Necrotizing Fasciitis: A Surgical and Medical Emergency (original) (raw)
Related papers
2022
Necrotizing fasciitis (NF) is a rapidly progressing fascial tissue inflammation and necrosis, with relative skin and underlying muscle sparing. A surgical emergency managed by patient optimization is the key to achieve high quality post operative results. There is a stark difference between inflamed tissue and necrotized tissue. Inflamed tissue is the damaged tissue in response to the microorganism or injury, which leads to an increased blood supply and permeability of blood vessels, while necrotized tissue consists of dead and decaying group of cells caused by infection, trauma, or toxins, which in turn delays the healing of the tissues. The average annual incidence of NF for every 100,000 inhabitants was 0.86. 1 With respect to all age groups, the incidence of NF spiked to 2.5 times more for men across all age groups. 1 Among the comorbid patients, diabetic individuals were found to be more affected. Clostridium infections also are major causative factor. Delay in surgical intervention can be fatal. Another pitfall in diagnosis of NF is that even patients with mild pain, absence of fever, and crepitus can have soft tissue infection. Diagnostic tools used in determining NF are Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) scoring system, Finger test, histopathology tissue
Necrotizing fasciitis [NF] describes a variety of rare necrotizing soft tissue infection characterized by rapidly spreading inflammation and necrosis of the fascia, the subcutaneous tissue, the skin, including the muscles when treatment is delayed. It is critical that NF be differentiated from other skin infections due to its rapid progression and high risk of mortality. This study emphasizes to find various etiology, predisposing factors, treatment modalities and most importantly the search for a tool that reliably and rapidly identifies patients with NF and helps to decide for earlier effective therapy to modify clinical outcome. Material & Methods : The study was done at RIMS, Ranchi in Dept. Of Surgery, between November 2017 and October 2019. Based on inclusion and exclusion criterias the patients were admitted and followed up. Results and Conclusion : NF was most commonly seen in the elderly males, was insidious in most of the cases. Diabetic mellitus was the most common co-morbid factor. The disease most commonly involved extremities followed by perineum. The disease was most common during monsoon and in patients who were barefooted. The disease was most commonly polymicrobical. LRINEC scoring system has a better positive predictive value in identifying the onset of NF and risk stratification of the patients with severe soft tissue infections. There is a statistically significant association between Diabetes Mellitus and the severity of risk. The significance of LRINEC score in predicting the amputation and mortality was statistically significant.
Necrotizing Fasciitis: Current Concepts, Pathogens and Management
Necrotizing fasciitis (NF) is a severe disease of sudden onset that spreads rapidly. The disease is more common in the adults and is rare in the children. The infection enters the body through a break in the skin such as cut or burn. Majority of the cases involve methicillin resistant Staphylococcus aureus(MRSA),anaerobic species, Enterobacteriaceae, hemolytic streptococcus group A are isolated alone or in combination. Streptococcal infections also associated with toxic-shock syndrome. Symptoms include inflammation, fever, and fast heart rate, diarrhea, vomiting, and crepitus may be present, discharge of fluid said to resemble " dish water ". Fournier's gangrene is a form of NF occurring about the male genitals. Gold standard for diagnosis is surgical exploration, with LRINEC score. Patient with a LRINEC score ≥6 have higher rate of mortality and amputation.Medical imaging is helpful to confirm diagnosis. Initial treatment includes a combination of intravenous antibiotics including piperacillin/tazobactam, vancomycin, and clindamycin or ampicillin-sulbactam combined with metronidazole, clindamycin or carbapenems(imipenem).Aggressive surgical debridement is always necessary. Amputation of infected limb(s) may be necessary. Ancillary therapies, neither a substitute for surgical debridement nor proven efficacy have been described. Some studies recommend using intravenous immunoglobulin (IVIG). Nutritional support is imperative. High mortality rates if left untreated. High index of suspicion and knowledge is essential for early diagnosis and outcomes of NF.
