What Demographic and Clinical Factors Are Associated with In-hospital Mortality in Patients with Necrotizing Fasciitis?

Abstract

Background Necrotizing fasciitis is a rare infection with rapid deterioration and a high mortality rate. Factors associated with in-hospital mortality have not been thoroughly evaluated. Although predictive models identifying the diagnosis of necrotizing fasciitis have been described (such as the Laboratory Risk Indicator for Necrotizing Fasciitis [LRINEC]), their use in predicting mortality is limited. Questions/purposes (1) What demographic factors are associated with in-hospital mortality in patients with necrotizing fasciitis? (2) What clinical factors are associated with in-hospital mortality? (3) What laboratory values are associated with in-hospital mortality? (4) Is the LRINEC score useful in predicting mortality? Methods We retrospectively studied all patients with necrotizing fasciitis at our tertiary care institution during a 10-year period. In all, 134 patients were identified; after filtering out patients with missing data (seven) and those without histologically confirmed necrotizing fasciitis (12), 115 patients remained. These patients were treated with early-initiation antibiotic therapy and aggressive surgical intervention once the diagnosis was suspected. Demographic data, clinical features, laboratory results, and treatment variables were identified. The median age was 56 years and 42% of patients were female. Of the 115 patients analyzed, 15% (17) died in the hospital. Univariate and receiver operating characteristic analyses were performed due to the low number of mortality events seen in this cohort. Results The demographic factors associated with in-hospital mortality were older age (median: 64 years for nonsurvivors [interquartile range (IQR) 57-79] versus 55 years for survivors [IQR 45-63]; p = 0.002), coronary artery disease (odds ratio 4.56 [95% confidence interval (CI) 1.51 to 14]; p = 0.008), chronic kidney disease (OR 4.92 [95% CI 1.62 to 15]; p = 0.006), and transfer from an outside hospital (OR 3.47 [95% CI 1.19 to 10]; p = 0.02). The presenting clinical characteristics associated with in-hospital mortality were positive initial blood culture results (OR 4.76 [95% CI 1.59 to 15]; p = 0.01), lactic acidosis (OR 4.33 [95% CI 1.42 to 16]; p = 0.02), and multiple organ dysfunction syndrome (OR 6.37 [95% CI 2.05 to 20]; p = 0.002). Laboratory values at initial presentation that were associated with in-hospital mortality were platelet count (difference of medians -136 [95% CI -203 to -70]; p < 0.001), serum pH (difference of medians -0.13 [95% CI -0.21 to -0.03]; p = 0.02), serum lactate (difference of medians 0.90 [95% CI 0.40 to 4.80]; p < 0.001), serum creatinine (difference of medians 1.93 [95% CI 0.65 to 3.44]; p < 0.001), partial thromboplastin time (difference of medians 8.30 [95% CI 1.85 to 13]; p = 0.03), and international normalized ratio (difference of medians 0.1 [95% CI 0.0 to 0.5]; p = 0.004). The LRINEC score was a poor predictor of mortality with an area under the receiver operating characteristics curve of 0.56 [95% CI 0.45-0.67]. Conclusions Factors aiding clinical recognition of necrotizing fasciitis are not consistently helpful in predicting mortality of this infection. Identifying patients with potentially compromised organ function should lead to aggressive and expedited measures for diagnosis and treatment. Future multicenter studies with larger populations and a standardized algorithm of treatment triggered by high clinical suspicion can be used to validate these findings to better help prognosticate this potentially fatal diagnosis. Level of Evidence Level III, therapeutic study.

Use of Clindamycin for Necrotizing Soft Tissue Infection Decreases Amputation Rate

“…Amputation rates in previous studies ranged from 14% to 26%. 7,11,[15][16][17] Some of the variables identified that were associated with increased amputation risk were older than 60 years, diabetes, sepsis, systolic blood pressure less than 90 mm Hg at admission, heart disease, transfer status, chronic wound as etiology, sodium less than 130 mEq/L, male sex, and non-White ethnicity. 11,12,18 Jansen-Winkeln et al 3 found the diagnosis of NSTI primarily clinical and that a regimen of clindamycin, gentamicin, and penicillin provides satisfactory coverage against 95% of causative pathogens.…”

“…12 Interestingly, mortality in patients with diabetes was found to be substantially lower (8.5% vs. 16.5%). 9,12,17…”

“…12 Interestingly, mortality in patients with diabetes was found to be substantially lower (8.5% vs. 16.5%). 9,12,17 The literature also explores and identifies risk factors that may predict an amputation outcome for a patient. Amputation rates in previous studies ranged from 14% to 26%.…”

Fulminant necrotizing streptococcal myositis with dramatic outcome – a rare case report

“…The standard of care is emergency surgical intervention with massive debridement of all necrotic tissues and broad spectrum antibiotherapy. Mortality rates are high, currently even with the most recent advances in medicine mortality is around 20% and is touching 100% in the absence of immediate medical intervention [2,3].…”

Diagnostic Key Points and Surgical Management of Necrotizing Fasciitis: A Retrospective Study

“…The presence of bullae showed a moderate positive correlation with amputation and mortality rate, suggesting that this symptom reflects a turning point in the prognosis of the disease. 3 1 The First Affiliated Hospital of Nanjing Medical University, Nanjing, China…”