The EGS grading scale for skin and soft-tissue infections is predictive of poor outcomes: a multicenter validation study.

INTRODUCTION: Over the last 5 years, the American Association for the Surgery of Trauma has developed grading scales for emergency general surgery (EGS) diseases. In a previous validation study using diverticulitis, the grading scales were predictive of complications and length of stay. As EGS encompasses diverse diseases, the purpose of this study was to validate the grading scale concept against a different disease process with a higher associated mortality. We hypothesized that the grading scale would be predictive of complications, length of stay, and mortality in skin and soft-tissue infections (STIs). METHODS: This multi-institutional trial encompassed 12 centers. Data collected included demographic variables, disease characteristics, and outcomes such as mortality, overall complications, and hospital and ICU length of stay. The EGS scale for STI was used to grade each infection and two surgeons graded each case to evaluate inter-rater reliability. RESULTS: 1170 patients were included in this study. Inter-rater reliability was moderate (kappa coefficient 0.472-0.642, with 64-76% agreement). Higher grades (IV and V) corresponded to significantly higher Laboratory Risk Indicator for Necrotizing Fasciitis scores when compared with lower EGS grades. Patients with grade IV and V STI had significantly increased odds of all complications, as well as ICU and overall length of stay. These associations remained significant in logistic regression controlling for age, gender, comorbidities, mental status, and hospital-level volume. Grade V disease was significantly associated with mortality as well. CONCLUSION: This validation effort demonstrates that grade IV and V STI are significantly predictive of complications, hospital length of stay, and mortality. Though predictive ability does not improve linearly with STI grade, this is consistent with the clinical disease process in which lower grades represent cellulitis and abscess and higher grades are invasive infections. This second validation study confirms the EGS grading scale as predictive, and easily used, in disparate disease processes. LEVEL OF EVIDENCE: Prognostic/Epidemiologic retrospective multicenter trial, level III.

Severe aplastic anemia associated with eosinophilic fasciitis: report of 4 cases and review of the literature.

Diffuse eosinophilic fasciitis (Shulman disease) is a rare sclerodermiform syndrome that, in most cases, resolves spontaneously or after corticosteroid therapy. It has been associated with hematologic disorders, such as aplastic anemia. The clinical features and long-term outcomes of patients with eosinophilic fasciitis and associated aplastic anemia have been poorly described. We report the cases of 4 patients with eosinophilic fasciitis and associated severe aplastic anemia. For 3 of these patients, aplastic anemia was refractory to conventional immunosuppressive therapy with antithymocyte globulin and cyclosporine. One of the patients received rituximab as a second-line therapy with significant efficacy for both the skin and hematologic symptoms. To our knowledge, this report is the first to describe rituximab used to treat eosinophilic fasciitis with associated aplastic anemia. In a literature review, we identified 19 additional cases of eosinophilic fasciitis and aplastic anemia. Compared to patients with isolated eosinophilic fasciitis, patients with eosinophilic fasciitis and associated aplastic anemia were more likely to be men (70%) and older (mean age, 56 yr; range, 18-71 yr). Corticosteroid-containing regimens improved skin symptoms in 5 (42%) of 12 cases but were ineffective in the treatment of associated aplastic anemia in all but 1 case. Aplastic anemia was profound in 13 cases (57%) and was the cause of death in 8 cases (35%). Only 5 patients (22%) achieved long-term remission (allogeneic hematopoietic stem cell transplantation: n = 2; cyclosporine-containing regimen: n = 2; high-dose corticosteroid-based regimen: n = 1).

