Treating necrotizing fasciitis patients at the topmost referral hospital in West Java, Indonesia: 6 years experience.

Necrotizing fasciitis is a progressive and rare disease, with high potential to be life-threatening because of its potential for systemic toxicity. Characterized by fascial infection, it is often followed by systemic toxicity, such as septic shock and multi-organ failure. The aim of this study is to establish reliable data on the treatment of necrotizing fasciitis patients at the topmost referral hospital in West Java, Indonesia. We collected medical record data from January 2015 to December 2021 at Rumah Sakit Umum Pusat Dr. Hasan Sadikin (RSHS), Bandung, Indonesia. We recorded the infection region, bacterial isolates, empirical antibiotics, waiting time for the first surgery, surgical management, length of stay and we analysed the pattern of bacterial isolates, antibiotic use, waiting time for the first surgery, length of stay and mortality. A total of 90 patients' medical records were analysed. We found that the infection was most found in the genitalia and inguinal region (37%). Eighty-five percent of all samples containing gram-negative bacteria. The most used empirical antibiotics were from Cephalosporin class (31%), most of them combined with nitroimidazole (metronidazole) and with quinolones (levofloxacin, ciprofloxacin). Overall mortality rate was 13.3%. Highest mortality rate came from gram-negative bacteria group (14.2%-11 out of 77 patients), patients receiving Ceftriaxone-Metronidazole as empirical antibiotics (28.57%-4 out of 14 patients), patients with no surgery group (37%-3 out of 8 patients), with no mortality came from patients, which were performed debridement followed by fasciotomy/skin graft/flap and amputation. We conclude that the most found bacterial aetiology was Acinetobacter baumanii though it has no significant relation to mortality. We highly recommend early aggressive surgical intervention in reducing mortality rate due to necrotizing fasciitis for source control accompanied by deliberate defect closure and early administration of empirical antibiotics with more susceptibility for gram-negative bacteria, such as Meropenem.

Necrotizing fasciitis: an update on epidemiology, diagnostic methods, and treatment.

PURPOSE OF REVIEW: The aim of this review is to discuss the latest evidence of epidemiology, diagnostic methods, and treatment of necrotizing soft tissue infections (NSTIs) with a particular focus on necrotizing fasciitis (NF). RECENT FINDINGS: NSTIs have been historically referred to as NF but encompass a broader range of infections, with variable rates ranging from 0.86 to 32.64 per 100 000 person-years, influenced by factors such as climate and seasonal variations. They have diverse microbiological profiles categorized into different types based on the involved pathogens, including polymicrobial or monomicrobial infections caused by organisms such as group A streptococcus (GAS), Staphylococcus aureus , some Gram-negative pathogens, and filamentous fungi following trauma and natural disasters. Diagnosis relies on clinical symptoms and signs, laboratory markers, and imaging. However, the gold standard for diagnosis remains intraoperative tissue culture. Treatment involves repeated surgical debridement of necrotic tissues in addition to intravenous antibiotics. Adjuvant therapies with intravenous immunoglobulin (IVIG) and hyperbaric oxygen therapy (HBOT) might have a role. Soft tissue reconstruction may be necessary following surgery. SUMMARY: Prompt diagnosis and proper medical and surgical management of NSTI will improve outcomes.

Fascitis necrosante periocular / Necrotizing Periocular Fasciitis

La fascitis necrosante es una enfermedad rara y potencialmente mortal, que se produce por una infección grave que se disemina desde las fascias superficiales destruyendo el tejido celular subcutáneo y la piel suprayacente. Las formas perioculares de la enfermedad son aún más raras y pueden tener graves consecuencias para el paciente. El objetivo de este estudio fue contrastar los hallazgos clínicos y los resultados terapéuticos en una serie de cuatro casos diagnosticados en el Centro Oftalmológico de Holguín en el curso de cinco años. Entre 2017 y 2022 se diagnosticaron cuatro pacientes con formas perioculares de fascitis necrosante en el Centro Oftalmológico de Holguín. Dos pacientes tuvieron antecedentes de trauma menor. El dolor predominó entre los síntomas locales. Se identificaron dos patrones de lesiones: bilateral con ulceración y afectación de la región palpebral superior y unilateral con extensión en ambos párpados y apariencia oscura de la piel. Los pacientes evolucionaron a la gravedad con deterioro del estado general. El desbridamiento del tejido necrótico y el tratamiento con antibióticos de amplio espectro permitieron detener el progreso de la enfermedad, aunque quedaron secuelas anatómicas y funcionales. Un paciente falleció como consecuencia de una leucemia diagnosticada durante su ingreso. El reconocimiento temprano de la fascitis necrosante periocular y su inmediato tratamiento es indispensable para garantizar resultados óptimos y la supervivencia del paciente. Las formas perioculares pueden tener apariencia clínica diversa, lo que debe ser tenido en cuenta ante la sospecha de este cuadro, sobre todo por la similitud inicial con la celulitis preseptal(AU)

