Predictors for gram-negative monomicrobial necrotizing fasciitis in southern Taiwan.

BACKGROUND: Necrotizing fasciitis (NF) is a rare and life-threatening necrotizing skin and soft-tissue infection. Infectious pathogens of NF must be detected early and treated rapidly to prevent loss of limb or a fatal outcome. This study aimed to detect more reliable predictors between gram-negative and gram-positive monomicrobial NF of limbs. METHODS: A total of 100 patients with limb monomicrobial NF were diagnosed prospectively from April 2015 to July 2018. These monomicrobial NF pathogens can be divided into gram-negative and gram-positive groups according to the result of Gram staining and final bacterial reports. Data such as demographics, seawater or seafood contact history, infectious location, comorbidities, presenting signs and symptoms, and laboratory findings were recorded and compared. RESULTS: A total of 55 patients were infected with gram-negative organisms and 45 patients with gram-positive organisms. Among the 55 cases of monomicrobial gram-negative NF, 48 (87.3%) were caused mainly by Vibrio spp. (38, 69.1%) and Aeromonas spp. (10, 18.2%). A higher incidence of chronic kidney disease, cerebrovascular accident, tachypnea, and septic shock; a higher rate of band forms of leukocytes of more than 3%, serum lactate of more than 20 mg/dL, and C-reactive protein level of less than 150 mg/dL; prolonged prothrombin time; and a lower fibrinogen level were observed in patients with gram-negative infection. In a multivariate analysis, a higher incidence of seawater or seafood contact history (odds ratio [OR]: 66.301; 95% confidence interval [CI]: 7.467-588.702), a higher rate of hyperlactatemia (OR: 7.904; 95% CI: 1.231-50.744), and a low fibrinogen level (OR: 1.013; 95% CI: 1.004-1.023) indicated gram-negative infection. CONCLUSIONS: In southern Taiwan, NF of limbs mainly affected the lower limbs, exhibited monomicrobial infection, and was predominated by gram-negative bacteria. Gram-negative monomicrobial NF of limbs often occurred in individuals with the more seawater or seafood contact history, hyperlactatemia, and low fibrinogen levels.

Identifying necrotizing soft tissue infection using infectious fluid analysis and clinical parameters based on machine learning algorithms.

Background: Determining the presence of necrotizing soft tissue infection (NSTI) poses a significant hurdle. As of late, there has been a notable increase in the application of artificial intelligence (AI) machine learning techniques in identifying diseases, a shift that can be attributed to their exceptional efficiency, unbiased nature, and high precision. Methods: Information was gathered from a cohort of 13 patients suffering from NSTI, alongside 12 patients with cellulitis. The construction of NSTI diagnostic machine learning models utilized four different algorithms, specifically random forest, k-nearest neighbors (KNN), support vector machine (SVM), and logistic regression. These models were constructed based on 28 distinctive attributes identified through statistical examination. Following this, the diagnostic efficiency of each algorithms was evaluated. A novel random forest model, streamlined for clinical use, was later developed by focusing on 6 attributes that had the most pronounced influence on the accuracy of our initial random forest model. Results: The following data was noted regarding the sensitivity and specificity of the four NSTI diagnostic models:logistic regression displayed 78.2 % and 83.7 %, KNN presented 79.1 % and 87.1 %, SVM showed 83.5 % and 86.3 %, and random forest exhibited 89.6 % and 92.9 %, respectively. In comparison, lactate levels in fluid demonstrated 100 % sensitivity and 76.9 % specificity at an optimal cut-off point of 69.6 mg/dL. Among all four machine learning models, random forest outperformed the others and also showed better results than fluid lactate. A newly constructed random forest model, created using 6 of the 13 identified features, displayed promising results in diagnosing NSTI, having a sensitivity and specificity of 90.2 % and 92.2 %, respectively. Conclusions: Developing a diagnostic model for NSTI employing the random forest algorithm has resulted in a diagnostic technique that is more efficient, cost-effective, and expedient. This approach could provide healthcare practitioners with the tools to identify and manage NSTI with greater efficacy.

Exploring Experiences of Conflict within Medical Teams in an Emergency Department: A Focus Group Approach during the COVID-19 Pandemic.

