Scientific paperEarly diagnosis, nutritional support, and immediate extensive debridement improve survival in necrotizing fasciitis
Abstract
Thirty patients with necrotizing fasciitis were analyzed. The first 20 patients were reviewed from the patient records of the University of Cincinnati Medical Center (Group A). An additional 10 patients from the University of Cincinnati Medical Center and the Medical University of South Carolina were more recently treated (Group B). The 20 patients in Group A had a mortality rate of 50 percent, whereas no deaths occurred in Group B. The age range and race and sex ratios were essentially identical between the groups. The most common site of infection in both groups was the leg or perirectal-perioneal area. Hemolytic streptococcus, Escherichia coli, and Staphylococcus aureus were the most frequently isolated organisms in Group B patients. The most common organisms isolated from patients in Group A were identical to those found in Group B, with the addition of Bacteriodes. The clinical manifestations in Group A patients were most commonly fever, edema, crepitus, gangrene, cellulitis, and pus in the involved area. In Group B patients clinical signs of fever, crepitus, skin anesthesia, and roentgenographic evidence of gas were the most common clinical manifestations. Ninety percent of patients in Group B were found to have roentgenographic evidence of soft tissue gas. Diabetes and atherosclerotic vascular disease occurred in more than 75 percent of all patients in both groups. Patients in Groups A and B were identical in nutritional status at the time of admission to the hospital. The improvement in the rate of survival in patients in Group B can be attributed to earlier diagnosis and referral, immediate and extensive debridement of all involved tissue, and aggressive protein replacement.
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Cited by (214)
Prospective Validation and Comparison of Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) and Site Other Than Lower Limb, Immunosuppression, Age, Renal Impairment, and Inflammatory Markers (SIARI) Scoring Systems for Necrotizing Fasciitis
2023, Journal of Surgical ResearchNecrotizing fasciitis (NF) is a rapidly progressing infection of the soft tissues associated with high morbidity and mortality and hence it is a surgical emergency. Early diagnosis and treatment are of paramount importance. LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) and SIARI (Site other than lower limb, Immunosuppression, Age, Renal impairment, and Inflammatory markers) scoring systems have been established for early and accurate diagnosis of necrotizing fasciitis. This study compared the two scoring systems for diagnosing NF, predicting management, and elucidating the prognostic performance for re-operation and mortality.
This prospective study was conducted in PGIMER Chandigarh, India, between February 2020 and June 2021. The study was approved by the Institutional Review Board (No. INT/IEC/2020-90). The clinical presentation, laboratory parameters, and imaging were used to classify patients into NF or severe cellulitis groups. We also calculated the LRINEC and SIARI scores. Demographic variables and mortality were recorded. The area under the receiver operating characteristic was used to express the accuracy of both scores at a cut-off LRINEC and SIARI scores of ≥6 and ≥ 4, respectively.
The study comprised 41 patients with NF and 11 with severe cellulitis. Informed written consent was taken from all the participants. At LRINEC score ≥6, the C-statistic for NF diagnosis was 0.839 (95% confidence interval [CI] 0.682-0.995, P 0.001), which was better than SIARI score at ≥ 4, C-statistic of 0.608 (95% CI 0.43-0.787, P 0.297). Both scores accurately predicted 30-day mortality. The LRINEC score showed a C-statistic of 0.912 (95% CI 0.798-1, P 0.001). Simultaneously, the SIARI score showed 70% sensitivity and 77% specificity, with a C-statistic of 0.805 (0.62-0.99, P = 0.017).
LRINEC score is an effective diagnostic tool for distinguishing necrotizing fasciitis from severe cellulitis. Additional research is required to establish the SIARI score's external validity.
To review patients seen in the emergency room, diagnosed with necrotizing fasciitis (NF) and the correlation of such complications with the Laboratory Risk Indicator for Necrotizing fasciitis scale (LRINEC). The purpose of this study is to assess the use of the LRINEC score for early diagnosis of NF and its prognostic use in a consecutive series of cases treated at our hospital.