Necrotizing fasciitis is a rare and potentially fatal disease caused by a severe infection that spreads from the superficial fasciae destroying the subcutaneous cellular tissue and overlying skin. Periocular forms of the disease are even rarer and can have serious consequences for the patient. The aim of this study was to contrast clinical findings and therapeutic outcomes in a series of four cases diagnosed at the Holguin Ophthalmology Center over the course of five years. Between 2017 and 2022, four patients with periocular forms of necrotizing fasciitis were diagnosed at the Holguín Ophthalmologic Center. Two patients had a history of minor trauma. Pain predominated among the local symptoms. Two patterns of lesions were identified: bilateral with ulceration and involvement of the upper palpebral region and unilateral with extension in both eyelids and dark appearance of the skin. Patients progressed to severity with deterioration of general condition. Debridement of necrotic tissue and treatment with broad-spectrum antibiotics halted disease progression, although anatomical and functional sequelae remained. One patient died as a result of leukemia diagnosed during his admission. Early recognition of periocular necrotizing fasciitis and its immediate treatment is essential to ensure optimal outcome and patient survival. Periocular forms can have different clinical appearances, which should be taken into account when suspecting this condition, especially due to the initial similarity with preseptal cellulitis(AU)

Necrotising Fasciitis During the COVID-19 Pandemic: An Australian Hospital Network Experience.

BACKGROUND: The clinical presentations of diseases and the provision of global healthcare services have been negatively affected by the COVID-19 pandemic. Our study aimed to determine the impact of this global pandemic on presentations of necrotising fasciitis (NF). METHODS: A retrospective study was conducted of adult patients with NF in South West Sydney Local Health District from January 2017 to October 2022. An analysis of sociodemographic and clinical outcomes was performed comparing the COVID-19 cohort (2020-2022) and the pre-COVID-19 cohort (2017-2019). RESULTS: Sixty-five patients were allocated to the COVID-19 cohort, and 81 patients were in the control cohort. The presentation to hospitals of the COVID-19 cohort was significantly delayed compared to the control cohort (6.1 vs. 3.2 days, P < 0.001). Patients of the age group of 40 years and younger experienced prolonged operative time (1.8 vs. 1.0 h, P = 0.040), higher number of operations (4.8 vs. 2.1, P = 0.008), and longer total length of stay (LoS) (31.3 vs. 10.3 days, P = 0.035) during the pandemic. The biochemical, clinical, or post-operative outcomes of two groups were not significantly different. CONCLUSION: This multi-centre study showed that the COVID-19 pandemic delayed presentations of NF but did not result in any significant overall changes in operative time, ICU admissions, LoS, and mortality rate. Patients aged less than 40 years in the COVID-19 group were likely to experience prolonged operative time, higher number of operations, and greater LoS.

Outcomes of Patients with Necrotizing Soft Tissue Infections: A Propensity-Matched Analysis Using the National Inpatient Sample.