Necrotizing fasciitis: risk factors of mortality
Risk Management and Healthcare Policy, 2015
Background: Necrotizing fasciitis (NF) is a serious infection of skin and soft tissues that rapidly progresses along the deep fascia. It becomes a fatal soft tissue infection with high mortality rate if treatment is delayed. Early diagnosis for emergency surgical debridement and broad-spectrum antibiotic therapy were the optimal treatments to reduce the mortality rate of NF. Objective: The aim of this study was to identify risk factors that increased the mortality rate in patients with NF under routine clinical practices. Methods: A retrospective cohort study was performed at three general hospitals located in northern Thailand. All medical records of patients with surgically confirmed NF treated between January 2009 and December 2012 were reviewed. Clinical predictors for mortality were analyzed using multivariable risk regression analysis. Results: Of a total of 1,504 patients with a diagnosis of NF, 19.3% (n=290) died in hospital and 80.7% (n=1,214) survived. From multivariable analysis, being female (risk ratio [RR] =1.37, 95% confidence interval [CI] =1.01-1.84); age .60 (RR =1.39, 95% CI =1.25-1.53); having chronic heart disease (RR =1.64, 95% CI =1.18-2.28), cirrhosis (RR =2.36, 95% CI =1.70-3.27), skin necrosis (RR =1.22, 95% CI =1.15-1.28), pulse rate .130/min (RR =2.26, 95% CI =1.79-2.85), systolic BP ,90 mmHg (RR =2.05, 95% CI =1.44-2.91)
Necrotizing fasciitis: a cumulative review and new techniques in emergency room diagnosis
2016
Necrotizing fasciitis (NF) is a rare and life threating soft-tissue infection specific to the skin's fascia layer. It is most often encountered in the peripheries, abdominal wall, and perineum and has numerous etiologies and associated pathogens. Early diagnosis and rapid surgical debridement are essential in treating NF as the infection progresses rapidly and mortality rate increases significantly with time. The current difficulty in initial diagnosis is due to the lack of obvious skin findings early on in the infection. Laboratory tests, including the laboratory risk indicator for necrotizing fasciitis (LRINEC) score, gas on imaging tests, and physical exam findings are the current clues to an early diagnosis but official diagnosis can only be confirmed by surgical exploration and discovery of a lack of resistance to dissection in the fascia layer. The LRINEC score analyzes one variable, specifically C-reactive protein (CRP), which is often not included in routine laboratory tests skin infections at the emergency department (ED). Furthermore, no specific set of physical exam findings has been distinctly associated with diagnosis of NF over other soft-tissue infections and the most specific imaging tests are too expensive for routine use. A new and modified LRINEC score based only on routine ED laboratory tests as well as an additional objective scoring system for physical exam findings are the next steps toward rapid diagnosis. This approach requires large-scale retrospective vii statistical analyses of NF cases across the country for identification of the most prevalent physical exam findings and abnormal laboratory values. viii
Laboratory Risk Indicators for Necrotizing Fasciitis and Associations with Mortality
Turkish Journal of Emergency Medicine, 2014
Objectives Necrotizing fasciitis (NF) is rare but life threatening soft tissue infection characterized by a necrotizing process of the subcutaneous tissues and fascial planes. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score has been verified as a useful diagnostic tool for detecting necrotizing fasciitis. A certain LRINEC score might also be associated with mortality. The aims of this study are to determine risk factors affecting the prognosis and to evaluate the prognostic value of the LRINEC score in NF. Methods Twenty-five patients with necrotizing fasciitis treated in Samsun Education and Research Hospital between January 2008 and April 2013 were enrolled in the study. Surviving and non-surviving patient groups were compared regarding demographic data, co-morbidity, predisposing factors, causative agents, number of debridements and LRINEC score. Results Mean age was 55.6±16.79 years (min: 17-max: 84), and the female/male ratio was 16/9. Mortality was observed in 6 (24%) patients. The most frequent comorbid diseases were diabetes mellitus (52) and peripheral circulatory disorders (24%), and the most frequent etiologies were cutaneous (32%) and perianal abscess (20%). Pseudomonas aeruginosa infection was higher in the non-surviving group (p=0.006). The mean number of debridements and LRINEC score were higher in the non-surviving group than in the surviving group (p=0.003 and p=0.003, respectively). Conclusions Pseudomans aeruginosa infection and multiple debridements are related with mortality. The LRINEC score might help predict mortality in NF.
Research Square (Research Square), 2021
Background: Necrotizing fasciitis(NF) is a life-threatening infection with high morbidity and mortality rates which should be diagnosed and treated with surgical and antibiotic therapy. Many studies have addressed NF and its subtypes, but few have reviewed the clinical, radiological and pathological differences between the poly-microbial and the mono-microbial groups. Objective: The objective of our study is to describe a relatively large cohort of patients with NF and study and compare the clinical, radiological and pathological differences between the poly-microbial(Pm) and the mono-microbial(Mm) groups. Methods: The charts of hospitalized patients with NF diagnosis from 2002-2019 at the Rabin Medical Center were reviewed. The primary outcome was all-cause mortality at 90 days, secondary outcomes included duration of hospitalization, intensive care unit(ICU) admission, LRINEC score and the need for vasopressor use. Results: 81 patients with NF were included in the study, 54(66.6%) had Mm growth and 27(33.3%) had Pm growth. There were no signi cant differences between the two groups in the 90 days mortality, and moreover in hospital mortality was also insigni cantly different. In a multivariate analysis, we found that 90 days mortality was more prevalent in the Mm group compared to Pm group. In addition, we found that in hospital mortality, ICU admission and vasopressors use were more frequent among the Mm-group compared to the Pm-group. Conclusions: our study is the rst to compare the differences between the two most prevalent entities of NF. The results demonstrate better prognosis for Pm-NF, with minimal ICU stay, lower mortality, and lower use of vasopressors.
