Scientific Article   |    
Necrotizing Fasciitis: Clinical Presentation, Microbiology, and Determinants of Mortality
Chin-Ho Wong, MBBS (Singapore); Haw-Chong Chang, MBBS (Singapore), FRCSEd (Ortho), MMed (Surgery), FRCS (Edin, Glas); Shanker Pasupathy, MBBS (Singapore), FRCS (Edin, Glas); Lay-Wai Khin, MBBS (Yangon), MSC (Singapore); Jee-Lim Tan, MBBS (Singapore), FRCS (Edin, Glas), FAMS, CASM (Sport Med); Cheng-Ooi Low, MBBS (Singapore), FRCS (Glas), FAMS
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Investigation performed at the Changi General Hospital, Singapore

Chin-Ho Wong, MBBS (Singapore)
Haw-Chong Chang, MBBS (Singapore), FRCSEd (Ortho), MMed (Surgery), FRCS (Edin, Glas)
Shanker Pasupathy, MBBS (Singapore), FRCS (Edin, Glas)
Jee-Lim Tan, MBBS (Singapore), FRCS (Edin, Glas), FAMS, CASM (Sport Med)
Cheng-Ooi Low, MBBS (Singapore), FRCS (Glas), FAMS
Departments of Orthopedic Surgery (C.-H.W., H.-C.C., J.-L.T, C.-O.L.) and General Surgery (S.P.), Changi General Hospital, 2 Simei Street 3, Singapore 529889. E-mail address for C.-H. Wong: wchinho@hotmail.com

Lay-Wai Khin, MBBS (Yangon), MSC (Singapore)
Clinical Trials and Epidemiology Research Unit, NMRC, Ministry of Health, 226 Outram Road, Blk A #02-02, Singapore 169039

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

J Bone Joint Surg Am, 2003 Aug 01;85(8):1454-1460
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Background: 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.

Methods: 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.

Results: 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).

Conclusions: 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.

Level of Evidence: Prognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Chin-Ho Wong
    Posted on November 20, 2003
    Dr. Wong responds to Dr. Schnall
    Department of Orthopedic Surgery, Changi General Hospital, Singapore.

    We thank Dr Schnall, et. al. for sharing their large experience of 99 patients with necrotizing fasciitis. In their series, the most significant predictor of adverse outcome was patient age and the presence of sepsis with positive blood cultures.

    We would like to clarify the findings of our study. Of the twelve factors previously reported to adversely affect survival, three factors ( patient age, the presence of 2 or more associated co-morbidites and a delay of operative débridement beyond 24 hours) were noted to be associated with patient mortality on univariate analysis. Because of the potential of inter-dependence between these factors, a more suitable test of significance would reside in multivariate analysis of the factors that were significant in the univariate model. We performed this analysis and found that the only factor that was independently associated with mortality was delayed operative débridement of beyond 24 hours after admission.

    This was also the strongest predictive factor noted by McHenry et al [1]. The association of intravenous drug abuse complicated by necrotizing fasciitis and mortality was not analyzed as only one such patient presented in this manner. The presence of diabetes in itself was not a predictor of mortality in our study.

    Dr Schnall noted in his series that adverse predictors of outcome included patient age and the presence of positive blood cultures taken at admission. While we did not analyze the association of positive blood cultures with mortality in necrotizing fasciitis, this finding is of interest and deserves further discussion. The angiothrombotic liquefactive necrosis of the fascia that characterizes necrotizing fasciitis suggests that delivery of antibiotics to the infected fascia will be compromised. Progression of infection despite intravenous antimicrobials is therefore the rule in necrotizing fasciitis, underscoring the need for aggressive surgical débridement. However, antimicrobial therapy reduces the bacterial load in the circulation and may decrease the incidence of organ failure.