Background: Necrotizing soft tissue infections (NSTIs) are severe, rapidly spreading infections with high morbidity and mortality. Attempts to identify risk factors for mortality and morbidity have produced variable results. We hope to determine which factors across the NSTI population impact mortality, morbidities, and discharge disposition. Patients and Methods: Retrospective data from the National Inpatient Sample from 2012-2018 of patients with primary diagnosis of NSTI (gas gangrene, necrotizing faciitis, cutaneous gangrene, or Fournier gangrene) were identified for analysis. A 1:4 greedy match was performed and risk factors for in-hospital mortality and discharge disposition were examined. Continuous variables were assessed using t-tests and Wilcoxon rank sum tests. Categorical variables were assessed using χ2 and Fisher exact tests. Statistical significance was defined as p < 0.05. Results: A total of 6,608 patients were identified. Weighted, this represents 33,040 patients; 32,390 are in the no-mortality cohort and 650 in the mortality cohort. Advanced age group was a risk factor for both in-hospital mortality and morbidity, but not for discharge to a skilled nursing or rehabilitation facility. Having two or more comorbidities was a risk factor for mortality, morbidity, and discharge to skilled nursing or rehabilitation facility. Cancer, liver disease, and kidney disease were predictors of in-hospital mortality. Diabetes mellitus and kidney disease were predictors of experiencing an in-hospital complication. Diabetes mellitus, heart disease, and kidney disease were predictors for discharge to skilled nursing or rehabilitation facility. Conclusions: Necrotizing soft tissue infections are associated with substantial morbidity and mortality. Identifying patients at higher risk for mortality, morbidity, and higher level of care at discharge can help providers properly allocate resources to improve patient outcomes and reduce the financial burden on patients and healthcare facilities. Special attention should be paid to those with existing or acute kidney dysfunction because this was the only comorbidity associated with increased risk mortality, morbidity, and discharge to higher level of care.

Necrotizing Soft Tissue Infection in the Elderly: Effect of Pre-Operative Factors on Mortality and Discharge Disposition.

Background: Necrotizing soft tissue infections (NSTIs) are rapidly progressing, life-threatening diseases associated with substantial morbidity and mortality, especially in patients 65 years or older. We aimed to evaluate clinical factors associated with mortality and discharge disposition after NSTIs in elderly patients. Patients and Methods: Retrospective data were obtained from the 2007-2017 American College of Surgeons-National Surgical Quality (ACS-NSQIP) database. Patients aged 65 years or older with a post-operative diagnosis of an NSTI (defined as gas gangrene, necrotizing fasciitis, or Fournier gangrene) were included. Univariable and multivariable analyses were performed to identify independent clinical and demographic factors associated with mortality and with discharge disposition. Results: A total of 1,460 patients were included. Median age was 71 years, 43% were females. Overall, 30-day mortality was 18.5% and 30-day morbidity was 63.6%. The most important predictors of mortality included pre-operative septic shock (odds ratio [OR], 6.36; 95% confidence interval [CI], 3.61-11.18), pre-operative dialysis dependence (OR, 2.99; 95% CI, 1.77-5.05), coagulopathy (international normalized ratio [INR], >1.5, OR, 2.25; 95% CI, 1.51-3.37), hepatobiliary disease (bilirubin >1.0 mg/dL; OR, 2.05; 95% CI, 1.38-3.04) and aged 80 years or older (OR, 3.36; 95% CI, 2.08-5.44). Patients without any of these risk factors had a mortality of 7.3%. Predictors of discharge to inpatient rehabilitation or skilled care included age 80 years or older (OR, 2.49; 95% CI, 1.44-4.30), American Society of Anesthesiologists (ASA) ≥3 (OR, 2.05; 95% CI, 1.03-4.05)] and amputation as opposed to debridement (OR, 2.53; 95% CI,1.48-4.32). Conclusions: We identified several pre-operative clinical factors that were associated with increased post-operative mortality and discharge to post-acute care. The next steps should focus on determining if optimization of modifiable predictors would improve mortality.

Biological factors predicting the length of hospital stay in odontogenic cellulitis.

