The laboratory risk indicator for necrotizing fasciitis (LRINEC) scoring: the diagnostic and potential prognostic role

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Abstract

Background

Necrotizing fasciitis (NF) is a devastating soft tissue infection associated with potentially poor outcomes. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score has been introduced as a diagnostic tool for NF. We aimed to evaluate the prognostic value of LRINEC scoring in NF patients.

Methods

A retrospective analysis was conducted for patients who were admitted with NF between 2000 and 2013. Based on LRINEC points, patients were classified into (Group 1: LRINEC < 6 and Group 2: LRINEC ≥ 6). The 2 groups were analyzed and compared. Primary outcomes were hospital length of stay, septic shock and hospital death.

Results

A total of 294 NF cases were identified with a mean age 50.9 ± 15 years. When compared to Group1, patients in Group 2 were 5 years older ( p = 0.009), more likely to have diabetes mellitus (61 vs 41%, p < 0.001), Pseudomonas aeruginosa infection ( p = 0.004), greater Sequential Organ Failure Assessment (SOFA) score (11.5 ± 3 vs 8 ± 2, p = 0.001), and prolonged intensive care (median 7 vs 5 days) and hospital length of stay (22 vs 11 days, p = 0.001). Septic shock (37 vs. 15%, p = 0.001) and mortality (28.8 vs. 15.0%, p = 0.005) were also significantly higher in Group 2 patients. Using Receiver operating curve, cutoff LRINEC point for mortality was 8.5 with area under the curve of 0.64. Pearson correlation analysis showed a significant correlation between LRINEC and SOFA scorings ( r = 0.51, p < 0.002).

Discussion

Early diagnosis, simplified risk stratification and on-time management are vital to achieve better outcomes in patients with NF.

Conclusions

Beside its diagnostic role, LRINEC scoring could predict worse hospital outcomes in patients with NF and simply identify the high-risk patients. However, further prospective studies are needed to support this finding.

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Most cited references 27

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The meaning and use of the area under a receiver operating characteristic (ROC) curve.

J A Hanley, B J McNeil, Marnix van Holsbeeck (1982)

A representation and interpretation of the area under a receiver operating characteristic (ROC) curve obtained by the "rating" method, or by mathematical predictions based on patient characteristics, is presented. It is shown that in such a setting the area represents the probability that a randomly chosen diseased subject is (correctly) rated or ranked with greater suspicion than a randomly chosen non-diseased subject. Moreover, this probability of a correct ranking is the same quantity that is estimated by the already well-studied nonparametric Wilcoxon statistic. These two relationships are exploited to (a) provide rapid closed-form expressions for the approximate magnitude of the sampling variability, i.e., standard error that one uses to accompany the area under a smoothed ROC curve, (b) guide in determining the size of the sample required to provide a sufficiently reliable estimate of this area, and (c) determine how large sample sizes should be to ensure that one can statistically detect differences in the accuracy of diagnostic techniques.

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Current Concepts in the Management of Necrotizing Fasciitis

Evangelos Misiakos, George Bagias, Paul Patapis … (2014)

Necrotizing fasciitis (NF) is a severe, rare, potentially lethal soft tissue infection that develops in the scrotum and perineum, the abdominal wall, or the extremities. The infection progresses rapidly, and septic shock may ensue; hence, the mortality rate is high (median mortality 32.2%). Prognosis becomes poorer in the presence of co-morbidities, such as diabetes mellitus, immunosuppression, chronic alcohol disease, chronic renal failure, and liver cirrhosis. NF is classified into four types, depending on microbiological findings. Most cases are polymicrobial, classed as type I. The clinical status of the patient varies from erythema, swelling, and tenderness in the early stage to skin ischemia with blisters and bullae in the advanced stage of infection. In its fulminant form, the patient is critically ill with signs and symptoms of severe septic shock and multiple organ dysfunction. The clinical condition is the most important clue for diagnosis. However, in equivocal cases, the diagnosis and severity of the infection can be secured with laboratory-based scoring systems, such as the laboratory risk indicator for necrotizing fasciitis score or Fournier’s gangrene severity index score, especially in regard to Fournier’s gangrene. Computed tomography or ultrasonography can be helpful, but definitive diagnosis is attained by exploratory surgery at the infected sites. Management of the infection begins with broad-spectrum antibiotics, but early and aggressive drainage and meticulous debridement constitute the mainstay of treatment. Postoperative management of the surgical wound is also important for the patient’s survival, along with proper nutrition. The vacuum-assisted closure system has proved to be helpful in wound management, with its combined benefits of continuous cleansing of the wound and the formation of granulation tissue.