Retrospective observational study including patients with a diagnosis of NF in the emergency room of a tertiary hospital over 11 years. The results are shown as median, interquartile range and absolute range for quantitative variables. In the case of qualitative variables, the results are shown as absolute and relative frequency. The comparison between the categories of the LRINEC scale was performed through a post-hoc comparison from a non-parametric rank-ANOVA analysis. Comparisons between LRINEC groups in the qualitative variables were performed using Fisher’s exact test.
A total of 45 patients with a mean age of 51 years were identified. There was a 20% mortality rate (9 cases). The highest mortality rate was registered in the high-risk group (LRINEC greater than 8) with 4 deceased individuals (44.44%), while in the low and moderate-risk groups, 3 and 2 deceased individuals (33% and 22%) were registered, respectively, without considering this result statistically significant (p=0.811). There was an amputation rate of 15.6% (7 cases). The average LRINEC score was greater in the cases that required amputation 9 (95% CI 7; 13) in comparison to the other patients, 6 (95% CI 5; 8), p=0.044. The average hospital stay lasted 32.5 days (95% CI: 25; 40); 30 days in the low-risk group, 41 days in the moderate-risk group and 40 days in the high-risk group. Mortality was associated to a smaller number of interventions (p=0.005) and was preceded by septic shock in all cases.
The LRINEC score may be useful to aid diagnosis. However, clinical suspicion is the most important in diagnosis. A LRINEC low score does not exclude NF. In this retrospective series, 35.71% of cases presented a low LRINEC score, making the rate of false negatives high. In view of these results, The LRINEC score cannot be used as a prognostic value since an initial low score does not rule out serious evolution.
Hepatitis influences the diagnosis of Necrotising soft-tissue infection: A proposed modification to the Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score from a retrospective study at a single institution
2021, Journal of Plastic, Reconstructive and Aesthetic SurgerySevere anemia may not be a contraindication to debridement in a Jehovah's witness patient with necrotizng fasciitis of the lower extremity – A case report
2019, International Journal of Surgery Case ReportsNecrotizing fasciitis is a severe soft tissue infection characterized by rapidly progressing necrosis involving the fascia and subcutaneous tissue. Necrotizing fasciitis of the lower extremity in a Jehovah’s Witness patient in the setting of severe anemia and systemic sepsis is uncommon.
A 62-year-old man of Jehovah’s Witness faith with a history of alcohol use disorder and uncontrolled diabetes mellitus initially presented with a non-healing diabetic foot ulcer, subsequently developed sepsis and necrotizing fasciitis. He underwent an above the knee amputation and was transferred to our institution’s Surgical Intensive Care Unit for further management. The patient presented in critical condition with a hemoglobin of 4.7 g/dL and progression of necrotizing fasciitis of the lower extremity stump. He underwent revision amputation and numerous excisional debridements along with IV antibiotics, epoetin alfa, and iron sucrose. He successfully recovered with minimal blood loss and was discharged with a hemoglobin of 8 g/dL.
This case highlights some of the challenges involved in managing necrotizing fasciitis. The conversation with the Jehovah’s Witness patient in a life-threatening condition must be held with the upmost respect. Surgical decision making and operative technique is critical in determining the boundary of excisional debridement to perform in the absence of the ability to transfuse blood. The medical management was focused on resuscitation for sepsis, severe anemia, hyperglycemia, and wound management.
Severely anemic patients in critical condition can survive necrotizing fasciitis with a well-planned interdisciplinary approach without compromising patient autonomy.
Necrotizing fasciitis attended in the Emergency Department in a tertiary Hospital: Evaluation of the LRINEC scale
2017, Revista Espanola de Cirugia Ortopedica y TraumatologiaDescribir la mortalidad y las complicaciones de pacientes atendidos en urgencias, con diagnóstico de infección necrosante de partes blandas (INPB) y su correlación con la escala Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC).