OBJECTIVE: The purpose of this study was to assess whether common biological factors are correlated with a longer hospital stay. STUDY DESIGN: All patients having odontogenic cellulitis, treated from January 2019 to December 2019 at Lille University Hospital, and requiring surgical drainage under general anesthesia, were included, retrospectively. Data, such as length of hospital stay and biological factors, namely, C-reactive protein (CRP) level, Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, and bacterial samples were collected. RESULTS: Significant moderate-strong correlations were found between postoperative length of stay and patients' LRINEC score (rs = 0.556) and presurgical CRP level (rs = 0.579). There was a significant moderate correlation between postoperative length of stay and presurgical procalcitonin level (rs = 0.451), and a weak correlation between postoperative length of stay and presurgical white blood cell count (rs = 0.282). Linear regression verified CRP as an independent predictor of length of hospital stay, showing a significant linear relationship between them (p < 0.0001). A significant regression equation was found (F(1,65) = 27.089; p = 0.0001), with an R2 of 0.294. CONCLUSION: In this study, CRP was the key biological predictor of length of hospital stay. STATEMENT OF CLINICAL RELEVANCE: The ability to predict length of hospital stay and identify patients requiring intensive care management, using simple and inexpensive biological parameters (such as CRP), will enable more cost-effective care and efficient hospital bed management.

Necrotizing Fasciitis (LRINEC): Epidemiology, Clinical Profiles, and Value of the Laboratory Risk Indicator in a Third-World Setting.

Acute bacterial dermohypodermites (ABDH) are frequent soft tissue infections. When left untreated, they can lead to severe regional or general complications. Our study evaluated the role of Laboratory Risk Indicator for Necrotizing (LRINEC) in ABDH global care by early detection of patients associated with risk of complication. From January 1, 2006 to December 31, 2015, 221 patients were included. The prevalence of ABDH was 1.02%. Women were the most observed (115/221), with a sex ratio of 0.92. The mean age was 49.8 years, and the majority was between 45 and 59 years old (34.39%). Farmers (30.32%), laborers (25.34%), and traders (18.10%) were the most observed professional categories. The main risk factors reported were anti-inflammatory drugs use (23.98%), alcohol (22.62%), obesity (15.84), medical history of ABDH (14.48%), diabetes mellitus (13.12%), smoking (11.31%), cardiovascular diseases (9.95%), HIV infection (9.90%), and skin blanching (7.6%). Infectious gateway was reported in 62% of cases. The most frequent infection site was the legs (90.05%). Fever was reported in 71.04% of cases. The LRINEC score was above 6 in 23% of cases. Complications occurred in 22.63% of cases, and comparing the two groups according to the LRINEC score, in group with the LRINEC score ≥ 6, we observed 64% of complications. The LRINEC score is an easily available, accessible, and user-friendly tool. It should be disseminated and used by all practitioners to predict complications in patient hospitalized for ABDH in a third-world setting.

Necrotising soft tissue infection in western Sydney: An 8-year experience.

BACKGROUND: This study aimed to assess the risk factors, management, imaging validity, Laboratory Risk Indicator for Necrotising infection (LRINEC) score and outcomes of necrotising soft tissue infection (NSTI) at a western Sydney tertiary hospital. METHODS: A retrospective study was conducted of all patients with NSTI from 2012 to 2019 at our institution. Patient characteristics, imaging, microbiology and site, LRINEC score, surgical management and outcomes/disposition were collected. RESULTS: Thirty-six patients met the inclusion criteria with mean age of 52 years and body mass index of 38.1; 55.6% were male, 48% of Polynesian descent and 55.6% were diabetic. The most frequent sites of NSTI were perineal (30.6%), lower limb (30.6%), perianal (19.3%) and trunk (11.1%). A total of 64% of patients underwent computed tomography radiological imaging with diagnostic accuracy of 50%. The mean LRINEC score was 7 (1-20). A total of 52.8% were transferred from another facility or non-surgical teams which delayed surgical review by 11.4 h (P < 0.03) and operating time by 12.4 h (P < 0.04) compared with direct emergency department referrals to the on-call surgical team. There was no statistical difference in outcomes in both groups. The overall average time to surgical debridement was 16.2 h (standard deviation 19.6, range 3.4-105.1). The mean hospital length of stay was 20.9 days; 44.4% of patients were transferred for rehabilitation or plastic reconstruction with a single mortality from multi-organ failure. CONCLUSION: The optimal management of NSTI requires a high index of suspicion and LRINEC score is a useful adjunct in aiding a clinician's decision. Early surgical debridement within 24 h of diagnosis and a multidisciplinary approach is associated with a lower mortality rate.

Clinical concern for necrotising fasciitis: a review of referrals to plastic surgery units at two tertiary centres.