Fascitis necrosante por Streptococcus pyogenes / Necrotizing fascitis caused by Streptococcus pyogenes

Introducción. La ascitis necrosante es una enfermedad infecciosa grave de los tejidos blandos y potencialmente fatal. Múltiples agentes etiológicos pueden ser los culpables de esta temible enfermedad, entre los que destaca Streptococcus pyogenes. Caso clínico. Femenino de 14 años de edad, previamente sana, con un cuadro de fascitis necrosante con rápida evolución hacia la necrosis de todos los músculos de la pierna y síndrome compartamental, con grave afección multisistémica llegando a síndrome de insuficencia respiratoria aguda. Después de realizar amputación supracondilea izquierda, la niña evolucionó favorablemente. Conclusiones. La intervención quirúrgica temprana con dermofasciotomías extensas y por compartimentos, la selección correcta de antibióticos y el manejo de sostén en Unidades de Cuidados Intensivos serán factores determinantes en el pronóstico de los pacientes que sufran esta enfermedad. En los últimos años ha existido un resurgimiento de enfermedades graves, potencialmente fatales por S. pyogenes invasor, como en el caso que se presenta

Necrotizing soft tissue infections. Risk factors for mortality and strategies for management.

OBJECTIVE: The authors evaluate in a retrospective fashion the factors influencing outcome in a large group of patients presenting with necrotizing soft tissue infections, and, based on this analysis, propose a plan for optimal care of such patients. SUMMARY BACKGROUND DATA: In many smaller series of patients with necrotizing soft tissue infections, similar analyses of risk factors for mortality have been performed, producing conflicting conclusions regarding optimal care. In particular, debate exists regarding the impact of concurrent physiologic derangements, type and extent of infection, and the role of hyperbaric oxygen in treatment. METHODS: A retrospective chart review of 198 consecutive patients with documented necrotizing soft tissue infections, treated at a single institution during an 8-year period, was conducted. Using a model for logistic regression analysis, characteristics of each patient and his/her clinical course were tested for impact on outcome. RESULTS: The mortality rate among the 198 patients was 25.3%. The most common sites of origin of infection were the perineum (Fournier's disease; 36% of cases) and the foot (in diabetics; 15.2%). By logistic regression analysis, risk factors for death included age, female gender, extent of infection, delay in first debridement, elevated serum creatinine level, elevated blood lactate level, and degree of organ system dysfunction at admission. Diabetes mellitus did not predispose patients to death, except in conjunction with renal dysfunction or peripheral vascular disease. Myonecrosis, noted in 41.4% of the patients who underwent surgery, did not influence mortality. CONCLUSIONS: Necrotizing soft tissue infections represent a group of highly lethal infections best treated by early and repeated extensive debridement and broad-spectrum antibiotics. Hyperbaric oxygen appears to offer the advantage of early wound closure. Certain markers predict those individuals at increased risk for multiple-organ failure and death and therefore assist in deciding allocation of intensive care resources.

Determinants of mortality for necrotizing soft-tissue infections.

OBJECTIVE: The authors determined the risk factors of mortality in patients with necrotizing soft-tissue infections (NSTIs) and examined the incidence and mortality from NSTI secondary to Streptococcus pyogenes. METHODS: All patients with NSTIs who were treated between January 1989 and June 1994 were analyzed for presentation, etiology, factors important in pathogenesis and treatment, and mortality. RESULTS: Sixty-five patients were identified with NSTIs secondary to postoperative wound complications (18), trauma (15), cutaneous disease (15), idiopathic causes (10), perirectal abscesses (3), strangulated hernias (2), and subcutaneous injections (2). Necrotizing soft-tissue infections were polymicrobial in 45 patients (69%). S. pyogenes was isolated in only 17% of the NSTIs, but accounted for 53% of monomicrobial infections. Eight of ten idiopathic infections were caused by a single bacterium (p = 0.0005), whereas 82% of postoperative infections were polymicrobial. An average of 3.3 operative debridements per patient and amputation in 12 patients were necessary to control infection. The overall mortality was 29%; mortality from S. pyogenes infection was only 18%. The average time from admission to operation was 90 hours in nonsurvivors versus 25 hours in survivors (p = 0.0002). Other risk factors previously associated with the development of NSTIs did not affect mortality. CONCLUSIONS: Early debridement of NSTI was associated with a significant decrease in mortality. S. pyogenes infection was the most common cause of monomicrobial NSTI, but was not associated with an increased mortality.

