[Wounds after necrotizing soft tissue infections: the treatment options]. / Wonden na een necrotiserende wekedeleninfectie.

Necrotizing soft tissue infection (NSTI) is a life-threatening illness that can seriously harm a person. Over the last years the incidence of NSTI has increased. A rapid and thorough debridement is crucial to let patients survive. After this debridement, patients will often end up with large skin defects. A burn center is specialized in treating skin defects. Patients with large skin defects after the acute phase of NSTI can be referred to this for a multidisciplinary approach. In this article we describe the surgical treatment of the complex wounds of three referred patients with NSTI in our burn center.

[Neutrophil-lymphocyte ratio as predictor of mortality in patients with necrotizing fasciitis]. / Índice neutrófilo-linfocito como predictor de mortalidad en pacientes con fascitis necrotizante.

Background: Necrotizing fasciitis (NF) can affect any soft tissue and skin of the body. Its progression is rapid and it is associated with a high mortality rate. Therefore, the search for easily accessible and low-cost biomarkers that could predict the prognosis of patients with NF is necessary. Objective: To evaluate the role of neutrophil-lymphocyte ratio (NLR) as a predictor of mortality in patients with NF. Material and methods: Observational, cross-sectional, retrospective and analytical study of patients admitted between April and October 2020 in a tertiary-care hospital. The statistical tests used for the comparison of variables between the study groups were chi-square, Fisher's exact, Student's t and Mann-Whitney U. A receiver operating characteristic (ROC) curve was performed to determine the accuracy of NLR in predicting mortality in patients with NF. Results: A total of 25 patients were included and stratified into non-survivors and survivors. The non-survivor group had an elevated NLR value compared to survivors (15.57 [13.75] vs. 7.91 [4.13]; p = 0.065). The NLR had an area under the curve (AUC) of 0.729 (95% confidence interval [95% CI] 0.516-0.886; p = 0.044), sensitivity of 77.78% (40-97.2), and specificity of 75% (47.6-92.7). The optimal cut-off point obtained for NLR was > 9.21. Conclusions: An NLR value > 9.21 could be a predictor of mortality in patients with NF.

Introducción: la fascitis necrotizante (FN) puede afectar cualquier tejido blando y piel del cuerpo. Su progresión es rápida y está relacionada con un índice de mortalidad alto. Por lo tanto, la búsqueda de biomarcadores de fácil acceso y bajo costo que puedan predecir el pronóstico de los pacientes con FN es necesaria. Objetivo: evaluar el papel del índice neutrofilo-linfocito (INL) como un predictor de mortalidad en los pacientes con FN. Material y métodos: estudio observacional, transversal, retrospectivo y analítico de pacientes admitidos entre abril y octubre del 2020 en un hospital de tercer nivel. Las pruebas estadísticas utilizadas para la comparación de las variables entre los grupos de estudio fueron chi cuadrado, exacta de Fisher, t de Student y U de Mann-Whitney. Una curva característica operativa del receptor (ROC) fue realizada para determinar la precisión del INL en la predicción de mortalidad en pacientes con FN. Resultados: un total de 25 pacientes fueron incluidos y estratificados en no sobrevivientes y sobrevivientes. El grupo no sobreviviente tuvo un valor elevado del INL en comparación con los sobrevivientes (15.57 [13.75] frente a 7.91 [4.13]; p = 0.065). El INL tuvo un área bajo la curva (AUC) de 0.729 (intervalo de confianza del 95% [IC 95%] 0.516-0.886; p = 0.044), sensibilidad de 77.78% (40-97.2) y especificidad de 75% (47.6-92.7). El punto de corte óptimo obtenido para el INL fue > 9.21. Conclusiones: un valor de INL > 9.21 podría ser un predictor de mortalidad en los pacientes con FN.

[Necrotizing soft tissue infections]. / Nekrotisierende Weichgewebsinfektionen.

Necrotizing soft tissue infections are a heterogeneous group of severe infections of the skin, connective tissue and muscles in which necrotic destruction of the tissue occurs at the site of infection. Various bacteria are known as "typical" triggering pathogens and the infection can occur on the entire surface of the body. Necrotizing soft tissue infections are always a time-sensitive emergency associated with high mortality. Many affected patients are critically ill and require treatment in an intensive care unit. The rapid and radical surgical treatment is an essential part of management and in addition an adequate and timely antimicrobial treatment is of great importance. The health consequences for surviving patients are often severe, as extensive soft tissue damage leads to functional impairments. In many cases extensive plastic surgery follow-up is necessary. Therefore, necrotizing soft tissue infections are "complicated" in every phase of the disease and require interprofessional treatment. This review article provides a current overview of various aspects of the diagnostics, treatment and aftercare of necrotizing soft tissue infections.