OBJECTIVES: To evaluate the impact of clinical suspicion on the diagnosis of necrotising fasciitis (NF) in two inpatient plastic surgery units. METHODS: A multicentre retrospective audit of all referrals of adult patients to the inpatient plastic surgery units of two Melbourne metropolitan tertiary centres from 1 February 2018 to 31 December 2018. RESULTS: A total of 53 patients (37 male, 16 female) were referred to evaluate for NF. There were 20 patients (37.04%) who underwent operative debridement. Of those, 15 were pre-operatively suspected of having NF and there were seven confirmed cases of NF (13.21%). Laboratory risk indicator for NF (LRINEC) score ≥ 6 had a statistically significant association with a diagnosis of NF (P = 0.03) and with operative debridement (P = 0.04). The incidence of NF in the cohort where the referrer had clinical concern for NF was 13.21% (P < 0.001) and when the referrer and the plastic surgeon suspected NF was 46.67% (P < 0.001). The number of patients needed to be referred for one case of NF to be diagnosed was 7.58. CONCLUSIONS: Clinical suspicion of NF is essential for diagnosis and clinicians who suspect NF should not hesitate to refer to the appropriate surgical unit. Prompt review is required of patients in whom NF is clinically suspected as these patients have a 13.21% incidence of NF. The laboratory risk indicator for NF score is not sufficiently specific nor sensitive to exclude or to diagnose NF as a stand-alone diagnostic tool but may have a role as an adjunct.

Predictors of fatal outcome after severe necrotizing fasciitis: Retrospective analysis in a tertiary hospital for 20 years.

BACKGROUND: Prognostic factors for fatal outcomes of patients with necrotizing fasciitis remain unclear. METHODS: We retrospectively analyzed data of patients with necrotizing fasciitis from January 1998 to July 2019 using our hospital's medical database. Clinical characteristics of patients who died during hospitalization or had been discharged were evaluated. Sex, age, body mass index, smoking history, alcohol use, comorbidities (diabetes mellitus, arteriosclerosis obliterans, heart disease, obstructive arteriosclerosis, dialysis, cancer, skin disease, steroid use history), shock vital, physical findings, Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, sepsis, disseminated intravascular coagulation, fascial administration, tracheal intubation, and surgical treatment (dismemberment and/or debridement) were compared between the survivor (group S) and nonsurvivor (group N) groups. RESULTS: Fifty-five patients with necrotizing fasciitis were included (40 patients in group S and 15 patients in group N). Serum creatine was a significant prognostic factor (odds ratio [OR], 3.03; 95% confidence interval [CI], 0.15-0.75; P = 0.0078), with a cutoff value of 1.56 mg/dL. Moreover, the estimated glomerular filtration rate was a significant prognostic factor (OR, 1.06; 95% CI, 1.02-1.10, P = 0.000548), with a cutoff value of 20.6 mL/min. CONCLUSION: Renal dysfunction is a significant prognostic factor for fatal outcomes of patients with necrotizing fasciitis. LEVEL OF EVIDENCE: Level IV, Case series.

Necrotizing Fasciitis of the Breast: A Review of the Literature.

Background: Necrotizing fasciitis (NF) is a rare, rapidly progressing, and potentially fatal tissue infection involving subcutaneous tissue, superficial fascia, and the overlying skin. Breast NF is often misdiagnosed because of the thick breast tissue between the skin and deep fascia. Only early diagnosis followed by prompt antibiotic treatment and surgical therapy can prevent disastrous consequences. There are many case reports on breast NF, but a systematic review is lacking. Methods: Using PubMed and Scopus we performed a systematic review of the literature covering a period of 20 years. We reviewed articles with predisposing comorbidities (risk factors), triggering factors, laboratory examinations, culture of organisms, antibiotic treatment, surgical interventions, the presence of septic shock, and final outcome. We also performed statistical tests of all these factors in relation to death. Results: Forty cases identified from 38 articles were included in our literature review. Twenty-one cases (52.5%) were primary, whereas 15 cases (37.5%) occurred after surgery. In 15 cases (37.5%), the single organism responsible for NF was Streptococcus pyogenes, whereas mixed organisms were found in 17 cases (42.5%). Surgical debridement was performed in 39 (97.5%) cases. Septic shock was found in all five (12.5%) deceased cases and was associated with patient's mortality (p < 0.001). Conclusions: Breast NF is a rare, severe, and easily misdiagnosed complication. Breast NF could differ from that in other body regions in etiology pattern and clinical manifestations. Confirmed diagnosis of breast NF is based on the combination of clinical, cultural, laboratory, and imaging findings. Urgent subsequent treatments, including surgical debridement, antibiotic therapy, and reconstructive surgery, are critical for better prognosis and survival of patients.