The factors related to conflicts in emergency departments (EDs) have been studied for decades. The post-pandemic digital era may transform the medical landscape in EDs, potentially changing the patterns of conflict between healthcare professionals. This study used focus group interviews to explore conflicts in EDs. Four groups, each with 4-6 participants, took part in this study. Semi-structured interviews were conducted using six research questions. Summative content analysis was used to analyze the data. The participant's average age was 37.82 years, and the average number of working years was 12.12. The following five themes emerged: multiple patterns of internal conflict; external conflicts arising from cross-departmental coordination; conflicts due to unclear job boundaries; adapting to conflicts in diverse ways; and seeking hospital arbitration. The results of this study suggest extending interdisciplinary collaborative practice from emergency departments to all coordinating departments. An inclusive environment for equality between professions and open communication should be promoted by hospitals.

Interdisciplinary simulation-based teaching and learning for healthcare professionals: A systematic review and meta-analysis of randomized controlled trials.

AIM: This study aimed to investigate the effects of interdisciplinary simulation-based teaching and learning on the interprofessional knowledge of healthcare professionals. BACKGROUND: Interdisciplinary simulation-based teaching and learning have been employed to prepare learners to collaborate in clinical settings. This strategy could help healthcare professionals to better understand each other, develop interdisciplinary shared values and promote mutual respect between professions, while reducing errors and adverse events in hospital. A meta-analysis was performed to investigate the effects of interdisciplinary simulation-based teaching and learning on healthcare professionals. DESIGN: A systematic review and meta-analysis. METHODS: A systematic search was conducted of databases including Academic Search Complete, CINAHL Plus with full text, Cochrane Library, Embase, Medline Complete, PubMed and Web of Science from their inception to September 5, 2023. The study included randomized controlled trials that provided interdisciplinary simulation-based education to healthcare professionals. Protocol trials or studies that did not include median or mean and standard deviation were excluded. The pooled standardized mean differences of outcomes were analyzed using a DerSimonian-Laird random-effects model. Heterogeneity was assessed using I2. Egger's regression test was used to examine publication bias indicated in forest plots. RESULTS: Ten randomized control trials with a total of 766 participants were included in the pooled analyses. Interdisciplinary simulation-based teaching and learning positively enhanced the interprofessional knowledge of healthcare professionals (pooled SMD = 0.30; 95% CI = 0.10-0.50; p < 0.001). Egger's regression test results were non-significant, indicating that publication bias had little impact on the pooled SMDs. CONCLUSION: Interdisciplinary simulation-based teaching and learning for health professionals appear to be significantly beneficial for increasing their interprofessional knowledge. This strategy highlights the importance of providing a well-developed scenario with relevant properties, which applies valid and rigorous instruments, to measure behavioral changes induced by interdisciplinary simulation-based teaching and learning.

The changes and the potential clinical applications of cytokines in Taiwan's major venomous snakebites patients.

BACKGROUND: Taiwan habu (Protobothrops mucrosquamatus), green bamboo viper (Viridovipera stejnegeri), and Taiwan cobra (Naja atra) are the most venomous snakebites in Taiwan. Patients commonly present with limb swelling but misdiagnosis rates are high, and currently available diagnostic tools are limited. This study explores the immune responses in snakebite patients to aid in differential diagnosis. METHODS: This prospective observational study investigated the changes in cytokines in snakebite patients and their potential for diagnosis. RESULTS: Elevated pro-inflammatory cytokines IL-6 and TNF-α were observed in all snakebite patients compared to the healthy control group. While no significant disparities were observed in humoral immune response cytokines, there were significant differences in IFN-γ levels, with significantly higher IL-10 levels in patients bitten by cobras. Patients with TNF-α levels exceeding 3.02 pg/mL were more likely to have been bitten by a cobra. CONCLUSION: This study sheds light on the immune responses triggered by various venomous snakebites, emphasizing the potential of cytokine patterns for snakebite-type differentiation. Larger studies are needed to validate these findings for clinical use, ultimately improving snakebite diagnosis and treatment.

Impacts of interprofessional education on collaborative practice of healthcare professionals: A systematic review and meta-analysis.