Infection of Mycoplasma hominis in the left lower leg amputation wound of a patient with diabetes: a case report.

BACKGROUND: Mycoplasma hominis is typically found on the mucosal epithelium of the human genital tract, with infections being rare. However, when the mucosal barrier is compromised or in individuals with weakened immune systems, this microorganism can trigger infections in both intragenital and extragenital sites. This study offers a comprehensive overview of infections caused by the rare pathogen M. hominis. This overview helps laboratories identify M. hominis infections in a timely manner, thereby enabling earlier clinical intervention for patients. CASE PRESENTATION: A 75-year-old Taiwanese man with type 2 diabetes mellitus initially underwent a left lower extremity amputation following a severe infection caused by necrotizing fasciitis. Subsequently, a poorly healing wound developed at the site of amputation. Upon culturing the wound abscess, M. hominis was isolated and identified as the causative agent. CONCLUSIONS: Through this case, we present clinical and microbiological observations along with a review of the literature to deepen our understanding of M. hominis. Our findings can be used to develop laboratory diagnostic protocols and innovative therapeutic approaches.

The Efficacy of LRINEC Scoring in Patients with Necrotizing Fasciitis and its Correlation with the Outcomes.

<b><br>Introduction:</b> Necrotizing fasciitis (NF) is an expeditiously escalating inflammatory infection of the fascia, with secondary necrosis of the subcutaneous tissues. To aid diagnosis, the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) scoring system was devised to stratify the likelihood of infection in patients on presentation.</br> <b><br>Aim:</b> The study aimed to investigate and quantify the relationships between the LRINEC scoring system and the outcomes such as the need for amputation, length of hospital stay, and mortality in patients with necrotizing fasciitis.</br> <b><br>Material and methods:</b> A total number of 90 patients were admitted with a provisional diagnosis of necrotizing fasciitis. LRINEC score was calculated for each case based on six laboratory variables at the time of presentation. Enrolled patients were divided into three groups on the basis of the LRINEC score. The differences in mortality, length of hospitalization, number of debridement procedures, and need for amputation between these groups were compared.</br> <b><br>Results:</b> Increasing age, male gender, and DM have a poor prognosis in necrotizing fasciitis patients. The amputation and mortality rates are better correlated with higher LRINEC scores.</br> <b><br>Conclusions:</b> The LRINEC score helps in stratifying the patients into three risk categories (low risk, moderate risk, and high risk) according to the severity in a much more organized way, and thus the appropriate management like surgical debridement can be introduced on time. LRINEC score is a robust index that is capable of detecting early cases of necrotizing fasciitis and is simple enough for routine use. It is a simplified bedside diagnostic tool for early diagnosis and prediction of outcomes in patients with necrotizing fasciitis.</br>.

Association between Insurance Status and Outcomes of Hospitalizations for Necrotizing Soft Tissue Infections.

Background: Lack of insurance is associated with poorer outcomes in hospitalized patients. However, few studies have explored this association in hospitalizations for necrotizing soft tissue infections (NSTIs). This study examined the impact of insurance status on the outcome of NSTI admissions. Methods: All adult hospitalizations for necrotizing fasciitis, gas gangrene, and Fournier gangrene between 2016 and 2018 were examined using the Nationwide Inpatient Sample database. Insurance status was categorized as insured (including Medicare, Medicaid, and Private, including Health maintenance organization (HMO) or uninsured (Self-pay). Outcome measures included mortality rates, limb loss, length of hospital stay, prolonged hospital stay, and critical care admissions. Statistical analysis included weighted sample analysis, chi-square tests, multivariate regression analysis, and negative binomial regression modeling. Results: Approximately 29,705 adult hospitalizations for NSTIs were analyzed. Of these, 57.4% (17,065) were due to necrotizing fasciitis, 22% (6,545) to gas gangrene, and 20.5% (6,095) to Fournier gangrene. Approximately 9.7% (2,875) were uninsured, whereas 70% (26,780) had insurance coverage. Among the insured, Medicare covered 39.6% (10,605), Medicaid 29% (7,775), and private insurance 31.4% (8,400). After adjustments, Medicare insurance was associated with greater odds of mortality (adjusted odds ratio [aOR]: 1.81; 95% confidence interval [CI]: 1.33-2.47; p = 0.001). Medicaid insurance was associated with increased odds of amputation (aOR: 1.81; 95% CI: 1.33-2.47; p < 0.001), whereas private insurance was associated with lower odds of amputation (aOR: 0.70; 95% CI: 0.51-0.97; p = 0.030). Medicaid insurance was associated with greater odds of prolonged hospital stay (aOR: 1.34; 95% CI: 1.09-1.64; p < 0.001). No significant association was observed between the lack of insurance or self-pay and the odds of primary or secondary outcomes. Conclusion: Medicare insurance was correlated with greater odds of mortality, whereas Medicaid insurance was associated with increased odds of amputation and longer hospital stay. Uninsured status was not associated with significant differences in NSTI outcomes.