Management and postoperative use of double-cannula irrigation-drainage tube in cervical necrotizing fasciitis: a Chinese single-institution experience of 46 patients.

PURPOSE: This study aimed to analyze a Chinese institution's experience with managing cervical necrotizing fasciitis (CNF) and observe the effects of a new therapeutic approach for postoperative drainage system. METHODS: A retrospective study was established including a total of 46 CNF patients who underwent surgical debridement between April 2006 and April 2018. Analyses of demographic data, etiology, comorbidity, microbiology, complications, treatment methods, duration of treatment, and treatment outcomes were obtained. RESULTS: There were 16 kinds of microbes cultured in 29 patients. Diabetic patients were more commonly infected by microbes (P < 0.05). There was a significant reduction in the number of operative time (P < 0.05) and length of hospitalization (P < 0.01) with postoperative therapy of double-cannula irrigation-drainage (DCID) system. CONCLUSION: CNF management includes controlling for comorbidities especially glycemic control and reasonable utilization of antibiotics and aggressive postoperative therapy. DCID system can effectively reduce operative frequency and duration of hospitalization.

Analyzing Outcomes Among Older Adults With Necrotizing Soft-Tissue Infections in the United States.

BACKGROUND: Necrotizing soft-tissue infections (NSTIs) encompass a group of severe, life-threatening diseases with high morbidity and mortality. Evidence suggests advanced age is associated with worse outcomes. To date, no large data sets exist describing outcomes in older individuals, and risk factor identification is lacking. METHODS: Retrospective data were obtained from the 2015 Medicare 100% sample. Included in the analysis were those aged ≥65 y with a primary diagnosis of an NSTI (gas gangrene, necrotizing fasciitis, cutaneous gangrene, or Fournier's gangrene). Risk factors for in-hospital mortality and discharge disposition were examined. Continuous variables were assessed using central tendency, t-tests, and Wilcoxon rank-sum tests. Categorical variables were assessed using the chi-squared and Fisher's exact tests. Statistical significance was defined as P < 0.05. RESULTS: 1427 patient records were reviewed. 59% of patients were male, and the overall mean age was 75.4±8.6 y. 1385 (97.0%) patients required emergency surgery for their NSTI diagnosis. The overall mortality was 5.3%. Several underlying comorbidities were associated with higher rates of mortality including cancer (OR: 3.50, P = 0.0009), liver disease (OR: 2.97, P = 0.03), and kidney disease (OR: 2.15, P = 0.01). While associated with high in-hospital mortality, these diagnoses were not associated with a difference in the rate of discharge to home compared with skilled nursing or rehab. Overall, patients discharged to skilled nursing facilities or rehab had higher rates of underlying comorbidities than patients who were discharged home (3 or more comorbid illness 84.3% versus 68.6%, P < 0.0001); however, no individual comorbid illness was associated with discharge location. CONCLUSIONS: In our Medicare data set, we identified several medical comorbidities that are associated with increased rates of in-hospital mortality. Patients with underlying cancers had the highest odds of increased mortality. The effect on outcomes of the potentially immunosuppressive cancer treatments in these patients is unknown. These data suggest that patients with underlying illnesses, especially cancer, kidney disease, or liver disease have higher mortalities and are more likely to be discharged to skilled nursing facilities or rehab. It is unclear why these illnesses were associated with these worse outcomes while others including diabetes and heart disease were not. These data suggest that these particular comorbid illnesses may have special prognostic implications, although further analysis is necessary to identify the causative factors.

Necrotising fasciitis deaths in Australia: patient characteristics and potential areas for improvement in clinical management.