OBJECTIVE: To investigate and statistically synthesise data on the effects of interprofessional education on healthcare professionals' collaborative practice among healthcare professionals. DESIGN: A systematic review and meta-analysis. DATA SOURCES: Seven databases and the grey literature were searched to collect relevant studies from database inception to 15 May 2023. REVIEW METHODS: A random-effects model was used to assess the pooled effect size. Each pooled analysis was tested for publication bias using Egger's regression test. RESULTS: Eleven studies were included in the final analysis. The evaluation of pooled results showed that interprofessional education significantly enhanced attitudes towards or mutual respect among healthcare professionals (pooled standardized mean difference: 0.14; 95 % Confidence Interval: 0.01-0.28; p = 0.04) and interprofessional knowledge (pooled standardized mean difference: 0.43; 95 % Confidence Interval: 0.22-0.65; p < 0.001). CONCLUSIONS: Interprofessional education is a feasible approach to enhance attitudes towards or mutual respect among healthcare professionals as well as their interprofessional knowledge. Future research is needed to consider the inclusion of a module designed to develop mutual interests and communication to enhance students' perspectives on the importance of the interprofessional education approach.

Predictor of gram-negative bacteremia in cirrhotic patients with skin and soft-tissue infections.

Cirrhosis always goes with profound immunity compromise, and makes those patients easily be the target of skin and soft-tissue infections (SSTIs). Cirrhotic patients with SSTIs have a dramatically increased mortality. To recognize the risk factors of gram-negative infections are critical for improving survival rate. A retrospective cohort study of hospitalized cirrhotic patients with SSTIs and gram-negative bacteremia (GNB) was conducted in 2 tertiary hospitals in southern Taiwan between March 2015 and January 2020. Another group were matched by controls with non-GNB based on time, demographics and immune status. Data such as infectious location, comorbidities, and laboratory findings were recorded and compared. Receiver operating curve and the area under the curve were used to evaluate its discriminating ability. A total of 186 patients were included, 62 in GNB group and 124 in non-GNB group. Comorbidities that were significant risk factors for gram-negative bacteremia included acute kidney injury. Significant risk factors evident in laboratory evaluations included higher model for end-stage liver disease score, higher serum lactate, higher C-reactive protein and higher creatinine level. This study found acute kidney injury, or those exhibiting hyperlactatemia (>16 mg/dL), high MELD score (>14), high CRP (>50 mg/dL), and high creatinine (>2.0 mg/dL) were risk factors associated with gram-negative bacteremia. Cirrhotic patients with SSTIs with aforementioned risk factors should pay more attention by clinicians due to higher mortality.

Taiwan cobra envenoming: serum venom concentration before and after specific treatment and relationship with debridement of necrotic wound tissue.

Background: Bivalent freeze-dried neurotoxic (FN) antivenom has been the primary treatment since the 1980s for Taiwan cobra (Naja atra) envenomation in Taiwan. However, envenomation-related wound necrosis is a significant problem after cobra snakebites. In the present study, we analyzed the changes in serum venom concentration before and after antivenom administration to discover their clinical implications and the surgical treatment options for wound necrosis. Methods: The patients were divided into limb swelling and wound necrosis groups. The clinical outcome was that swelling started to subside 12 hours after antivenom treatment in the first group. Serum venom concentrations before and after using antivenoms were measured to assess the antivenom's ability to neutralize the circulating cobra venom. The venom levels in wound wet dressing gauzes, blister fluids, and debrided tissues were also investigated to determine their clinical significance. We also observed the evolutional changes of wound necrosis and chose a better wound debridement timing. Results: We prospectively enrolled 15 Taiwan cobra snakebite patients. Males accounted for most of this study population (n = 11, 73%). The wound necrosis group received more antivenom doses than the limb swelling group (4; IQR:2-6 vs 1; IQR:1-2, p = 0.05), and less records of serum venom concentrations changed before/after antivenom use (p = 0.0079). The necrotic wound site may release venom into circulation and cause more severe envenomation symptoms. Antivenom can efficiently diminish limb swelling in cobra bite patients. However, antivenom cannot reduce wound necrosis. Patients with early debridement of wound necrosis had a better limb outcome, while late or without debridement may have long-term hospital stay and distal limb morbidity. Conclusions: Antivenom can efficiently eliminate the circulating cobra venom in limb swelling patients without wound necrosis. Early debridement of the bite site wound and wet dressing management are suggestions for preventing extended tissue necrosis and hospital stay.

The association of leptin and C-reactive protein with the cardiovascular risk factors and metabolic syndrome score in Taiwanese adults.

