is a destructive infection of the skin and subcutaneous tissues associated with significant mortality and morbidity. Survival from the condition often necessitates patient referral for appropriate reconstructive surgery and supportive medical management. The aim of our study was to identify emerging patterns, characteristics and outcomes of necrotising fasciitis in Northern Ireland. A retrospective analysis of all patients referred to the Regional Plastic Surgery Service in Belfast between 2007 and 2012 was performed. Forty-six patients were identified with clinical, intraoperative and histopathological confirmation of necrotising fasciitis. Mean patient age was 59.4 years (range 32-88) with a 25:21 male to female ratio. 13 patients died from the disease. Smoking, obesity, diabetes and immunocompromise were the most prevalent co-morbidities identified. 37 patients had no identifiable mechanism of infection initiation in the history. Painful cellulitis (44/46), skin necrosis (26/46), skin blistering (8/46) and subcutaneous emphysema (3/46) were the most common presenting features. The median LRINEC score at presentation was 7 (range 2-12). The mean serum lactate at presentation was 4.0 mmol/L (range 1.6-13.5). LRINEC scores and serum lactate at presentation exhibited diagnostic sensitivities of 65% and 90% respectively. The lower extremity was the most commonly affected anatomical site (16/46). Group A Streptococcus was the most frequently isolated causative bacterium from debrided tissue cultures (16/46). The prevalence of necrotising fasciitis in the population studied is increasing, particularly in relation to patient cases caused by Group A Streptococcal infection. Increasing bacterial virulence and levels of patient immunocompromise may explain this increasing trend. The LRINEC scoring system lacked diagnostic sensitivity. Elevated serum lactate was supported as both a diagnostic and prognostic indicator. The findings of our study are somewhat limited in their application to other regions and highlight the need for a national analysis of necrotising fasciitis in the UK. Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
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Necrotising soft tissue infection (NSTI) is an extremely serious condition that relies on a high index of suspicion, prompt diagnosis and emergent radical surgical treatment. We explored the presentation, management and outcomes of NSTI within our department. We also assessed the potential benefit of using risk predictor scoring system. Retrospective review using departmental electronic database and hospital records. Twenty-four patients were treated for NSTI within our department between 2004 and 2010. Seventeen presented in our hospital to various surgical and medical teams. All patients presented with pain, swelling, erythema and tenderness at palpation. Only 40% of necrotising fasciitis and 28.6% of Fournier's gangrene were diagnosed as NSTI at initial assessment. Average mean interval time from admission to primary surgery was 17.7 h and 4 h from diagnosis to primary surgery. There were four mortalities. The average risk predictor Laboratory Risk Indicator for Necrotising Fasciitis score was 7.9. Significant morbidities post-operatively included bowel stoma, long-term urinary catheter and new diagnoses of carcinomas. Physicians and surgeons need to be suspicious of NSTI in severe cases of soft tissue infection to prevent delay in diagnosis and life-saving treatment. Scoring system can be used judiciously as adjunct to aid diagnosis.
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Necrotising fasciitis of the extremities is a rapidly progressive, potentially life threatening soft tissue infection. Early diagnosis, aggressive surgical and critical care management is vital in preventing mortality. This series reports the clinical presentation, behaviour of inflammatory markers, histological, microbiological and radiological findings in seven cases, which presented to our orthopaedic unit over the last one year. Seven patients (4 male and 3 female) were included. Usual presentation was spreading erythema and pain. Duration of symptoms varied from 3 to 14 days. All except one case affected the lower limbs. The average Laboratory risk indicator for necrotising fasciitis (LRINEC) score on the day of presentation was 5. Imaging demonstrated subcutaneous oedema, fluid and air pockets in muscular planes. Group A beta haemolytic Streptococcus was the most common organism isolated from culture. Treatment modalities included antibiotics, immunoglobulins and surgical debridement. Four of the patients showed full remission. However, three (one with pre-existing carcinoma) of them succumbed to the condition.