BACKGROUND: Necrotising fasciitis (NF) is a life-threatening bacterial infection with high mortality. This retrospective study aimed to investigate patient characteristics and potential areas for improvement in clinical management in NF cases in Australia. METHODS: Retrospective analysis of surgical death data from all public and private Australian hospitals in every state and territory, excluding New South Wales, collected through the Australian and New Zealand Audit of Surgical Mortality for the 9-year period, January 2009 to February 2018. RESULTS: A total of 290 NF cases were identified. Among these NF cases, obesity and diabetes mellitus were two of the most common comorbidities, with a prevalence of 26% and 41%, respectively. A total of 41 clinical management issues (CMIs) were identified among 36 NF cases. A larger proportion of NF cases had CMIs compared with non-NF surgical mortality cases. Delay in diagnosis was the leading CMI (n = 28, 68.3%), followed by delay to surgery (n = 7, 17.1%). The majority of delayed diagnoses were attributed to non-surgical clinicians in the hospital. CONCLUSION: CMIs were identified in a larger proportion of NF cases than in other non-NF surgical mortality cases, suggesting that there are areas for improvement in NF diagnosis and management in Australia. The leading potentially avoidable issue identified in NF deaths was delay in diagnosis. This highlights the importance of awareness among non-surgical clinicians that NF is a surgical emergency requiring urgent debridement.

Epidemiología, manifestaciones clínicas y microbiología de los pacientes con fascitis necrosante en el Hospital Nacional de Niños de Costa Rica / Epidemiology, clinical manifestations and microbiology of children with necrotizing fasciitis in a Costa Rican pediatric hospital

Resumen Introducción: A pesar de la morbilidad significativa asociada a la fascitis necrosante (FN), hay pocas publicaciones al respecto y esta es la serie pediátrica más grande proveniente de Latinoamérica. Objetivo: Describir la epidemiología, características clínicas y microbiología de la FN en niños costarricenses. Pacientes y Métodos: Revisión de registros clínicos y anatomo-patológicos, período abril de 2002 a abril de 2014 en pacientes bajo 13 años de edad. Resultados: Cumplían requisito de inclusión 19/22 pacientes, 12 tenían co-morbilidad: 26% con antecedente de cirugía reciente y 21% eran neonatos. Etiología se documentó en hemocultivos en 26% y mediante cultivo de tejidos en 63% (un tercio de ellos polimicrobianos). Pseudomonas aeruginosa, Escherichia coli y Staphylococcus aureus fueron los agentes etiológicos más comúnmente hallados. La tasa de fatalidad fue de 42%, una de las más altas de la región. Conclusiones: La FN es una patología grave, inusual, asociada frecuentemente a neonatología y pacientes post-quirúrgicos, con etiología mixta que requiere de asociación de antimicrobianos y cirugía precoz. Su letalidad es elevada en nuestro medio, por sobre series previamente publicadas.

Abstract Background: Despite the significant associated morbidity of necrotizing fasciitis (NF), few studies have been published and this is the larger pediatric series in Latin America. Aim: To describe the epidemiology, clinical characteristics and microbiology of NF in Costa Rican children. Methods: Review of clinical and pathological records, period April 2002 to April 2014, in patients under 13 years of age. Results: 19/22 patients met the inclusion requirement, 12 had co-morbidity: 26% with a history of recent surgery and 21% were neonates. Etiology was documented in blood cultures in 26% and by tissue culture in 63% (one third of them polymicrobial). Pseudomonas aeruginosa, Escherichia coli and Staphylococcus aureus were the three most common etiologic agents. Case fatality rate was 42%, one of the highest in our region. Conclusion: NF is a serious, unusual pathology, frequently associated with neonatology and post-surgical patients, with a mixed etiology that requires the association of antimicrobials and early surgery. Its lethality is high in our setting, over previously published series.

A 16-year Longitudinal Cohort Study of Incidence and Bacteriology of Necrotising Fasciitis in England.