[Fournier gangrene]. / Fournier-Gangrän.

Fournier's gangrene is a relatively rare, mixed aerobic and anaerobic soft tissue infection in the perineoscrotal area. Although it is convenient to give it a separate name, it is really either necrotizing fasciitis or nonclostridial myonecrosis of the scrotal and perineal areas. The condition frequently develops from perineal diseases, including perianal abscess, and fistulas, inflamed haemorrhoids and indwelling urethral catheter. In patients with Fournier's gangrene morbidity is extreme and mortality high. This article is based on a retrospective study of 15 cases of Fournier's gangrene, 13 in male and 2 in female patients. A combination of surgery and antibiotics was used to treat 9 patients. The last 6 cases were treated with a combination of surgery, antibiotics and hyperbaric oxygen. In 13 cases, the diagnosis was made on the basis of the fulminating progression of the infection to a scrotal gangrene, identification of multiple underlying pathogenic organisms and toxaemia. In the 2 female patients, a similar infection developed in the labia majora and perineum and extended to the buttocks and the anterior abdominal wall.

Idiopathic necrotizing fasciitis: recognition, incidence, and outcome of therapy.

Early recognition and treatment of necrotizing fasciitis (NF) is essential for survival. The diagnosis of primary or idiopathic NF may be particularly challenging because it occurs in the absence of a known causative factor or portal of entry for bacteria. Patients with NF treated between 1989 and 1993 were reviewed to determine the incidence, clinical features, bacteriology, and results of treatment in patients with idiopathic NF. Idiopathic NF occurred in nine (18%) of 51 patients, five men and four women, ranging in age from 21 to 67 years. Associated conditions included diabetes mellitus (4), alcoholism (3), remote infection (3), and pregnancy (2). NF affected the lower extremity in eight and the perineum in one patient. Pain and tenderness occurred in all patients, soft tissue gas was recognized in two, and the presence of erythema and edema was variable. Idiopathic NF was monomicrobial in seven (78%) patients, compared to 21 per cent of patients with secondary NF (P = 0.003). S. pyogenes was the causative organism in five of seven monomicrobial infections. Time from admission to operation was significantly longer (62.3 +/- 54.8 hours) in patients with idiopathic NF compared to patients with secondary NF (17.0 +/- 16.6 hours) (P = 0.001). Treatment included operative debridement (means = 3.3) and limb amputation (n = 1) to control infection. Three patients (33%) with idiopathic NF died. Primary or idiopathic NF is principally a monomicrobial infection usually caused by S. pyogenes that most commonly occurs in the extremities. Mortality is high but is comparable to secondary NF. It is important to recognize that NF may occur spontaneously, and it should be suspected in patients with unexplained soft tissue pain and tenderness.

Necrotizing surgical infection and necrotizing fasciitis in obstetric and gynecologic patients.

Necrotizing fasciitis (NF) is a rapidly progressive disease characterized by extensive necrosis of the skin, fascia, and subcutaneous tissue, with sparing of the underlying muscle. Diabetes mellitus, Bartholin's gland abscess, and recent surgical procedures (including episiotomy) are factors often found in obstetric and gynecologic patients. Mortality in this group of patients is higher than in the general surgical population. Death is usually due to overwhelming sepsis, renal and respiratory failure, and multiple organ failure. The infections are usually polymicrobial, with alpha-hemolytic streptococci, gram-negative coliforms, and anaerobic bacteria. Lower survival has been reported in large series when the groin is involved or when the general nutritional state is poor. From October 1988 to August 1990, we treated five patients with necrotizing fasciitis. Certain important characteristics of such patients have not been discussed in the obstetric and gynecologic literature. Nutritional status, with special emphasis on total protein, albumin, and the effects of alcoholism, has a significant impact on mortality. Nutritional support of these patients may improve survival. To limit the impact of secondary infections, surgical approaches should be modified by the anatomic location of the initial lesions. More frequent debriding in the operating room and early fecal diversion are recommended.

Implications of risk factors in necrotizing fasciitis.

