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

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.

Clinical presentations and outcomes of necrotizing fasciitis in males and females over a 13-year period.

BACKGROUND: Necrotizing fasciitis (NF) is a rapidly progressive infection of fascia and subcutaneous tissue resulting in serious outcomes. We aimed to evaluate the clinical presentations, hospital course and outcomes of NF based on patient gender. PATIENTS AND METHODS: All patients admitted with NF were enrolled in the study over a 13-year period in the main tertiary hospital in Qatar. Clinical presentations, co-morbidities, severity and outcomes were analyzed and compared in male and female patients. RESULTS: A total of 331 NF patients were identified with a mean age of 51 ± 15 years and male to female ratio of 3:1. However, Arab Qatari females were more frequently affected by NF in comparison to their male counterparts and south Asian females (p < 0.001), respectively. Female patients were older and had significantly higher incidence of abdominal and groin NF (p < 0.004). There were 13 cases with recurrent NF; 85% of them were males. Male NF patients had significantly higher rate of organ failure (p = 0.02), but there was no significant difference in the hospital length of stay as well as mortality in both genders. Overall, there were 85 (25.7%) deaths (23 females and 62 males). CONCLUSION: Necrotizing fasciitis remains a life threatening entity. Although, NF is more common in males, Qatari females are more likely to develop NF than males. NF of abdominal wall and groin is significantly higher in females. Development of organ failure is more common in males with NF. NF remains a challenging clinical problem in Qatar with a mortality rate ranging from 25 to 27% for both genders.

Risk Stratification of Necrotizing Fasciitis Based on the Initial Procalcitonin Concentration: A Single Center Observational Study.

BACKGROUND: Necrotizing fasciitis (NF) is a potentially fatal subcutaneous tissue and fascia infection. We studied the role of serum procalcitonin in the identification and assessment of severity of sepsis in patients with NF. METHODS: A retrospective analysis was conducted from January 2000 to December 2013 for all patients who admitted to surgical intensive care with provisional diagnosis of NF. Patients were categorized into four groups based on the initial procalcitonin concentrations (Group I: <0.5 low risk, Group II: ≥0.5-<2 moderate risk, Group III: ≥2-<10 high risk, and Group IV: ≥10 ng/mL high likelihood of severe sepsis). RESULTS: During the study period, 331 cases were identified to have NF with a mean age of 51 ± 14 years. Serum procalcitonin was tested in 62 cases (only between 2011 and December 2013) and all were positive (Group I: 22%, Group II: 18%, Group III: 21%, and Group IV: 39%). The most common affected regions were thigh and chest in Group II (46% and 9%, respectively), lower limbs in Group III (46%), and perineum and abdomen in Group IV (25% and 21%, respectively). In the four groups, 21 patients developed septic shock (Group I: 0%, Group II: 14%, Group III: 24%, and Group IV: 62%). The cut off procalcitonin value for septic shock was 5.6 ng/mL. Using receiver-operating characteristic curve, this cut off with the Area under the Curve (AUC) of 0.77 was found to have sensitivity 81% and specificity 67%. Sequential Organ Failure Assessment (SOFA) score was substantially greater in Group III and Group IV in comparison to Group I and Group II, p = 0.006. Procalcitonin levels were correlated well with SOFA score (r = 0.34, p = 0.007). There were 17 deaths in the four groups (Group I: 6%, Group II: 23%, Group III: 12%, and Group IV: 59%). CONCLUSION: Initial procalcitonin concentration in NF carries an important prognostic value and it correlates well with SOFA score and can predict the development of septic shock early in patients with NF.

Pneumoperitoneum in a patient with pneumothorax and blunt neck trauma.

INTRODUCTION: Blunt trauma as a cause of pneumoperitoneum is less frequent and its occurrence without a ruptured viscus is rarely seen. PRESENTATION OF CASE: We report a case of blunt neck trauma in which a motorcycle rider hit a fixed object causing severe laryngotracheal injury. The patient developed pneumothorax bilaterally and had pneumoperitoneum despite no injury to the internal viscus. Bilateral chest tube drainage and abdominal exploratory laparotomy was performed. CONCLUSION: Free air in the abdomen after blunt traumatic neck injury is very rare. If pneumoperitoneum is suspected in the presence of pneumothorax, exploratory laparotomy should be performed to rule out intraabdominal injury. As, there is no consensus for this plan yet, further prospective studies are warrant. Conservative management for pneumoperitoneum in the absence of viscus perforation is still a safe option in carefully selected cases.