Pattern and predictors of mortality in necrotizing fasciitis patients in a single tertiary hospital

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Abstract

Background

Necrotizing fasciitis (NF) is a fatal aggressive infectious disease. We aimed to assess the major contributing factors of mortality in NF patients.

Methods

A retrospective study was conducted at a single surgical intensive care unit between 2000 and 2013. Patients were categorized into 2 groups based on their in-hospital outcome (survivors versus non-survivors).

Results

During a14-year period, 331 NF patients were admitted with a mean age of 50.8 ± 15.4 years and 74 % of them were males Non-survivors (26 %) were 14.5 years older ( p = 0.001) and had lower frequency of pain ( p = 0.01) and fever ( p = 0.001) than survivors (74 %) at hospital presentation. Diabetes mellitus, hypertension, and coronary artery disease were more prevalent among non-survivors ( p = 0.001). The 2 groups were comparable for the site of infection; except for sacral region that was more involved in non-survivors ( p = 0.005). On admission, non-survivors had lower hemoglobin levels ( p = 0.001), platelet count ( p = 0.02), blood glucose levels ( p = 0.07) and had higher serum creatinine ( p = 0.001). Non-survivors had greater median LRINEC (Laboratory Risk Indicator for NECrotizing fasciitis score) and Sequential Organ Failure Assessment (SOFA) scores ( p = 0.001). Polybacterial and monobacterial gram negative infections were more evident in non-survivors group. Monobacterial pseudomonas ( p = 0.01) and proteus infections ( p = 0.005) were reported more among non-survivors. The overall mortality was 26 % and the major causes of death were bacteremia, septic shock and multiorgan failure. Multivariate analysis showed that age and SOFA score were independent predictors of mortality in the entire study population.

Conclusion

The mortality rate is quite high as one quarter of NF patients died during hospitalization. The present study highlights the clinical and laboratory characteristics and predictors of mortality in NF patients.

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Most cited references 47

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Necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality.

Chin J. Wong, Eric Tan, Lay Khin … (2003)

Necrotizing fasciitis is a life-threatening soft-tissue infection primarily involving the superficial fascia. The present report describes the clinical presentation and microbiological characteristics of this condition as well as the determinants of mortality associated with this uncommon surgical emergency. The medical records of eighty-nine consecutive patients who had been admitted to our institution for necrotizing fasciitis from January 1997 to August 2002 were reviewed retrospectively. The paucity of cutaneous findings early in the course of the disease makes the diagnosis difficult, and only thirteen of the eighty-nine patients had a diagnosis of necrotizing fasciitis at the time of admission. Preadmission treatment with antibiotics modified the initial clinical picture and often masked the severity of the underlying infection. Polymicrobial synergistic infection was the most common cause (forty-eight patients; 53.9%), with streptococci and enterobacteriaceae being the most common isolates. Group-A streptococcus was the most common cause of monomicrobial necrotizing fasciitis. The most common associated comorbidity was diabetes mellitus (sixty-three patients; 70.8%). Advanced age, two or more associated comorbidities, and a delay in surgery of more than twenty-four hours adversely affected the outcome. Multivariate analysis showed that only a delay in surgery of more than twenty-four hours was correlated with increased mortality (p < 0.05; relative risk = 9.4). Early operative débridement was demonstrated to reduce mortality among patients with this condition. A high index of suspicion is important in view of the paucity of specific cutaneous findings early in the course of the disease.

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Determinants of mortality for necrotizing soft-tissue infections.

Allison R. McHenry, Wojciech J. Piotrowski, D Petrinic … (1995)

The authors determined the risk factors of mortality in patients with necrotizing soft-tissue infections (NSTIs) and examined the incidence and mortality from NSTI secondary to Streptococcus pyogenes. All patients with NSTIs who were treated between January 1989 and June 1994 were analyzed for presentation, etiology, factors important in pathogenesis and treatment, and mortality. Sixty-five patients were identified with NSTIs secondary to postoperative wound complications (18), trauma (15), cutaneous disease (15), idiopathic causes (10), perirectal abscesses (3), strangulated hernias (2), and subcutaneous injections (2). Necrotizing soft-tissue infections were polymicrobial in 45 patients (69%). S. pyogenes was isolated in only 17% of the NSTIs, but accounted for 53% of monomicrobial infections. Eight of ten idiopathic infections were caused by a single bacterium (p = 0.0005), whereas 82% of postoperative infections were polymicrobial. An average of 3.3 operative debridements per patient and amputation in 12 patients were necessary to control infection. The overall mortality was 29%; mortality from S. pyogenes infection was only 18%. The average time from admission to operation was 90 hours in nonsurvivors versus 25 hours in survivors (p = 0.0002). Other risk factors previously associated with the development of NSTIs did not affect mortality. Early debridement of NSTI was associated with a significant decrease in mortality. S. pyogenes infection was the most common cause of monomicrobial NSTI, but was not associated with an increased mortality.

