Prognostic factors for intraoperative detection of necrotizing fasciitis in severe soft tissue infections

Abstract

Background Necrotizing fasciitis (NF) is a rare but lethal soft-tissue infection. There is still a paucity of information regarding the diagnostic tools and therapeutic strategies for the treatment of this devastating disease. This study aims to identify important perioperative parameters related to necrotizing fasciitis and to assess their relevance in terms of identifying NF. Methods and material We retrospectively analyzed patients who underwent surgical exploration for suspected necrotizing fasciitis at a tertiary referral center, to explore the clinical features and factors related to the presence of necrotizing fasciitis and mortality. Results Between 2010 and 2017, 88 patients underwent surgical exploration for suspected NF. The infection occurred in the lower extremities in 48 patients, in the thoracocervical region in 18 patients, and the perineum and abdomen in 22 patients. Histological evidence of NF was present in 59 of 88 patients. NF was associated with a longer hospital stay and ICU stay (p = 0.05 and 0.019 respectively) compared to patients without NF. ROC analysis showed that only macroscopic fascial appearance could discriminate patients with histological evidence of NF. Moreover, multivariate logistic regression revealed, that liver failure (p = 0.019), sepsis (p = 0.011), positive Gram stain (p = 0.032), and macroscopic fascial appearance (p <0.001) were independent prognostic parameters for histological evidence of NF. Conclusion Intraoperative tissue evaluation by an experienced surgeon is the most important diagnostic tool in identifying necrotizing fasciitis. An intraoperative Gram stain is an independent prognostic tool and therefore its use can be recommended especially in case of clinical uncertainty.

Prognostic Factors in Necrotizing Fasciitis: Insights from a Two-Decade, Two-Center Study Involving 209 Cases

“…Our study showed an overall mortality rate of 18%, which is in line with the existing literature (12%; 22% and 32%) that also examined prognostic factors for NF and found an overall mortality rate [ 15 , 16 , 18 ]. However, the dispersion is striking and should be analyzed.…”

“…These have already been examined with regard to their reliability for diagnosis and also for prognostic accuracy [ 9 , 10 , 11 , 12 , 13 , 14 ]. Despite the importance of these decision-supporting tools in the acute situation, the prognostic factors for the further course of NF have not yet been conclusively clarified and are still the subject of current research [ 15 , 16 , 17 ]. The present study aims to determine prognostic factors in a large number of patients that are important for the clinical course of necrotizing fasciitis.…”

“…To our knowledge, our study is the largest cohort of patients ever investigated in Europe with regard to prognostic factors related to mortality in necrotizing fasciitis. By analyzing our extensive data set, we aim to gain crucial insights into the prognosis of necrotizing fasciitis and also make a significant contribution to the body of knowledge for clinical practice [ 15 , 16 , 18 ].…”

Successfully drug treatment for necrotizing fasciitis caused by Streptococcus pyogenes in 88‐year‐old patient

“…The typical patient of type II NF is quite young and fit, with a previous history of skin injury, commonly from extremity trauma 5 . Appropriate treatment for NF is the surgical exploration and debridement of the affected tissue remaining the mainstay of therapy, which sometimes requires limb amputation 6 . The most recent Infectious Disease Society of America guideline recommends penicillin plus clindamycin to treat documented group A Streptococcus infections 7 .…”

“…The surgical debridement was not performed but treatment with amoxicillin‐clavulanic acid was administered as empiric measure at the time of admission of emergency department. However, this initiated treatment failed to comply with the recommendations 6 . As the causative bacterium of NF was group A Streptococcus, the treatment on arrival of the patient was promptly reconsidered with a combination of amoxicillin‐clavulanic acid and clindamycin.…”