    The mortality noted in our series was 21.3 %. This was somewhat lower than many series reported in the literature [1]. We postulate that this may be due to the increasing use of broad-spectrum antibiotics in the pre-hospital setting by primary care physicians (70.8 % of our patients were given antibiotics empirically prior to admission). Patients who delay seeking medical attention and are admitted with severe sepsis without antimicrobial therapy are more likely to yield positive cultures in the blood. One could speculate that patients with bacteremia may have more severe sepsis and multi-organ involvement, and therefore a higher mortality. This is consistent with Dr Schnall’s finding of association of bacteremia with mortality. Blood cultures obtained at admission are certainly helpful not only in the prediction of a more fulminant course but are an indispensable guide for appropriate antimicrobial selection.

    We reiterate that early recognition and débridement are the cornerstones of management and should be the focus of our approach to this dreaded disease. However, as we have shown, necrotizing fasciitis is often clinically indistinguishable from other more benign soft-tissue infections such as cellulitis. While modalities such as frozen section biopsy and magnetic resonance imaging (MRI) of the affected part have been shown to be capable of detecting early cases of necrotizing fasciitis, these investigations are not readily available on an emergent basis at many centers [2, 3]. They are also costly if performed for all suspicious cases of soft-tissue infections. We therefore developed a diagnostic scoring system based on laboratory parameters routinely performed for all soft- tissue infections and readily available on admission (complete blood count, electrolytes and C-reactive protein) [4].We think that this diagnostic scoring system, the LRINEC (laboratory risk indicator for necrotizing fasciitis) score is capable of distinguishing even early cases of necrotizing fasciitis from other soft-tissue infections. With a focused approach in the evaluation of soft-tissue infections, we hope that necrotizing fasciitis can be detected even early in its evolution and survival improved.

    Chin-Ho Wong, MBBS, MRCSEd Department of Orthopedic Surgery Changi General Hospital 2 Simei Street 3, Singapore 529889 E-Mail: wchinho@hotmail.com

    References: 1. McHenry CR, Piotrowski JJ, Petrinic D, Drazen P, Mark AM. Determinants of mortality in necrotizing soft tissue infections. Ann Surg 1995; 304-08. 2. Schmid MR, Kossmann T, Duewell S. Differentiation of necrotizing fasciitis from cellulites using MR imaging. AJR Am J Roentgenol 1998; 170: 615-20. 3. Stamenkovic I, Lew PD. Early recognition of potentially fatal necrotizing fasciitis: The use of frozen section biopsy. N Eng J Med. 1984; 310: 1689-93. 4. Wong CH, Khin LW, Heng KS, Low CO. Risk Stratifying Strategy in the Management of Necrotizing Fasciitis using a Novel Inflammatory Index. Abstract in European Surgical Research 2003; 35: 235. Presented at the 38th Congress of the European Society of Surgical Research.

    Stephen B Schnall
    Posted on October 21, 2003
    Necrotizing Fasciitis
    Keck School of Medicine University of California

    To the Editor:

    We have reviewed 99 cases of necrotizing fasciitis that were treated over a six year period at our institution (July 1989 through June 1995, and have have noted a 219% increased incidence during that period. Our mortality rate overall was 18% (11% during the final three years of the study).

    Unlike the study by Wong, et.al., we did not find any increased mortality in diabetic patients or in patients who were intravenous drug abusers. We did however, find two factors that were significantly related to mortality: patient age, and the presence of a positive blood culture.

    In our patients there was one death among 36 patients who were younger than 40, and 17 deaths among the 63 patients who were older than 40. Not noted in the study by Wong,et.al, but seen in our cohort was a statistically significant relationship between a positive blood culture and mortality. Of the 71 patients who had blood cultures drawn on admission, 8/19 patients with a positive blood culture died, while only 7/52 with negative blood cultures died (p=0.02)

    We agree that early recognition and aggressive debridement are the cornerstones in care for this devastating disease. We suggest blood cultures also be drawn at the time of admission because in our experience, this has been shown to be a predictor of a more fulminant problem.

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