The following risk factors, previously associated with necrotizing fasciitis, were identified in 25 consecutive patients: diabetes mellitus, intravenous drug abuse, age greater than 50, hypertension, and malnutrition/obesity. Additional data recorded included the duration of illness to the time of the first operative procedure, the type of procedure performed, the anatomic location of the infection, the etiology, culture reports, and leukocyte counts. The goal of this study was to determine whether the number of risk factors present in a patient was predictive of mortality. Six patients (24%) died and 19 patients survived. The nonsurvivors exhibited a significantly higher percentage of diabetes mellitus, 83 per cent versus 37 per cent (P = 0.047). Fifteen of 19 survivors (79%) and only one of six nonsurvivors (17%) had fewer than three risk factors (P = 0.006). In conclusion, more than three previously identified risk factors present in patients with necrotizing fasciitis were found to be predictive of a mortality rate of 50 per cent. The mainstay of treatment remains aggressive surgical intervention, broad-spectrum antibiotics, and nutrition support.

Bacteriology of necrotizing fasciitis: a review of 58 cases.

Necrotizing fasciitis is a relatively rare soft tissue infection that is characterized by rapidly widespread necrosis of the fascia and subcutaneous tissue. Fifty-eight cases were reviewed over a 5.5-year period. The majority of wound cultures were polymicrobial and single culture rate was 18.6%. The facultative organisms were most frequently recovered. The most frequently discovered bacteria were E. coli, Proteus mirabilis, Klebsiella pneumoniae, Staphylococcus aureus and group D enterococcus. The overall mortality rate was 48.3%. Early recognition, serial radical surgical debridement and strong and appropriate antibiotics were essential for survival.

Hyperbaric oxygen in the treatment of gas gangrene and perineal necrotizing fasciitis. A clinical and experimental study.

Between 1971 and 1987, 32 patients with clostridial gas gangrene were treated in the Department of Surgery, University of Turku. A presumptive diagnosis of gas gangrene was made on the basis of the clinical appearance of the patient and a predominance of Gram positive rods on stain. Between 1973 and 1989, 11 patients with perineal necrotizing fasciitis (Fournier's gangrene) were treated. The diagnosis was based on fulminating progression of perineal gangrene and on the presence of multiple pathogenic organisms in the primary Gram stain or culture. All patients in both series underwent surgical debridement, antibiotic therapy, and intensive care. In addition, the patients were exposed to pure oxygen at 2.5 atmospheres absolute pressure (ATA) for 120 minutes. Three such treatments were given during the first 24 hours after admission after which the treatment was repeated twice daily. Seventeen patients with clostridial gas gangrene had diffusely spreading myonecrosis; 6 died. Fifteen patients developed clostridial cellulitis with toxicity; 3 died. Thus, the overall mortality in gas gangrene was 28%. All the 9 patients who died had been transferred from other hospitals in Finland and were moribund on arrival. The infection in 8 of these patients developed postoperatively. None of the patients with a posttraumatic infection died. Each of the patients with Fournier's gangrene had had nonspecific symptoms before the gangrene became evident. The infection originated from the anorectal area in 5 patients, 1 patient had sustained a scrotal trauma and in 5 patients the underlying condition was unknown. One patient died 2 days after admission. Six patients required a colostomy. To evaluate the therapeutic value of hyperbaric oxygen (HBO) treatment, two experimental models of clostridial gas gangrene, mono- and multimicrobial, were developed in rats. In the monomicrobial infection model, 10(7) colony forming units (cfu) of Clostridium perfringens were injected intramuscularly into the left hind limb of the rat. The mortality of untreated rats was 100%. The mortality of the rats treated with surgery alone was 38% compared to 13% when surgery was used in combination with HBO (p < 0.01; chi 2 test). In the group treated with HBO and surgery, 94% of the survivors healed completely and were able to walk normally, whereas the corresponding figure in the rats treated with surgery alone was 20% (p < 0.001; chi 2-test). In the multimicrobial gas gangrene model the infection was induced by an intramuscular injection of a mixture containing approximately 10(7) cfu of each of the following bacteria: Clostridium perfringens, Bacteroides fragilis, Escherichia coli and Streptococcus faecalis.(ABSTRACT TRUNCATED AT 400 WORDS)

Complications of percutaneous endoscopic gastrostomy.