BACKGROUND: Necrotising fasciitis (NF) is a rapidly progressive, destructive soft tissue infection with high mortality. The primary aim of this study was to evaluate the incidence and mortality of NF amongst patients admitted to English National Health Service (NHS) hospitals. The secondary aims included the identification of risk factors for mortality and causative pathogens. METHODS: The Hospital Episodes Statistics database identified patients with NF admitted to English NHS Trusts from 1/1/2002 to 31/12/2017. Information on patient demographics, co-morbid conditions, microbiology specimens, surgical intervention and in-hospital mortality was collected. Uni- and multivariable analyses were performed to investigate factors related to in-hospital mortality. RESULTS: A total of 11,042 patients were diagnosed with NF. Age-standardised incidence rose from 9 per million in 2002 to 21 per million in 2017 (annual percentage change = 6.9%). Incidence increased with age and was higher in men. Age-standardised mortality rate remained at 16% over the study period, while in-hospital mortality declined. On multivariable analysis, the following factors were associated with increased risk of in-hospital mortality: emergency admission, female sex, history of congestive heart failure, peripheral vascular disease, chronic kidney disease and cancer. Admission year and diabetes, which was significantly prevalent at 27%, were not associated with increased risk of mortality. Gram-positive pathogens, particularly Staphylococci, decreased over the study period with a corresponding increase in Gram-negative pathogens, predominantly E. coli. CONCLUSION: The incidence of NF increased markedly from 2002 to 2017 although in-hospital mortality did not change. There was a gradual shift in the causative organisms from Gram-positive to Gram-negative.

[Epidemiology, clinical manifestations and microbiology of children with necrotizing fasciitis in a Costa Rican pediatric hospital]. / Epidemiología, manifestaciones clínicas y microbiología de los pacientes con fascitis necrosante en el Hospital Nacional de Niños de Costa Rica.

BACKGROUND: Despite the significant associated morbidity of necrotizing fasciitis (NF), few studies have been published and this is the larger pediatric series in Latin America. AIM: To describe the epidemiology, clinical characteristics and microbiology of NF in Costa Rican children. METHODS: Review of clinical and pathological records, period April 2002 to April 2014, in patients under 13 years of age. RESULTS: 19/22 patients met the inclusion requirement, 12 had co-morbidity: 26% with a history of recent surgery and 21% were neonates. Etiology was documented in blood cultures in 26% and by tissue culture in 63% (one third of them polymicrobial). Pseudomonas aeruginosa, Escherichia coli and Staphylococcus aureus were the three most common etiologic agents. Case fatality rate was 42%, one of the highest in our region. CONCLUSION: NF is a serious, unusual pathology, frequently associated with neonatology and post-surgical patients, with a mixed etiology that requires the association of antimicrobials and early surgery. Its lethality is high in our setting, over previously published series.

Periocular necrotizing soft tissue infection in Greater Copenhagen.

PURPOSE: Necrotizing soft tissue infection, also known as necrotizing fasciitis (NF), is a fast-spreading life-threatening infection that most commonly affects the lower limbs, groin, or abdomen. Periocular necrotizing fasciitis (PNF) is rare. Limited data exist on PNF immune cell subset; hence, this study aims to determine the representation of immune cell subsets in patients diagnosed with PNF using immunohistochemical stainings. METHODS: All patients diagnosed with PNF at Copenhagen University Hospital from 2008 to 2018 were included. Their electronic medical records and pathology reports were assessed, and available tissue specimens were reviewed and stained with monoclonal antibodies for CD1a+ Langerhans' cells, CD3+ T lymphocytes, CD15+ granulocytes, CD44+ lymphohematopoietic cells, CD68+ histiocytes, CD79α+ B lymphocytes, and FXIIIa+ dendritic macrophages and Langerhans' cells. The number of positive cells was counted, and an average score was calculated. The location of immune cells and bacteria was assessed. RESULTS: The specimens were characterized by acute inflammation and necrosis of the fascia, while striated muscle involvement was less frequent. Haemolytic group A streptococci and Staphylococcus aureus were identified and mainly located in the deep dermis and subcutis in close relation to the fascia. Only few areas harboured both bacteria and inflammatory cells. Granulocytes, histiocytes and CD44+ lymphohematopoietic cells were demonstrated to be abundant in all patients, while B and T lymphocytes, dendritic macrophages and Langerhans' cells were less frequent. CONCLUSION: The immune cell subsets found in this study of PNF were consistent with those identified in the literature on NF in other anatomical locations. This study concludes that immune cells are abundant and exhibit a typical pattern in PNF.