Necrotizing fasciitis: The need for urgent surgical intervention and the impact of intravenous drug use

Waldron, Carmel; Solon, J.G.; O’Gorman, Joanne; Humphreys, Hilary; Burke, John P.; McNamara, Deborah A.

doi:10.1016/j.surge.2014.01.005

Cited by 23 publications

(16 citation statements)

References 17 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…NF is quickly progressing and leads to severe, life threatening situations that require immediate antibiotic i.v. administration and surgical debridement of affect tissue even before the pathogen can be identified [ 5 – 7 ]. Delayed diagnosis of NF results in worsened outcome including death of the patient [ 8 – 10 ].…”

Section: Introductionmentioning

confidence: 99%

Improvement of a Clinical Score for Necrotizing Fasciitis: ‘Pain Out of Proportion’ and High CRP Levels Aid the Diagnosis

Borschitz¹,

Schlicht

Siegel

et al. 2015

PLoS ONE

View full text Add to dashboard Cite

Necrotizing fasciitis (NF) is a rare mono-/polymicrobial skin infection that spreads to underlying tissues. NF is quickly progressing and leads to life threatening situations. Immediate surgical debridement together with i.v. antibiotic administration is required to avoid fatal outcome. Early diagnosis is often delayed due to underestimation or confusion with cellulitis. We now compared the initial clinical and laboratory presentation of NF and cellulitis in detail to assess if a typical pattern can be identified that aids timely diagnosis of NF and avoidance of fatal outcome. 138 different clinical and laboratory features of 29 NF patients were compared to those of 59 age- and gender matched patients with severe erysipelas requiring a subsequent hospitalization time of ≥10 days. Differences in clinical presentation were not obvious; however, NF patients suffered significantly more often from strong pain. NF patients exhibited dramatically elevated CRP levels (5-fold, p>0.001). The overall laboratory risk indicator for necrotizing fasciitis (LRINEC) score was significantly higher in NF patients as compared to cellulitis. However, a modification of the score (alteration of laboratory parameters, addition of clinical parameters) led to a clear improvement of the score with a higher positive predictive value without losing specificity. In summary, clinical differentiation of NF from cellulitis appears to be hard. ‘Pain out of proportion’ may be an early sign for NF. An improvement of the LRINEC score emphasizing only relevant laboratory and clinical findings as suggested may aid the early diagnosis of NF in the future leading to improvement of disease outcome by enabling rapid adequate therapy.

show abstract

Section: Introductionmentioning

confidence: 99%

Improvement of a Clinical Score for Necrotizing Fasciitis: ‘Pain Out of Proportion’ and High CRP Levels Aid the Diagnosis

Borschitz¹,

Schlicht

Siegel

et al. 2015

PLoS ONE

View full text Add to dashboard Cite

show abstract

“…Between 1 death per 3 to 5 patients (21% [10], 25-35% [1], 29% [13]) to more varying percentages ranging from low to very high (6-76% [7]) are found in the literature. A recent review found average rates between 20 and 40% [2].…”

Section: Necrotizing Fasciitismentioning

confidence: 99%

Toxic shock syndrome toxin-I producing Staphylococcus aureus in fulminant necrotizing fasciitis