Necrotizing Fasciitis: When skin confuses - An autopsy case report.

Necrotizing Fasciitis (NF) is a severe life-threatening soft tissue infection characterized by the rapid destruction of muscle, fat and fascial layers. This report details an autopsy case report of a 40year old male, unclaimed body lacking the complete history except that given by the Police personnel accompanying in which there is no prior history of trauma. This person succumbed to septic shock secondary to NF, despite clinical interventions. This case emphasizes the importance of early diagnosis and the need for heightened clinical awareness to improve patient outcomes.

[Post-mastectomy necrotizing fasciitis and immediate prosthetic breast reconstruction: First case report]. / Fasciite nécrosante postmastectomie et reconstruction mammaire immédiate par prothèse : premier cas rapporté.

Necrotizing fasciitis is a rapidly progressive soft tissue infection extending from the skin to the fascia, resulting in extensive necrosis. It is a very rare but serious complication, with mortality ranging from 10 to 15%. Optimal management involves early diagnosis followed by treatment combining antibiotic therapy and wide surgical removal as soon as possible. Localisation in the breast is uncommon. Although most cases are primary necrotizing fasciitis of the breast, several cases of necrotizing fasciitis have been reported in the post-operative aftermath of breast surgery. We present a case of necrotizing fasciitis of the breast following submammary mastectomy with immediate reconstruction using a pre-pectoral silicone implant, which resulted in multiple organ failure and the death of the patient despite optimal medical and surgical management. This is the first case to occur after immediate breast reconstruction.

[Treatment of Fournier's gangrene with "firebreak" drainage based on skin preservation].

Objective: To observe the clinical efficacy of a new type of "firebreak" drainage with skin preservation in the treatment of Fournier's gangrene. Methods: This technique is suitable for patients with perianal necrotizing fasciitis who can tolerate surgery without large area of skin blackness and necrosis. Procedure and key points: (1) The dividing line between inflammatory tissue and normal tissue was determined according to imaging examination and intraoperative exploration; (2) The abscess cavity was cut along the most obvious part of the abscess fluctuation, with a long diameter of 3~4 cm and a short diameter of 1~2 cm; (3) Necrotic tissue was discreetly separated and removed from the main incision to the outer edge of the infection. A fusiform incision was made every 3 to 5 cm, with a long diameter of 2 to 3 cm and a short diameter of 1 cm, and discreetly separated until the normal tissue, and a hose was hung between the adjacent incisions for drainage. (4) Each adjacent edge cut between the stealth separation and hanging hose drainage, forming a "firebreak"; (5) Rinse the wound repeatedly; (6) If the infection invades the rectum, colostomy is performed as required. The case data of 11 patients with perianal necrotizing fasciitis admitted to the Second Affiliated Hospital of Nanjing University of Chinese Medicine from July 2019 to February 2023 were retrospectively analyzed. All patients were treated with emergency surgical debridement by "firebreak" drainage with skin preservation. Results: All 11 cases were cured with 100%. One case underwent multiple operations. The hospitalization time was 11-46 days, with an average of 22 days. The wound healing time was 28-75 days, with an average of 43 days. Except for 1 patient with trauma, all the other patients had no significant anal function injury after surgery. All the 11 patients recovered and were discharged from hospital with a median follow-up of 136 (115-413) days. Conclusions: The "firebreak" drainage based on skin preservation has the advantages of less trauma and faster recovery, and do not cause obvious anal function damage.

Difficult intubation in a patient with acute epiglottitis and abscess complicated with cervical necrotizing fasciitis: A case report.