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Early diagnosis of necrotizing fasciitis.

T. Goh, L G Goh, C Ang … (2014)

Necrotizing fasciitis is a rapidly progressing skin infection characterized by necrosis of the fascia and subcutaneous tissue, accompanied by severe systemic toxicity. The objective of this systematic review was to identify clinical features and investigations that will aid early diagnosis. A systematic literature search of PubMed was undertaken using the keywords 'necrotising fasciitis', 'necrotising skin infection', 'diagnosis' and 'outcome'. Case series of 50 or more subjects with information on symptoms and signs at initial presentation, investigations and clinical outcome were included. Nine case series were selected, with a total of 1463 patients. Diabetes mellitus was a co-morbidity in 44.5 per cent of patients. Contact with marine life or ingestion of seafood in patients with liver disease were risk factors in some parts of Asia. The top three early presenting clinical features were: swelling (80.8 per cent), pain (79.0 per cent) and erythema (70.7 per cent). These being non-specific features, initial misdiagnosis was common and occurred in almost three-quarters of patients. Clinical features that helped early diagnosis were: pain out of proportion to the physical findings; failure to improve despite broad-spectrum antibiotics; presence of bullae in the skin; and gas in the soft tissue on plain X-ray (although this occurred in only 24.8 per cent of patients). A high index of suspicion of necrotizing fasciitis is needed in a patient presenting with cutaneous infection causing swelling, pain and erythema, with co-morbidity of diabetes or liver disease. The presence of bullae, or gas on plain X-ray can be diagnostic. Early surgical exploration is the best approach in the uncertain case. © 2013 BJS Society Ltd. Published by John Wiley & Sons Ltd.

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Author and article information

Contributors

Gaby Jabbour: GJabbour@hamad.qa

Ayman El-Menyar:

ORCID: http://orcid.org/0000-0003-2584-953X

+97444394029 , aymanco65@yahoo.com

Ruben Peralta: rperaltamd@gmail.com

Nissar Shaikh: nissatfirdous99@gmail.com

Husham Abdelrahman: hushamco@hotmail.com

Insolvisagan Natesa Mudali: IMudali@hamad.qa

Mohamed Ellabib: MEllabib@hamad.qa

Hassan Al-Thani: althanih@hotmail.com

Journal

Journal ID (nlm-ta): World J Emerg Surg

Journal ID (iso-abbrev): World J Emerg Surg

Title: World Journal of Emergency Surgery : WJES

Publisher: BioMed Central (London )

ISSN (Electronic): 1749-7922

Publication date (Electronic): 8 August 2016

Publication date PMC-release: 8 August 2016

Publication date Collection: 2016

Volume: 11

Electronic Location Identifier: 40

Affiliations

[1 ]Department of Surgery, Hamad General Hospital (HGH), Doha, Qatar

[2 ]Clinical Research, Trauma Surgery, Hamad General Hospital, Doha, Qatar

[3 ]Clinical Medicine, Weill Cornell Medical School, Doha, Qatar

[4 ]Trauma Surgery Section, Hamad General Hospital, Doha, Qatar

[5 ]Surgical Intensive Care Unit, HGH, Doha, Qatar

Author information

Ayman El-Menyar http://orcid.org/0000-0003-2584-953X

Article

Publisher ID: 97

DOI: 10.1186/s13017-016-0097-y

PMC ID: 4977757

PubMed ID: 27508002

SO-VID: d0e414ff-3456-4051-b458-5301ebfd000f

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 24 May 2016

Date accepted : 2 August 2016

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ScienceOpen disciplines: Surgery

Keywords: necrotizing fasciitis,predisposing factors,presentation,management,mortality

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ScienceOpen disciplines: Surgery

Keywords: necrotizing fasciitis, predisposing factors, presentation, management, mortality

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Pattern and predictors of mortality in necrotizing fasciitis patients in a single tertiary hospital

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Most cited references 47

Necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality.

Determinants of mortality for necrotizing soft-tissue infections.

Early diagnosis of necrotizing fasciitis.

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