Necrotizing Fasciitis: A Predictable Burden in Rural Kenya.

BACKGROUND: Necrotizing fasciitis (NF) is a devastating disease with substantial morbidity and mortality. Poor outcomes are attributed to delayed diagnosis and management. Tenwek Hospital, a teaching and referral center in rural Kenya, manages many cases despite variable resources. We aimed to understand the burden of NF. METHODS: All patients with admission NF diagnosis who presented in 2017 were reviewed for demographics, investigations, treatment, and outcomes. The primary outcome was unfavorable outcome defined as in-hospital mortality or amputation. Secondary outcomes were discharge diagnosis of NF and cost. Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was calculated. Logistic regression models were utilized to assess the impact of risk factors. RESULTS: Sixty-seven patients were identified with an average age of 49.2 (±21) years. Medical comorbidities were present in 48% and history of trauma in 58%. Discharge diagnosis of NF occurred in 61% (N = 41). Overall, mortality occurred in 10% (N = 7) of patients with an initial NF diagnosis. At discharge, patients without NF had favorable outcomes in 96% (N = 25) compared to 78% (N = 32) with NF (p = 0.043). Final NF diagnosis costs 122,098 Kenyan Shillings more (95% confidence interval 36,142-208,054) than non-NF diagnosis (p value = 0.006). Factors associated with unfavorable outcome include diabetes mellitus, any comorbidity, increased heart rate, fever, hyperglycemia, anemia, and discharge NF diagnosis. Increased LRINEC score was associated with discharge NF diagnosis (p = 0.0006) and unfavorable outcome (p = 0.0157). CONCLUSIONS: Patients with NF in rural Kenya experience delays to presentation, unfavorable outcomes, and substantial costs. Certain factors, including LRINEC score, help predict diagnosis and outcome.

Antibacterial gauzes are effective in preventing infections after percutaneous endoscopic gastrostomy placement: a retrospective analysis.

OBJECTIVES: The most common complication after percutaneous endoscopic gastrostomy (PEG) placement is peristomal wound infection (up to 40% without antibiotic prophylaxis). Single-dose parenteral prophylactic antibiotics as advised by current guidelines decrease the infection rate to 9-15%. We assume a prolonged effect of local antibiotic treatment with antibacterial gauzes. This study is the first to describe the effect of antibacterial gauzes in preventing infections in PEG without the use of antibiotics. METHODS: A retrospective data analysis was carried out of all patients with PEG insertion between January 2009 and October 2014 in the Catharina Hospital Eindhoven. Data include placement and the period of the first 2 weeks after PEG placement, and long-term follow-up. All patients received a locally applied antibacterial gauze polyhexamethylene biguanide immediately following PEG insertion for 3 days. No other antibiotics were administered. The main outcomes were wound infection, peritonitis, and necrotizing fasciitis; secondary outcomes included other complications. RESULTS: A total of 331 patients with only antibacterial gauzes were analyzed. The total number of infections 2 weeks after PEG insertion was 9.4%, including 8.2% minor and 1.2% major infections (peritonitis). No wound infection-related mortality or bacterial resistance was found. Costs are five times lower than antibiotics, and gauzes are more practical and patient friendly for use. CONCLUSION: Retrospectively, antibacterial gauzes are at least comparable with literature data on parenteral antibiotics in preventing peristomal wound infection after PEG placement, with an infection rate of 9.4%. Rates of other complications found in this study were comparable with current literature data.

Single-specialty management and reconstruction of necrotizing fasciitis of the upper extremities: clinical and economic benefits from a case series.

PURPOSE: Patients with necrotizing fasciitis are managed with multiple prompt, radical surgical debridements and critical care support. Debridement and reconstruction are often provided by different surgical teams. Anecdotally, single-specialty management seemed to be a more efficient management strategy. This study aimed to investigate and compare the outcomes of management by plastic surgery versus multiple disciplines through a retrospective economic and clinical analysis of patients with necrotizing fasciitis treated over 8 years. We also present 3 index cases for which our service functioned as the primary management team. METHODS: Necrotizing fasciitis cases evaluated and treated by our department, covering both Level I and Level II Trauma Centers, were reviewed for total charges, length of hospital stay, length of intensive care unit (ICU) stay, and number of procedures. The admission Acute Physiology and Chronic Health Evaluation II score was calculated for each patient. Three comparative index cases of upper extremity necrotizing fasciitis managed primarily by the plastic surgery team are presented in greater detail. RESULTS: Patients managed primarily by the plastic surgery service had equivalent Acute Physiology and Chronic Health Evaluation II scores to patients managed by multiple services for their necrotizing fasciitis, with the average score higher for patients managed by plastic surgery alone. In a case-matched series of upper extremity necrotizing fasciitis, the patients admitted directly to plastic surgery had shorter average lengths of hospital and ICU stays as well as decreased total number of procedures, resulting in decreased average total hospital charges. There were no amputations among the cases treated primarily by the plastic surgery. The patients also required smaller areas of reconstruction with skin grafting despite large initial areas of debridement compared to those whose reconstructive teams differed from the team performing the debridement. CONCLUSIONS: Improved economic and clinical outcomes-as indicated by the reduced lengths of overall and ICU stay, the reduced number of procedures, none of the cases requiring amputation, and the reduced need for skin grafting-may be attainable when the surgeon eventually performing the reconstruction is involved early in management. We propose that, in the interest of improving patient care, a closer collaboration should be established between the reconstructive and primary managing teams.