Verweij¹,

Kolwijck²,

Pompe³

2016

Clin Case Rep Rev

View full text Add to dashboard Cite

A 67-year old man was admitted to our Intensive Care Unit (ICU) with septic shock. Five days earlier he presented to the Emergency Department with a mild fever (up to 38 degrees Celsius) and paravertebral back pain. An abdominal ultrasound revealed no pathologic findings (no abdominal aneurysm, gall stones or pancreatitis). His symptoms were attributed to muscular pain possibly caused by influenza (endemic at the time) and he was discharged.Over the course of 5 days he deteriorated, with severe and progressive back pain with radiation to both legs (which caused an inability to walk) and high fever (up to 41 degrees Celsius). On examination he was tachycardic (heart rate 130 bpm), hypotensive (initial systolic BP 70 mmHg, 99 mmHg after 3 L fluid resuscitation). He was alert with a respiratory rate of 20/min and oxygen saturation of 97% on 4 L O 2 /min. Abnormalities on physical examination included basal crepitations, a small pustulous skin lesion on his right upper abdomen and cold extremities with mottled blue skin; no other skin lesions were present, nor were any cardiac murmurs present. Examination of his legs showed no sensory or motor deficits, normal peripheral arterial pulsations and soft, non-tender calves. Laboratory results showed a slight leucopenia (3.8 × 10 9 /L), thrombocytopenia (59 × 10 9 /L), C-reactive protein 360 mg/L, creatinine 280 µmol/L and lactate 5.4 mmol/L. Blood cultures were drawn, the patient received antibiotics (ceftriaxone 2000 mg according to local protocol) and was admitted to the ICU for further treatment. On repeated examination he developed a discolouration of the skin on the dorsal side of his left thigh extending to just below the knee. It was blue/purple with surrounding erythema and mildly tender on palpation. A CT-scan was performed, showing induration of skin and subcutaneous tissue in the left thigh. No abdominal or retroperitoneal pathology was detected. Because necrotizing fasciitis was suspected, the patient was started on penicillin, clindamycin, gentamicin, intravenous immunoglobulins (IVIG) and underwent emergency surgical exploration. The subcutaneous tissue and fascia were swollen and excisional biopsies showed extensive presence of gram positive cocci. The diagnosis of necrotizing fasciitis was confirmed. Extensive surgical debridement of skin, subcutaneous tissue and muscle fascia of the dorsum of the left upper leg was performed. The patient developed severe septic shock with multi-organ failure and required high dose norepinephrine, vasopressin and steroid treatment. His condition slightly improved after surgery, antibiotics and IVIG administration. However, soon after the initial stabilisation he developed new skin lesions on his right leg for which he underwent a second surgical procedure. During surgery, similar findings to those in the left leg necessitated another debridement. Upon return to the ICU his condition had deteriorated further, with persistent anuria, severe metabolic acidosis with lactate levels of more than 15 mmol/L and cardiac failure. A...

show abstract

“…[ 3 4 ] Nonetheless, progress has been made, particularly in understanding the surgical aspects of management of necrotizing fasciitis, and the recent literature shows a decline in mortality trends. [ 5 ] Early surgical intervention is associated with improved survival in many studies; however, those studies differ in defining “early” intervention. [ 1 6 7 ] Moreover, a multicenter analysis of a large patient population concludes to the contrary.…”

mentioning

confidence: 99%

“…[ 1 6 7 ] The overall mortality rate in this study was also lower than described in the literature, although considerable heterogeneity exists in this regard. [ 5 6 7 ] This was in spite of the fact that nearly half of the patients had necrotizing fasciitis involving a lower extremity, which entails a higher mortality rate. [ 5 ]…”

mentioning

confidence: 99%

See 1 more Smart Citation

What's new in emergencies, trauma and shock? The tortuous path in the management of necrotizing fasciitis: Is early surgical intervention critical?

Bandyopadhyay

Jacobs

Panchabhai

2016

J Emerg Trauma Shock

View full text Add to dashboard Cite

Necrotizing fasciitis: The need for urgent surgical intervention and the impact of intravenous drug use

Cited by 23 publications

References 17 publications

Improvement of a Clinical Score for Necrotizing Fasciitis: ‘Pain Out of Proportion’ and High CRP Levels Aid the Diagnosis

Improvement of a Clinical Score for Necrotizing Fasciitis: ‘Pain Out of Proportion’ and High CRP Levels Aid the Diagnosis

Toxic shock syndrome toxin-I producing Staphylococcus aureus in fulminant necrotizing fasciitis

What's new in emergencies, trauma and shock? The tortuous path in the management of necrotizing fasciitis: Is early surgical intervention critical?

Contact Info

Product

Resources

About