BACKGROUND: Serum C-reactive protein (CRP) and leptin levels have been independently associated with the cardiovascular risk factors. The aim of the present study was to determine if their serum levels were associated with cardiovascular risk factors or metabolic syndrome as well as their correlation in the Taiwanese population. METHODS: This retrospective study included 999 subjects (> 18 y), who underwent a physical examination in Chang-Gung Memorial Hospital-Linkou and Chiayi in Taiwan. The associations between CRP and/or leptin levels and cardiovascular risk factors and metabolic syndrome were determined using independent two sample t-tests to detect gender differences and chi-square tests to evaluate differences in frequencies. To compare the means of the variables measured among the four groups (high and low leptin and high and low CRP), analysis of variance (ANOVA) was used. RESULTS: Both CRP and leptin levels were independently associated with several cardiovascular risk factors, including diabetes, hypercholesterolemia and metabolic syndrome in both men and women (P < 0.05). In addition, a positive correlation between leptin and CRP levels was observed in both genders. Both high-CRP and high-leptin were associated with high blood glucose, waist circumference and serum triglyceride. Whereas increased metabolic syndrome incidence was observed in males with elevated leptin regardless of CRP levels, females with elevated CRP or leptin had increased incidence of metabolic syndrome. CONCLUSION: Both leptin and CRP levels were associated with cardiovascular risk factors as well as metabolic syndrome score in both men and women although gender-specific differences were observed. Thus, CRP and leptin may represent useful biomarkers for predicting the onset of cardiovascular disease or metabolic syndrome in Taiwanese adults. TRIAL REGISTRATION: IRB/CGMH 100-3514B.

Correction: Prospective Validation of the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) Score for Necrotizing Fasciitis of the Extremities.

[This corrects the article DOI: 10.1371/journal.pone.0227748.].

The microbiological profile and presence of bloodstream infection influence mortality rates in necrotizing fasciitis.

INTRODUCTION: Necrotizing fasciitis (NF) is a life threatening infectious disease with a high mortality rate. We carried out a microbiological characterization of the causative pathogens. We investigated the correlation of mortality in NF with bloodstream infection and with the presence of co-morbidities. METHODS: In this retrospective study, we analyzed 323 patients who presented with necrotizing fasciitis at two different institutions. Bloodstream infection (BSI) was defined as a positive blood culture result. The patients were categorized as survivors and non-survivors. Eleven clinically important variables which were statistically significant by univariate analysis were selected for multivariate regression analysis and a stepwise logistic regression model was developed to determine the association between BSI and mortality. RESULTS: Univariate logistic regression analysis showed that patients with hypotension, heart disease, liver disease, presence of Vibrio spp. in wound cultures, presence of fungus in wound cultures, and presence of Streptococcus group A, Aeromonas spp. or Vibrio spp. in blood cultures, had a significantly higher risk of in-hospital mortality. Our multivariate logistic regression analysis showed a higher risk of mortality in patients with pre-existing conditions like hypotension, heart disease, and liver disease. Multivariate logistic regression analysis also showed that presence of Vibrio spp in wound cultures, and presence of Streptococcus Group A in blood cultures were associated with a high risk of mortality while debridement > = 3 was associated with improved survival. CONCLUSIONS: Mortality in patients with necrotizing fasciitis was significantly associated with the presence of Vibrio in wound cultures and Streptococcus group A in blood cultures.

Effectiveness of a Nurse-Delivered Intervention on Illness Perceptions and Quality of Life in Patients With Injury.

BACKGROUND: Research has shown that nursing interventions are able to affect short-term outcomes in patients with injury. However, evidence based on a comprehensive nurse-led intervention may be beneficial for trauma care. PURPOSE: This study was designed to assess the effect of a nursing intervention on the illness perceptions and quality of life of patients with injury. METHODS: A two-group experimental design and a follow-up period of 12 months were used. Ninety-four patients were randomly assigned to either the experimental group or the control group. A nurse-led cognitive behavioral therapy intervention was used to improve outcomes. RESULTS: The illness perception variables of "personal control" and "treatment control" were found to be significantly improved in the experimental group at 3 months after discharge, whereas "emotional perception" was significantly improved at 6 months after discharge. The intervention was also shown to improve "social quality of life" at 6 and 12 months after injury. CONCLUSIONS: This study adds new knowledge related to nursing interventions for patients with injury in terms of the intervention achieving longer-term effects than the interventions examined in previous studies. The results highlight the importance of providing interprofessional collaborative care. However, the intervention protocol should be tested further in future studies.

