Necrotizing fasciitis: presentation, microbiology and outcomes in a community hospital
DOI:
https://doi.org/10.18203/2349-2902.isj20203225Keywords:
Community hospital, Mortality, NF, Polymicrobial, ProceduresAbstract
Background: Necrotizing fasciitis (NF) is an aggressive and often fatal, soft tissue infection. Delayed surgical therapy leads to worsened outcomes. This study evaluates the mortality, outcomes, and characteristics of patients with NF in a diverse New York City Community Hospital Network.
Methods: Retrospective chart review from 2012 to 2019 using ICD-9 and ICD-10 codes of gas gangrene, Fournier’s gangrene, and necrotizing fasciitis was done. Of the 297 patients reviewed 28 met inclusion criteria of imaging findings, operative reports, and clinical diagnosis of NF by an attending surgeon.
Results: On average patients in ER were seen by the surgical team within less than 12 hours. Most patients were debrided within 10 hours of surgical consultation and on average received 2.2 procedures. Of the wound cultures obtained 65.38% were polymicrobial in nature. The average length of stay was 17.4 days and 32% of patients required ICU admission. The surgical mortality rate was 7.61%.
Conclusions: Necrotizing fasciitis is a rare entity and increasing provider knowledge on patient characteristics as well as the complexity of these patients and the types and number of procedures they require may help guide clinical decision making. We identified that while most of our patients had negative blood cultures on admission, those that had positive blood cultures had multiple organisms growing. Knowing that these patients are complex and likely require multiple procedures, prompt operative intervention is key.
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References
Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A. Current concepts in the management of necrotizing fasciitis. Frontiers Surg. 2014;1:36.
Dworkin MS, Westercamp MD, Park L, McIntyre A. The epidemiology of necrotizing fasciitis including factors associated with death and amputation. Epidemiol Infect. 2009;137(11):1609-14.
Keeley J, Kaji A, Kim D, Yan H, Putnam BA, Plurad D, et al. Predictors of mortality in necrotizing soft tissue infection. Am Surg. 2014;80(10):989-93.
Bonne SL, Kadri SS. Evaluation and management of necrotizing soft tissue infections. Infect Dis Clin North Am. 2017;31(3):497‐511.
Goh T, Goh LG, Ang CH, Wong CH. Early diagnosis of necrotizing fasciitis. Br J Surg. 2014;101(1):119-25.
Sarani B, Strong M, Pascual J. Necrotizing fasciitis: current concepts and review of the literature. J Am Coll Surg. 2009;208(2):279-88.
Wong CH, Chang HC, Pasupathy S. Necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality. J Bone Joint Surg Am. 2003;85(8):1454-60.
Underwood TJ, Southgate J, Talbot R, Nash GF. Perforated diverticulitis presenting as necrotising fasciitis of the leg. World J Emerg Surg. 2008;3(1):10.
Haas DW, Dharmaraja P, Morrison JG. Necrotizing fasciitis following percutaneous endoscopic gastrostomy. Gastrointest Endosc. 1988;34(6):487-8.
Artul S, Nseir W, Assaf V, Abboud N. Abdominal wall necrotizing fasciitis due to dislodged percutaneous endoscopic gastrostomy tube. BMJ Case Rep. 2014;2014:bcr2013201346.
Kumar R, Fisher M. Fatal necrotizing fasciitis after PEG insertion in a patient with diabetes. Pract Diab Int. 2004;21(1): 32-4.
Gallup DG, Freedman MA, Meguiar RV, Freedman SN, Nolan TE. Necrotizing fasciitis in gynecologic and obstetric patients: a surgical emergency. Am J Obstet Gynecol. 2002;187(2):305-11.
Yen ZS. Ultrasonographic screening of clinically-suspected necrotizing fasciitis. Acad Emerg Med. 2002;9(12):1448-51.
van Stigt SF, de Vries J, Bijker JB. Review of 58 patients with necrotizing fasciitis in the Netherlands. World J Emerg Surg. 2016;11:21.
Hsiao CT, Chang CP, Huang TY, Chen YC, Fann WC. Prospective validation of the laboratory risk indicator for necrotizing fasciitis (LRINEC) score for necrotizing fasciitis of the extremities. Plos One. 2020 Jan 24;15(1):e0227748.
Tuncel A, Aydin O, Tekdogan U. Fournier’s Gangrene: Three Years of Experience with 20 Patients and Validity of the Fournier’s Gangrene Severity Index Score. Eur Urol. 2006;50(4):838-43.