Percutaneous endoscopic gastrostomy (PEG) has become a commonly performed procedure to provide nutritional support to chronically ill patients. Following a PEG-related death, we retrospectively reviewed our complication rate with that of the published values. In the past 48 months at Madigan Army Medical Center and Eisenhower Army Medical Center, 147 PEGs have been performed. We have had 20 minor complications and 5 major complications, with 2 reported deaths directly related to the procedure. Minor complications included 14 cases of localized cellulitis and 5 cases of prolonged ileus. The major complications included two cases of necrotizing fasciitis (both fatal), two cases of tube extubation within 24 hours, both resulting in surgical gastrostomy, and one bowel obstruction requiring laparotomy. Both patients who developed necrotizing fasciitis had several predisposing factors including diabetes, malnutrition, obesity, and long-term hospitalization. In conclusion, we believe PEG is an extremely valuable procedure which should be utilized with caution in the immunocompromised or morbidly obese patient.

Necrotizing fasciitis of the vulva.

OBJECTIVE: We attempted to characterize the natural history of necrotizing fasciitis of the vulva. STUDY DESIGN: The records of 29 nonpregnant women with necrotizing fasciitis of the vulva were evaluated. RESULTS: These women experienced a rapidly progressing polymicrobial infection. Initially, the infections in many women were thought to be labial cellulitis, appearing mild and innocuous. Delays in recognition and aggressive surgical management were associated with increased morbidity and mortality. Of 15 women with a delay greater than 48 hours between presentation and treatment, 11 died. Twenty of 29 (69%) were diabetic, accounting for 11 of the 14 deaths. CONCLUSION: Early diagnosis and aggressive surgical debridement in spite of mild symptoms will improve outcome in this serious disease process.

Necrotizing fasciitis and nonsteroidal anti-inflammatory drugs.

We have presented a case of fulminant necrotizing fasciitis that occurred after excessive NSAID intake with granulocytopenia. This case parallels those previously reported as outlined in the above discussion. We concur with previous investigators who have concluded that NSAIDs should be used with caution in patients with phlebitis or apparently benign inflammatory cutaneous lesions.

Necrotizing fasciitis: 10 years' experience in a district general hospital.

Of 14 patients with necrotizing fasciitis who presented between 1979 and 1988, six (43 per cent) died. The deaths were associated with delays in diagnosis, poor surgical technique and diabetes. Prompt diagnosis, resuscitation and early radical surgery are essential to the successful management of necrotizing fasciitis.

Necrotizing soft tissue lesions after a volcanic cataclysm.

A volcanic cataclysm of major proportions, the fourth largest in terms of total casualties in the history of mankind, wiped out the town of Armero, Colombia, in 1985 resulting in over 23,000 deaths and 4,500 wounded. Among the hundreds of survivors who were transferred to hospitals in the capital city of Bogotá, there was as overwhelming number who developed necrotizing fasciitis. These patients constitute, perhaps, the single largest group of this type of lesions in the recorded literature. Thirty-eight patients with well established necrotizing fasciitis were identified at 4 selected hospitals in Bogotá; 8 of them presented with zygomycetic infection (mucormycosis), a highly lethal entity. Many additional cases were treated at other hospitals in Bogotá and several cities in Colombia. The main clinical features of these 38 patients affected by necrotizing fasciitis are reviewed, with special emphasis on the patients with mucormycosis. Patients with necrotizing fasciitis had an overall mortality rate of 47.7%; patients with mucormycosis, 80%. A plea is made for an early diagnosis, utilizing tissue sampling and microbiological studies, so that prompt and radical treatment can be instituted. This is especially pertinent in situations of natural disasters resulting in massive numbers of casualties and seriously injured survivors.