Utility of the Lactate/Albumin Ratio as a Predictor for Mortality in Necrotizing Fasciitis Patients.

BACKGROUND: The lactate/albumin (L/A) ratio has been proposed as a prognostic marker because the ratio is associated with multiple organ failure and mortality in critically ill patients. We aimed to investigate the clinical utility of the L/A ratio as a good prognostic indicator of mortality in a cohort of necrotizing fasciitis patients. METHOD: This retrospective study was conducted in two tertiary hospitals in Taiwan between 2015 and 2020. We reviewed adult patients with measured serum lactate and albumin on the emergency department (ED) arrival to evaluate the prognostic performance of the lactate and lactate/albumin (L/A) ratio for outcome prediction. RESULT: Of the 262 NF patients, 20 (7.63%) died in the hospital. The area under the receiver operating characteristic curve (AUROC) value of the L/A ratio (0.76, 95% confidence interval [CI] 0.69-0.81, P < 0.01) was higher than lactate alone (0.71, 95% CI 0.65-0.74 P < 0.01) for predicting in-hospital mortality. The optimal cutoff of the L/A ratio was 1.61. The AUROC value of the L/A ratio was better than lactate alone regardless of normal lactate level. The cutoff of L/A ratio and hypoalbuminemia showed further discriminative value for in-hospital mortality even in patients with normal lactate levels. CONCLUSION: The prognostic performance of the L/A ratio was superior to a single measurement of lactate for predicting in-hospital mortality and intensive care unit (ICU) lengths in necrotizing fasciitis patients. Aggressive intervention and intensive care were necessary for high-risk NF patients upon ED arrival.

Prospective Validation of the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) Score for Necrotizing Fasciitis of the Extremities.

OBJECTIVES: The Laboratory Risk Indicator for Necrotizing Fasciitis score was developed as a clinical decision tool for distinguishing necrotizing fasciitis from other soft tissue infections. We prospectively evaluated the performance of the Laboratory Risk Indicator for Necrotizing Fasciitis score for the diagnosis of patients with necrotizing fasciitis in the extremities. METHODS: We conducted a prospective and observational cohort study of emergency department patients with necrotizing fasciitis or severe cellulitis in the extremities between April 2015 and December 2016. The Laboratory Risk Indicator for Necrotizing Fasciitis score was calculated for every enrolled patient. The sensitivity, specificity, positive predictive value, and negative predictive value of cut-off scores of 6 and 8 were evaluated. The accuracy of the Laboratory Risk Indicator for Necrotizing Fasciitis score was expressed as the area under the receiver operating characteristic curve. RESULTS: A total of 106 patients with necrotizing fasciitis and 825 patients with cellulitis were included. With an Laboratory Risk Indicator for Necrotizing Fasciitis cut-off score ≥6, the sensitivity was 43% (95% confidence interval 34% to 53%), specificity was 83% (95% confidence interval 80% to 86%), positive predictive value was 25% (95% confidence interval 20% to 30%), and negative predictive value was 92% (95% confidence interval 91% to 93%); with an Laboratory Risk Indicator for Necrotizing Fasciitis cut-off score ≥8, the sensitivity was 27% (95% confidence interval 19% to 37%), specificity was 93% (95% confidence interval 91% to 94%), positive predictive value was 33% (95% confidence interval 25% to 42%), and negative predictive value was 91% (95% confidence interval 90% to 92%). The area under the receiver operating characteristic curve for accuracy of the Laboratory Risk Indicator for Necrotizing Fasciitis score was 0.696 (95% CI 0.640 to 0.751). CONCLUSION: The Laboratory Risk Indicator for Necrotizing Fasciitis score may not be an accurate tool for necrotizing fasciitis risk stratification and differentiation between severe cellulitis and necrotizing fasciitis in the emergency department setting based on our study.

Clinical predictors and impact of bacteremia in cirrhotic patients with acute skin and skin structure infection.