International Surgery Journal
Background: Necrotizing fasciitis (NF) is a potentially life threatening disease. Delayed recognition and surgical intervention is directly linked to increased mortality. Laboratory risk indicator for necrotizing fasciitis (LRINEC) score, a laboratory oriented tool has potential to prevent morbidity and mortality but there exhibits a controversy regarding its utility which needs re-evaluation to prove it’s utility.Methods: A tertiary care hospital based observational study aims to evaluate diagnostic and prognostic value of LRINEC score. Patient above 18 years clinically diagnosed as SSTI and confirmed as NF histopathologically without co-morbidities were enrolled as subjects. Clinical evaluation and laboratory oriented LRINEC score were the study factors. Outcome factors were morbidity and mortality and histopathological confirmation of NF. Patients were analyzed as cellulitis and NF with identification of factors associated with NF; Univariate analysis with Kaplan-Meier survival a...
Mortality Risk in Necrotizing Fasciitis: National Prevalence, Trend, and Burden
Surgical Infections, 2020
Background: Necrotizing fasciitis (NF) is a fulminant, life-threating infection of fascia and subcutaneous tissue. Because of the low incidence, previous studies were statistically underpowered to assess factors associated with the risk of mortality. The aim of this study is to identify the risk factors associated with mortality in this select group of patients. Methods: A retrospective cross-sectional study was performed utilizing the Nationwide Readmissions Database, 2010-2014. The database captures 56.6% of all U.S. annual hospitalizations. Study population included inpatients admitted emergently with NF. Results: A total of 4,178 cases were included, of which 2,061(48.9%) patients had a history of diabetes mellitus (DM). The most common presentation was septicemia (39.5%) and 9.2% were admitted initially as cellulitis/ abscess. Overall mortality risk was 12.6% with no substantial change in the annual trend. Mortality in patients with diabetes was substantially lower (8.5% vs. 16.5%, odds ratio [OR]: 0.44, 95% confidence interval [CI] = [0.34, 0.56], p < 0.001). Factors associated with a higher mortality risk included: older age, chronic liver diseases, disseminated intravascular coagulopathy, septic shock, pulmonary complications, acute renal failure, and not undergoing surgical intervention (p < 0.05 each). Patients who did not undergo surgical debridement were more likely to be ‡65 years of age and have multiple comorbidities. Hyperbaric oxygen therapy and intravenous immunoglobulin were used in 1.3% and 0.3% of the sample, respectively, with no reported use among patients who died. Conclusions: This study provides a new and updated perspective on the prevalence, trend, and outcomes of NF in the United States. Necrotizing fasciitis is associated with septicemia and lack of surgical intervention is associated with a higher mortality.
Tzu Chi Medical Journal, 2012
Objective: Necrotizing fasciitis is a surgical emergency. It has a poor outcome after late operative intervention but the clinical diagnosis is difficult. The laboratory risk indicator for necrotizing fasciitis (LRI-NEC) score was first introduced in 2004 and several clinicians have suggested it is useful for early recognition of necrotizing fasciitis but its validation still needs to be examined. We collected our hospital data from May 2003 to September 2010 to validate whether the LRINEC score can aid in early recognition of necrotizing fasciitis. Materials and Methods: This is a validation cohort study. We reviewed all necrotizing fasciitis patients admitted from the emergency department at Buddhist Tzu Chi Dalin General Hospital in Taiwan from May 2003 to September 2010. All patients had pathological diagnoses. We used multiple imputations for missing patient data. We analyzed these data and examined whether the LRINEC score had a higher diagnostic value than the clinical diagnosis before admission. We also examined the LRINEC score in patients with severe cellulitis to determine its usefulness in excluding necrotizing fasciitis. Results: A total of 233 patients with necrotizing fasciitis and 3155 with severe cellulitis were included in our study. A LRINEC score 6 had a sensitivity of 59.2% (CI 52.9e65.6%), specificity of 83.8% (CI 81.9 e85.7%), likelihood ratio of 3.89, positive predictive ratio of 37.9% (95% CI 32.9e42.9%), and negative predictive ratio of 92.5% (95% CI 91.0e94.0%). The rate of clinical diagnosis of necrotizing fasciitis by emergency physicians before admission was 58.4% (95% CI 52.0e64.8%). Of the 97 patients with necrotizing fasciitis who were not clinically diagnosed before admission, 43.3% (95% CI 36.9e49.7%) had a LRINEC score <6. Conclusion: The LRINEC score is an impressive diagnostic tool to distinguish necrotizing fasciitis from other severe soft tissue infections, but it is not useful for early recognition of necrotizing fasciitis.