Waldron C, Solon JG, O'gorman J. Necrotizing fasciitis: The need for urgent surgical intervention and the impact of intravenous drug use. Surgeon. 2015;13(4):194-9.
Esayag Y, Brautbar A, Popov A, Wiener-Well Y. Necrotizing soft tissue infection: an unusual and devastating complication of pressure sores. The Israel Med Assoc J. 2011;13(7):442-3.
Huang TY, Peng KT, Hsiao CT, Fann WC, Tsai YH, Li YY, et al. Predictors for gram-negative monomicrobial necrotizing fasciitis in southern Taiwan. BMC Infect Dis. 2020;20(1):60.
Bair MJ, Chi H, Wang WS. Necrotizing fasciitis in southeast Taiwan: clinical features, microbiology, and prognosis. Int J Infect Dis. 2009;13(2):255-60.
Liu YM, Chi CY, Ho MW. Microbiology and factors affecting mortality in necrotizing fasciitis. J Microbiol Immunol Infect. 2005;38(6):430-5.
Anaya DA. Predictors of mortality and limb loss in necrotizing soft tissue infections. Arch Surg. 2005;140(2):151-7.
Misiakos EP, Bagias G, Papadopoulos I, Danias N, Patapis P, Machairas N, et al. Early Diagnosis and Surgical Treatment for Necrotizing Fasciitis: A Multicenter Study. Front Surg. 2017;4:5.
Mok MY, Wong SY, Chan TM. Necrotizing fasciitis in rheumatic diseases. Lupus. 2006;15(6):380‐3.
Shaw JJ, Psoinos C, Emhoff TA, Shah SA, Santry HP. Not just full of hot air: hyperbaric oxygen therapy increases survival in cases of necrotizing soft tissue infections. Surg Infect. 2014;15(3):328-35.
Morykwas MJ, Argenta LC, Shelton-Brown EI. Vacuum-assisted closure: a new method for wound control and treatment. Ann Plast Surg. 1997;38(6):553-62.
Huang WS, Hsieh SC, Hsieh CS, Schoung JY, Huang T. Use of vacuum-assisted wound closure to manage limb wounds in patients suffering from acute necrotizing fasciitis. Asian J Surg. 2006;29(3):135-9.
Lifton J, Gould DJ, Ghodoussipour SB. Surviving fourniers gangrene: contemporary treatment and development of a novel scoring system. Plast Reconstr Surg Glob Open. 2017;5(9):133-4.
Arif N, Yousfi S, Vinnard C. Deaths from necrotizing fasciitis in the United States, 2003-2013. Epidemiol Infect. 2015;144(6):1338-44.
Faraklas I, Stoddard GJ, Neumayer LA. Development and validation of a necrotizing soft-tissue infection mortality risk calculator using NSQIP. J Am Coll Surg. 2013;217(1):153-60.
Elliott DC, Kufera JA, Myers RA. Necrotizing soft tissue infections. Risk factors for mortality and strategies for management. Ann Surg. 1996;224(5):672‐83.
Sudarsky LA, Laschinger JC, Coppa GF, Spencer FC. Improved results from a standardized approach in treating patients with necrotizing fasciitis. Ann Surg. 1987;206(5):661.
Khamnuan P, Chongruksut W, Jearwattanakanok K, Patumanond J, Yodluangfun S, Tantraworasin A. Necrotizing fasciitis: risk factors of mortality. Risk Manag Healthcare Policy. 2015;8:1.
Golger A, Ching S, Goldsmith CH. Mortality in Patients with Necrotizing Fasciitis. Plast Reconstr Surg. 2007;119(6):1803-7.
Huang KF, Hung MH, Lin YS, Lu CL, Liu C, Chen CC, et al. Independent predictors of mortality for necrotizing fasciitis: a retrospective analysis in a single institution. J Trauma Acute Care Surg. 2011;71(2):467-73.
For Clinicians: Type II Necrotizing Fasciitis. Centers for Disease Control and Prevention. 2018. Available from: https://www.cdc.gov/groupastrep/ diseases-hcp/necrotizing-fasciitis.html. Accessed on 2 May 2020.
Verma S, Sayana A, Kala S, Rai S. Evaluation of the utility of the fournier's gangrene severity index in the management of Fournier's gangrene in North India: a multicentre retrospective study. J Cutan Aesthet Surg. 2012;5(4):273‐6.
Sartelli M, Guirao X, Hardcastle TC, Kluger Y, Boermeester MA, Raşa K, et al. 2018 WSES/SIS-E consensus conference: recommendations for the management of skin and soft-tissue infections. World J Emerg Surg. 2018;13(1):1-24.