OBJECTIVE: Acute bacterial skin and skin structure infection (ABSSSI) is a common cause of acute admissions in patients with cirrhosis worldwide, but the disease is not well-understood epidemiologically with respect to factors that determine positive blood cultures or patient mortality. The aim of this study was to understand the utility of blood cultures and the association between bacteremia and mortality in cirrhotic patients with ABSSSI. We conducted a retrospective study to investigate factors associated with positive blood cultures and mortality in cirrhotic patients with ABSSSI. METHODS: A retrospective cohort study of hospitalized adult cirrhotic patients with ABSSSI was conducted in a tertiary hospital in Taiwan between March 2015 and December 2016. RESULTS: A total of 122 hospitalized cirrhotic patients with ABSSSI were included. The overall mortality rate was 9% (11/122), and 23 patients had positive blood culture results. Comorbidities that were significant risk factors for a positive blood culture included diabetes mellitus, acute kidney injury (AKI), and acute-on-chronic liver failure (ACLF). Significant risk factors evident in laboratory evaluations included higher model for end-stage liver disease (MELD) score, higher serum lactate, and lower serum albumin level. Bacteremia was also a significant factor associated with mortality. CONCLUSION: A blood culture should be considered for cirrhotic patients with ABSSSI with diabetes mellitus, AKI, ACLF or those exhibiting abnormal albumin, lactate levels, or high MELD score because of the positive correlation between bacteremia and mortality.

Risk factors associated with bacteremia correlated with mortality in patients with acute bacterial skin and skin structure infection.

Acute bacterial skin and skin structure infections (ABSSSI) is a common cause of acute admissions worldwide, but the disease is not well understood epidemiologically with respect to factors that determine positive blood cultures or patient mortality. To understand the utility of blood cultures and the association between bacteremia and mortality in patients with ABSSSI, we conducted a retrospective study to investigate factors associated with positive blood cultures and mortality in patients with ABSSSI. A retrospective cohort study of hospitalized adult patients with ABSSSI was conducted in a tertiary hospital in Taiwan between March 2015 and December 2016. A total of 1322 hospitalized patients with ABSSSI are included. The overall mortality rate is 2.1% (28/1322), and 122 patients had positive blood culture results. Comorbidities that are significant risk factors for a positive blood culture include diabetes mellitus and chronic kidney disease. Significant risk factors evident in laboratory evaluations include high C-reactive protein (CRP) level (> 20 mg/dL), hyperglycemia, and hypoalbuminemia. Bacteremia is also a significant factor associated with mortality. A blood culture should be considered for patients with ABSSSI with diabetes mellitus or chronic kidney disease or those exhibiting abnormal CRP, glucose, or albumin levels because of the positive correlation between bacteremia and mortality.

Do Emergency Nurses Spend Enough Time on Nursing Activities? The Relationship Between Actual and Expected Patient Care Nursing Time.

BACKGROUND: The overcrowded environments of emergency departments (EDs) lead to increased clinical workloads for nurses and infl uences the quality of patient care. This study aimed to evaluate whether the quality of patient care meets the expectations of emergency nurses in Taiwan by measuring the amount of time nurses spend on patient care activities. METHODS: The direct observation study was conducted in one suburban academic hospital with approximately 80,000 annual ED visits. This study observed emergency nurses and the time they spent on their nursing activities. The directly measured times and nurse expected patient care nursing times were compared. RESULTS: For all 88 types of nursing activities recorded, each measured nursing time was less than the expected nursing time. On average, the measured nursing time was 82% less than the expected nursing time (2.0 ± 0.3 minutes vs. 11.6 ± 1.5 minutes, p < 0.01). Among the 88 types of nursing activities recorded, the average measured time spent on 76 types (86%) was less than 3 minutes. The nursing activity on which the longest time was spent was cerebrospinal fl uid study nursing (7 minutes). The most frequent nursing activity was documentation. CONCLUSION: The nursing time spent on patient-care activities in EDs was much less than the nurses expected. The results may provide a basis for nursing quality measurements and manpower calculations for EDs.

Lactate on emergency department arrival as a predictor of in-hospital mortality in necrotizing fasciitis: a retrospective study.