Hyperbaric oxygen for the treatment of fournier's gangrene.

PURPOSE: Fournier's gangrene is a necrotizing fasciitis of the genitalia that is associated with high morbidity and mortality. Groups at many institutions have initiated routine adjuvant hyperbaric oxygen (HBO) therapy. We examined whether HBO has made a difference in the morbidity, mortality and costs associated with treating this disease. We also analyzed predictors of extended hospital stay and mortality. MATERIALS AND METHODS: The records of patients with the hospital discharge diagnoses of Fournier's gangrene, necrotizing fasciitis, gangrene of the genitalia and scrotal gangrene from 1993 to 2002 were reviewed. Data concerning clinical presentation characteristics, hospital stay, complications, hospital charges and outcomes, including graft failure and death, were analyzed. RESULTS: A total of 42 patients were identified and followed a median 4.2 years. Of the patients 16 underwent surgical debridement and antibiotic therapy alone, and 26 were treated with HBO plus surgery and antibiotics. Overall disease specific mortality was 21.4%, that is 12.5% in the nonHBO group and 26.9% in the HBO group. Three or more complications occurred in 13% of nonHBO and in 19% of HBO cases, of which the most common was myocardial infarction. The skin graft failure rate was 6% (nonHBO) and 8% (HBO). Physical disability was a statistically significant predictor of extended hospital stay (p <0.01). There was a trend toward a correlation between known coronary artery disease and death (p = 0.2). A statistically significant difference was noted in average daily hospital charges in nonHBO vs HBO cases ($2,552 vs $3,384 daily, p <0.01). CONCLUSIONS: These data do not support routine HBO in the treatment of Fournier's gangrene. There was a trend toward higher morbidity and mortality in the HBO group, suggesting that treatment may have been given to patients who were more ill.

The hospital costs of treating necrotizing fasciitis.

BACKGROUND: Management of necrotizing fasciitis places significant demands upon hospital and medical resources. A successful management usually requires extensive surgical intervention and an adjunct hyperbaric oxygen treatment. The cost impact on the health care system has not been well characterized. We have, therefore, analysed the cost of treating this disease at an Australian tertiary referral hospital with extensive case experience and well-developed financial costing systems and have compared this with the current casemix-based government funding arrangements applying in Victoria, Australia. METHODS: Data was extracted from the medical records of 92 sequential patients treated by the Alfred Hospital (Melbourne, Australia) during the four financial years 2000-04. Clinical costing data and government funding data was provided by the hospital's Finance Departments. RESULTS: The total Alfred Hospital in-patient costs for treating the patients was $5,935,545 with a mean cost per patient of $64,517 (range, $1025 to $514,889). The total casemix-based funding allocation derived from treating these patients was calculated at $3,208,664 with the per patient mean $34,887 (range, $1331 to $387,168). This analysis does not include allowance for non-Alfred Hospital costs such as those incurred by the ambulance service, referring hospitals, for rehabilitation or as a result of the burden of residual disability. CONCLUSIONS: This study has confirmed that a significant economic burden is involved in treating necrotizing fasciitis. There is a substantial difference between the hospital costs and government funding for treating these patients in the Australian setting.

Burn center management of necrotizing soft-tissue surgical infections in unburned patients.

BACKGROUND: Patients with necrotizing soft-tissue infections present great challenges in management from initial presentation through definitive care. Because burn centers concentrate expertise in critical care, wound management, and rehabilitation, we examined the effectiveness of burn center care for patients with necrotizing infections. METHODS: We reviewed our burn center's experience with all patients admitted from 1990 through 1999 with a primary diagnosis of necrotizing fasciitis (NF) or Fournier's gangrene (FG). RESULTS: Fifty-seven patients were identified, 18 with FG and 39 with NF. Patients had a high incidence of preexisting medical problems, including diabetes (37%), obesity defined as greater than 20% above ideal body weight (33%), and hypertension (33%). Seven of 57 (12%) patients died. Patients required a mean of 4.1 operative procedures (range 1 to 15) for definitive wound closure. The mean length of stay (survivors only) was 28.5 days, (range 3 to 70). Although costs increased throughout this period, a formal program of cost-containment resulted in no increase in actual charges per day, from a mean of $4,735 in 1991 to $5,202 in 1999. CONCLUSIONS: Burn centers can provide successful and cost-effective acute care, definitive wound closure, and rehabilitation for patients with NF and FG.