Estudio observacional retrospectivo con inclusión de pacientes con diagnóstico de INPB en urgencias de un hospital terciario durante 7 años. Los resultados se muestran como mediana, rango intercuartílico y rango absoluto para las variables cuantitativas. En el caso de las variables cualitativas, como frecuencias absoluta y relativa. La comparación se ha llevado a cabo mediante comparación post-hoc a partir de un análisis ANOVA con aproximación no paramétrica. Las comparaciones entre grupos de LRINEC en las variables cualitativas se han realizado con la prueba exacta de Fisher.
Se identificaron 24 pacientes con edad media de 51,9 años. La escala LRINEC se determinó en 21 pacientes: en 10 indicó bajo riesgo (< 6), en 4 riesgo intermedio (6 o 7) y en 7 alto riesgo (≥ 8). La tasa de amputación en riesgos bajo, intermedio y alto fue del 10, 25 y 66%, respectivamente, con una mortalidad del 4,2%. Se observa un aumento en la estancia hospitalaria entre los niveles bajo y alto de la escala (p = 0,007).
En general no se ha podido constatar un cambio en el pronóstico entre los niveles medio y alto de la escala LRINEC. Pero sí entre la estancia hospitalaria entre el nivel bajo y el alto, triplicando prácticamente la mediana de días de estancia hospitalaria.
To describe mortality and complications of patients seen in the emergency room, diagnosed with necrotizing soft tissue infection (NSTI) and the correlation of such complications with the Laboratory Risk Indicator for Necrotizing fasciitis scale (LRINEC).
Retrospective observational study including patients with a diagnosis of NSTI in the emergency room of a tertiary hospital over 7 years. The results are shown as median, interquartile range and absolute range for quantitative variables. In the case of qualitative variables, the results are shown as absolute and relative frequency. The comparison between the categories of the LRINEC scale was performed through a post-hoc comparison from a non-parametric ANOVA analysis. Comparisons between LRINEC groups in the qualitative variables were performed using Fisher's Exact test.
24 patients with a mean age of 51.9 years were identified. The LRINEC scale was used on 21 patients: in 10, the value indicated low risk (< 6), in 4 it indicated intermediate risk (6 or 7) and in 7 it indicated high risk (≥ 8). The amputation rate in patients with low, intermediate and high risk was 10%, 25% and 66% respectively with a mortality of 4.2%. There was an increase in hospital stay between the low and high level of the scale (p = 0,007).
In general, a change in the prognosis between the medium and high levels of the LRINEC scale could not be recorded, but was recorded in hospital stay between the low and the high level, practically tripling the median of days of hospital stay.
A rare case report of vulvar necrotizing fasciitis in a healthy patient
2017, International Journal of Surgery Case ReportsNecrotizing fasciitis (NF), a necrotizing infection of the soft tissue, is a medical emergency usually occurring in the lower extremities and abdominal regions and often difficult to diagnose promptly.
This case report looks at one atypical presentation of NF with the unusual location of the vulva and no known associated comorbidities or risk factors.
Diagnosing this patient was particularly difficult due to the inconsistent clinical, laboratory and imaging findings. The CT scans and WBC count were indicative of NF, but the LRINEC score was not high enough to make the diagnosis of NF. As a result, we relied on the hemodynamic instability and clinical findings of the physical exam to be strong indicators of NF, and acted on that indication.
Acting quickly on the hemodynamic findings and suspicion as opposed to waiting for a confirmed diagnosis resulted in a good prognosis since immediate surgical debridement is imperative to surviving this acute condition. Despite major advancements in the imaging modalities and the introduction of a laboratory score, our case suggests that the diagnosis still heavily relies on clinical findings, such as hemodynamic instability. Furthermore, our case suggests that NF should be included in the differential regardless of atypical location and lack of common clinical associations.
- 1
From the Departments of Surgery, Medical University of South Carolina, Charleston, South Carolina.
- 2
From the University of Cincinnati Medical Center, Cincinnati, Ohio.