BACKGROUND: Hyperlactatemia is known to be associated with adverse outcome in critical illness. In this study, we attempted to identify if hyperlactatemia on emergency department (ED) arrival is a reliable predictor for in-hospital mortality in necrotizing fasciitis (NF) patients. METHOD: A prospective cohort study of hospitalized patients with NF was conducted in two tertiary teaching hospitals in Taiwan between March 2010 and March 2018. Blood samples were collected in the ED upon arrival, and the lactate levels were determined. Sequential organ failure assessment (SOFA) scores were calculated during the first 24 h after admission. All collected data were statistically analyzed. RESULT: Of the 707 NF patients, 40 (5.66%) died in the hospital. The median (interquartile range) blood lactate level in all NF patients was 3.6 mmol/l (2.2-4.8). The blood lactate level upon ED arrival was significantly associated with mortality (odds ratio [OR] = 1.35; 95% confidence interval [CI], 1.30-1.46; P < 0.001), even after adjustment for age and SOFA score (OR = 1.27; P < 0.001). Multivariate regression analysis showed that a high blood lactate level (OR = 1.17; 95% CI, 1.07-1.29; P = 0.001) and a high SOFA score (OR = 1.15; 95% CI, 1.11-1.20; P < 0.001) were independent risk factors for in-hospital mortality in NF. Blood lactate achieved an area under-the-receiver-operating-characteristic curve (AUC) of 0.79 (P < 0.001) for predicting mortality that was similar to that of SOFA score (AUC = 0.82; P < 0.001). Blood lactate displayed a sensitivity of 62% and a specificity of 86% in predicting mortality at the optimal cutoff value of 5.80 mmol/l. CONCLUSION: In necrotizing fasciitis patients, hyperlactatemia on ED arrival is independently associated with in-hospital mortality. NF patients with hyperlactatemia on ED arrival should be closely monitored for signs of deterioration and consider early and aggressive intervention to prevent mortality.

The Relationship Between Fluid Accumulation in Ultrasonography and the Diagnosis and Prognosis of Patients with Necrotizing Fasciitis.

Necrotizing fasciitis is a severe soft-tissue infection with a high mortality rate. There is little literature on the relationship between the ultrasonographic finding of fluid accumulation along the deep fascia and the diagnosis and prognosis of necrotizing fasciitis. This retrospective study showed that when fluid accumulation was present along the deep fascia, patients with clinically suspected necrotizing fasciitis had a higher probability of having necrotizing fasciitis. The ultrasonographic finding of fluid accumulation with a cutoff point of more than 2 mm of depth had the best accuracy (72.7%) for diagnosing necrotizing fasciitis. In regard to the prognosis of necrotizing fasciitis, when fluid accumulation was present along the deep fascia, patients with necrotizing fasciitis had a longer length of hospital stay and were at risk of amputation or mortality. Ultrasonography is a point-of-care imaging tool that facilitates the diagnosis and prognosis of necrotizing fasciitis.

Risk factors for mortality in the late amputation of necrotizing fasciitis: a retrospective study.

Background: Necrotizing fasciitis (NF) is a rapidly progressive infectious disease that primarily involves the fascia and subcutaneous tissue. If not promptly treated, it can lead to morbidity as well as mortality. It can affect any part of the body, most commonly the extremities. Early and aggressive surgical treatment is the proper way of management. The purpose of this study was to identify the risk factors for mortality in late amputation among NF patients that may be used in routine clinical practice to prevent mortality. Methods: A retrospective cohort study of hospitalized patients with NF was conducted in a tertiary teaching hospital in Taiwan between March 2015 and March 2018. All collected data were statistically analyzed. Results: A total of 582 patients with NF were included; 35 of them had undergone amputation (7 primary and 28 late amputations), with a 6% amputation rate. Thirteen amputated patients still died eventually (all in the late amputation group). Significant risk factors for mortality identified in the late amputation group included hemorrhagic bullae (p = 0.001, OR 4.7, 95% confidence interval (CI) 2.68-8.69), peripheral vascular disease (p < 0.001, OR 3.2, 95% CI 1.12-10.58), bacteremia (p = 0.021, OR 2.87, 95% CI 2.07-5.96), and Laboratory Risk Indicator of Necrotizing Fasciitis (LRINEC) score > 8 (p < 0.001, OR 1.97, 95% CI 1.28-4.61). Vibrio vulnificus was the main causative organism based on our study, but the microbiology results showed no significant correlation. Conclusion: NF patients with hemorrhagic bullae, comorbidity with peripheral vascular disease, presence of bacteremia, or LRINEC score > 8 should receive early and primary amputation in order to prevent mortality.