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Necrotising fasciitis is a life-threatening illness that is often difficult to diagnose. Immediate debridement and intravenous antibiotic therapy are required to limit the spread of infection. This five-year audit aimed to review the number and outcomes of all cases of necrotising fasciitis admitted to a tertiary referral unit and to assess the validity of the Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) scoring system. A retrospective analysis of patient notes over the five-year period from October 2006 to October 2011 was undertaken. The LRINEC score was calculated for each patient to evaluate its usefulness. Overall, 15 patients were diagnosed with necrotising fasciitis. Three patients died. The median age of patients was 51.0 years (range: 34-76 years). There were no obvious predisposing factors in 8 cases but patients had a median of 2.0 co-morbidities. The most common infective agent, present in five patients, was Group A Streptococcus. Other monomicrobial agents included Group G Streptococcus and Klebsiella pneumoniae. Polymicrobial infections were less common than mono-microbial infections and two patients had a polymicrobial infection including methicillin-resistant Staphylococcus aureus. Although the LRINEC scoring system identified 12 of the 15 patients as having a high or intermediate likelihood of necrotising fasciitis, 3 were classified as low likelihood. This limited case series strongly suggests that the LRINEC system is too insensitive for diagnosis.
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Necrotizing soft tissue infections (STIs) are serious complications that may arise from pressure ulcers. However, there are few studies on this important issue. In addition, diagnostic criteria for necrotizing STIs developing from pressure ulcers and infected pressure ulcers are not well established. We defined necrotizing STIs developing from pressure ulcers based on clinical findings. Based on the definition, we retrospectively analyzed the medical records of 24 elderly patients with this condition to determine patient age, gender, comorbid disease, laboratory findings, wound location, bacteriology, and treatment outcomes. In the examined population, necrotizing STIs developed primarily from pressure ulcers over the sacrum. Dementia and diabetes mellitus were also frequently observed in patients with necrotizing STIs. The average Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was relatively low. Bacterial cultures from the debrided deep tissues exhibited mixed infections of gram-positive cocci and gram-negative bacilli, except 1 case. Anaerobic pathogens were isolated from 18 patients (72%), and 7 patients (29%) developed bacteremia. None of the cases were preceded by wounds dominated by granulation tissue. Surgical intervention, combined with antibacterial therapy involving intravenous carbapenem or cephem, was successfully used in most cases. Necrotizing STIs arising from pressure ulcers are generally caused by mixed pathogens and exhibit symptoms that are milder than those of necrotizing fasciitis caused by group A Streptococcus.
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Streptococcus pyogenes (group A streptococcus, GAS) is a major cause of necrotizing soft tissue infection (NSTI). On rare occasions, other β-haemolytic streptococci may also cause NSTI, but the significance and nature of these infections has not been thoroughly investigated. In this study, clinical and molecular characteristics of NSTI caused by GAS and β-haemolytic Streptococcus dysgalactiae subsp. equisimilis of groups C and G (GCS/GGS) in western Norway during 2000-09 are presented. Clinical data were included retrospectively. The bacterial isolates were subsequently emm typed and screened for the presence of genes encoding streptococcal superantigens. Seventy cases were identified, corresponding to a mean annual incidence rate of 1.4 per 100 000. Sixty-one of the cases were associated with GAS, whereas GCS/GGS accounted for the remaining nine cases. The in-hospital case fatality rates of GAS and GCS/GGS disease were 11% and 33%, respectively. The GCS/GGS patients were older, had comorbidities more often and had anatomically more superficial disease than the GAS patients. High age and toxic shock syndrome were associated with mortality. The Laboratory Risk Indicator for Necrotizing Fasciitis laboratory score showed high values (≥6) in only 31 of 67 cases. Among the available 42 GAS isolates, the most predominant emm types were emm1, emm3 and emm4. The virulence gene profiles were strongly correlated to emm type. The number of superantigen genes was low in the four available GCS/GGS isolates. Our findings indicate a high frequency of streptococcal necrotizing fasciitis in our community. GCS/GGS infections contribute to the disease burden, but differ from GAS cases in frequency and predisposing factors.