INTRODUCTION: Acute epiglottitis is not uncommon and it can cause high mortality due to airway obstruction. Acute epiglottitis complicated with cervical necrotizing fasciitis has rarely been reported, and it is also a life-threatening disease with a fatality rate of 7% to 50%. PATIENT CONCERNS: A 64-year-old woman presented to our hospital with chief complaints of sore throat and cervical swelling, long with foreign body sensation and hoarseness. Endoscopic laryngoscopy showed erythematous and swollen epiglottis with purulent secretions on the surface. Computed tomography (CT) scan showed swollen epiglottis and swelling of the neck with air- and fluid-containing necrotizing tissue. DIAGNOSES: The diagnosis was acute epiglottitis and abscess complicated with cervical necrotizing fasciitis. INTERVENTIONS: With the patient in awake condition, airway access was established by performing intubation with adjunctive use of gum elastic bougie, followed by surgical debridement under general anesthesia; a flap was used for skin coverage and intravenous piperacillin-tazobactam was administered. OUTCOMES: The patient was discharged without complications. CONCLUSION: Gum elastic bougie is a usable tool in difficult intubation. Adequate pre-anesthesia evaluation, patient sedation, and gentle manipulation assured the intubation success in this case.

Efficacity of hyperbaric oxygen therapy for necrotizing fasciitis in the maxillofacial region: The review of the literature.

Necrotizing fasciitis (NF) is a rare, dangerous, potentially fatal infectious disease of soft tissue. The treatment consists of antibiotic therapy, surgical debridement and subsequent reconstruction. Hyperbaric oxygen (HBO) therapy has been applied in NF patients recently, so our aim was to gather the findings and outcomes for HBO therapy. A PubMed and Google Scholar literature search was conducted regarding the effect of HBO therapy in patients with NF following key words: 'necrotizing fasciitis' AND 'maxillofacial region' OR 'head and neck' AND 'hyperbaric oxygen' OR 'HBO'. A total of 3333 studies have been identified, of which only 16 articles met the inclusion criteria of this review. A conclusion was made, that aggressive combinations of antibiotics and surgical debridement followed by incorporation of HBO therapy, as an adjuvant treatment, in patients with NF and in company by immunoglobulin therapy are showing promising results. In addition, multi-centric studies should be in consideration for further research.

[Invasive Streptococcal infections - an interdisciplinary challenge]. / Invasive Streptokokken-Infektionen ­ eine interdisziplinäre Herausforderung.

HISTORY AND CLINICAL FINDINGS: We report on a 34-year-old female patient and a 50-year-old male patient, both of whom were admitted to our emergency department with severe septic conditions. MEDICAL EXAMINATIONS: Both patients were resuscitated and exhibited clinical as well as laboratory evidence of a severe bacterial infection. DIAGNOSIS: Both patients had an invasive infection with Group A Streptococcus. The female patient had a Streptococcal sepsis with severe pneumonia, while the male patient had a Streptococcus-induced necrotizing fasciitis of the upper extremity. THERAPY AND COURSE: While the female patient unfortunately died in the emergency department`s resuscitation room despite all intensive medical treatments, the male patient survived after prompt surgical therapy and an extended stay in the intensive care unit. CONCLUSION: Patients with invasive infections caused by Group A Streptococcus can deteriorate rapidly clinically. Prompt diagnosis and initiation of often interdisciplinary treatment are important. Nevertheless, these conditions can be fatal.

Association between time to surgery and hospital mortality in patients with community-acquired limb necrotizing fasciitis: an 11-year multicenter retrospective cohort analysis.

BACKGROUND: Necrotizing fasciitis (NF) is a rare but potentially life-threatening soft tissue infection. The objective of this study was to assess the association between timely surgery within 6 h and hospital mortality in patients with limb NF, and to describe the trends in patients with NF, time to surgery and standardized mortality ratio (SMR) over 11 years. METHODS: This was a multicenter, retrospective cohort study of all intensive care unit patients who had emergency surgery within 24 h of hospitalization for limb NF between April 1, 2008 and March 31, 2019 in Hong Kong. Timely surgery was defined as the first surgical treatment within 6 h of initial hospitalization. Appropriate antibiotics were achieved if the patient was given antibiotic(s) for all documented pathogens prior to or on day of culture results. The primary outcome was hospital mortality. RESULTS: There were 495 patients (median age 62 years, 349 (70.5%) males) with limb NF treated by surgery within 24 h of hospitalization over the 11 years. Appropriate antibiotic(s) were used in 392 (79.2%) patients. There were 181 (36.5%) deaths. Timely surgery was not associated with hospital mortality (Relative Risk 0.89, 95% CI: 0.73 to 1.07) but admission year, advanced age, higher severity of illness, comorbidities, renal replacement therapy, vasopressor use, and type of surgery were significant predictors in the multivariable model. There was an upward trend in NF diagnosis (1.9 cases/year, 95% CI: 0.7 to 3.1; P < 0.01; R2 = 0.60) but there was no downward trend in median time to surgery (-0.2 h/year, 95% CI: -0.4 to 0.1; P = 0.16) or SMR (-0.02/year, 95% CI: -0.06 to 0.01; P = 0.22; R2 = 0.16). CONCLUSIONS: Among patients operated within 24 h, very early surgery within 6-12 h was not associated with survival. Increasing limb NF cases were reported each year but mortality remained high despite a high rate of appropriate antibiotic use and timely surgical intervention.