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Independent predictors of mortality for necrotizing fasciitis: a retrospective analysis in a single institution.

Kuo-Chin Huang, Kuei-Hsiang Hung, An-Hsuan Lin … (2011)

Necrotizing fasciitis (NF), a life-threatening soft tissue infection, requires early diagnosis, prompt and repeated surgical intervention, and broad-spectrum antibiotic therapy. The aim of this study was to identify the independent predictors of mortality among patients with NF in Taiwan. We retrospectively reviewed the medical records of all patients who were admitted to Chi-Mei Medical Center, Tainan, Taiwan, with a diagnosis of NF. The definitive diagnosis was confirmed by the surgical findings, including (1) dishwater or foul-smelling discharge, (2) presence of necrotic fascia or lack of fascial bleeding, and (3) lack of resistance of normally adherent muscular fascia to blunt dissection. To identify factors associated with mortality, variables including personal history and comorbidities, clinical symptoms and signs, laboratory data, and microbiological data were compared between survivors and nonsurvivors. From January 2003 to December 2009, 472 patients treated for NF were included in the study. The overall mortality was 12.1% (n = 57) and the 30-day mortality was 11.0% (n = 52). Multivariate analysis revealed eight independent predictors of mortality for NF including liver cirrhosis, soft tissue air, Aeromonas infection, age older than 60 years, band polymorphonuclear neutrophils >10%, activated partial thromboplastin time >60 s, bacteremia, and serum creatinine >2 mg/dL. We identified eight independent predictors of mortality that provided useful information on the severity of NF and guidance for treatment. Prospective studies are required to examine the fitness and sufficiency of these variables as effective predictors of NF mortality.

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Author and article information

Contributors

Ayman El-Menyar:

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

+97444394029 , aymanco65@yahoo.com

Mohammad Asim: masim1@hamad.qa

Insolvisagan N. Mudali: imudali@hamad.qa

Ahammed Mekkodathil: mekkodathil@yahoo.co.uk

Rifat Latifi: Rifat.Latifi@wmchealth.org

Hassan Al-Thani: althanih@hotmail.com

Journal

Journal ID (nlm-ta): Scand J Trauma Resusc Emerg Med

Journal ID (iso-abbrev): Scand J Trauma Resusc Emerg Med

Title: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

Publisher: BioMed Central (London )

ISSN (Electronic): 1757-7241

Publication date (Electronic): 7 March 2017

Publication date PMC-release: 7 March 2017

Publication date Collection: 2017

Volume: 25

Electronic Location Identifier: 28

Affiliations

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

[2 ]ISNI 0000 0004 0637 437X, GRID grid.413542.5, , Clinical Research, Trauma Surgery, Hamad General Hospital (HGH), ; Doha, Qatar

[3 ]Department of Surgery, Intensive Care Unit, HGH, Doha, Qatar

[4 ]Department of Surgery, Westchester Health, Valhalla, NY USA

[5 ]Department of Surgery, trauma Surgery, HGH, Doha, Qatar

[6 ]Weill Cornell medical college, Clinical Research, Trauma Surgery, Hamad General Hospital, Doha, Qatar

Author information

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

Article

Publisher ID: 359

DOI: 10.1186/s13049-017-0359-z

PMC ID: 5341454

PubMed ID: 28270166

SO-VID: fcdac2b0-5806-4fa1-abd0-4b1869e19eab

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 : 1 October 2016

Date accepted : 6 February 2017

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ScienceOpen disciplines: Emergency medicine & Trauma

Keywords: necrotizing fasciitis,lrinec score,sofa score,prognosis,sepsis,outcomes

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ScienceOpen disciplines: Emergency medicine & Trauma

Keywords: necrotizing fasciitis, lrinec score, sofa score, prognosis, sepsis, outcomes

The laboratory risk indicator for necrotizing fasciitis (LRINEC) scoring: the diagnostic and potential prognostic role

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Irish Journal of Paramedicine

Most cited references 27

The meaning and use of the area under a receiver operating characteristic (ROC) curve.

Current Concepts in the Management of Necrotizing Fasciitis

Independent predictors of mortality for necrotizing fasciitis: a retrospective analysis in a single institution.

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