Necrotizing fasciitis of the thigh secondary to perforated rectal cancer: the sciatic foramen as a route for infective spread.

Necrotizing fasciitis (NF) is a potentially life-threatening surgical emergency. It is a rapidly progressive infection of soft tissues, and mortality is related to the degree of sepsis and the general condition of the patient. It is a rare condition that requires a rapid diagnosis and surgical treatment is aggressive debridement. There are a small number of reported cases of perforation of a rectal malignancy leading to NF of the thigh. We present a case with rectal cancer in which the sciatic foramen had provided a channel for the spread of pelvic infection into the thigh.

La fascitis necrotizante es una emergencia quirúrgica potencialmente mortal. Es una infección de tejidos blandos rápidamente progresiva y la mortalidad está relacionada con el grado de sepsis y el estado general del paciente. Es una condición poco común que requiere un diagnóstico rápido, y el tratamiento quirúrgico consiste en un desbridamiento agresivo. Existe un pequeño número de casos notificados de perforación de neoplasia maligna de recto que conduce a fascitis necrotizante del muslo. Presentamos un caso de cáncer de recto en el cual el foramen ciático fue el canal para la propagación de la infección pélvica al muslo.

Necrotizing soft-tissue infection of the upper limb: A single-center study of 24 cases.

OBJECTIVES: Necrotizing soft-tissue infection and necrotizing fasciitis of the upper limb are infrequent. Studies are rare, and often include other anatomical regions. The specificities and particularities of this pathology are not well known. The aim of this study was to report diagnosis and treatment aspects. METHODS: A retrospective study was conducted over 10 years on every patient treated for necrotizing fasciitis of the upper limb with clinical, bacteriological and histological confirmation. One hundred ninety-eight items were extracted for each patient concerning clinical, biological, radiological and therapeutic data. RESULTS: During 10 years, 24 patients were diagnosed with necrotizing fasciitis of the upper limb: 18 males, 6 females; mean age, 59.9 years; mean body mass index, 25. Local erythema, pain and fever were the most frequent symptoms. Skin necrosis was present in fewer than 40% of patients. Sixteen cases (66.6%) had prior skin lesions and/or an entry point on the limb. Ten had non-steroidal anti-inflammatory drug prescription before acute symptom onset (42%), requiring intensive care unit admission. Treatment comprised surgical resection, resuscitative measures, antibiotic therapy and reconstructive surgery. Seven patients (30.4%) had 1 session of cutaneous excision, and the others had more than 2. Microbiological analysis found mono-microbial beta-hemolytic group A streptococci (BHGAS) infection in 14 patients (58.4%). Antibiotics were prescribed in 91% of cases before surgery, and in 100% after. The most frequently prescribed substance was clindamycin (18 patients, 75%). Ten patients (42%) stayed in the intensive care unit during treatment. Seventeen patients (70.8%) had thin skin graft reconstruction, including 50% with dermal substitute. Five patients (20.8%) had partial upper limb amputation. Two patients (8.3%) died in the 30 days following diagnosis. CONCLUSIONS: The death rate in necrotizing fasciitis of the upper limb was rather low but the amputation rate was higher than in other locations. This study shows the specific clinical, biological and treatment features of this rare but serious pathology of the upper limb.

[Fatal retroperitoneal necrotizing fasciitis due to Aeromonas caviae septicaemia]. / Fatale retroperitoneale nekrotisierende Fasziitis durch Aeromonas-caviae-Bakteriämie.

Aeromonas is well-recognized for causing diarrhea and post-traumatic wound infections. The most common Aeromonas species include Aeromonas hydrophila, Aeromonas caviae, and Aeromonas sobria. In cases of immunocompromise and malignancy, Aeromonas infections can prove fatal. Instances of deadly necrotizing fasciitis in the extremities due to Aeromonas infection have been documented. Herein, a case of previously unreported fatal retroperitoneal necrotizing fasciitis involving Aeromonas caviae in a patient with a history of gastric cancer is presented.