Predictive Ability of LRINEC Score for Lower Extremity Amputation in Moderate to Severe Diabetic Foot Infection.

OBJECTIVE: To assess the predictive ability of the laboratory risk indicator for necrotising fasciitis (LRINEC) score for lower extremity amputation in patients with moderate to severe diabetic foot infection (DFI). STUDY DESIGN: Observational study. Place and Duration of the Study: Department of General Surgery, Combined Military Hospital, Rawalpindi, Pakistan, from June to September 2023. METHODOLOGY: Patients admitted to the surgical ward with moderate to severe DFI were included by convenience sampling. Patients with severe sepsis, unstable haemodynamics, pressure injuries, and terminal illnesses were excluded. Demographic and clinical data of patients were noted down. LRINEC score was calculated on the day of admission. Final outcome (amputation or otherwise) was recorded on the 30th day the since the day of admission. RESULTS: Two hundred patients with moderate to severe DFI were included. The median age of patients was 56 years (IQR 49-66 years). The median duration of diabetes was 11 years (IQR 4 - 18.75 years). The median LRINEC score at admission was 6 (IQR 3-9). The majority of the patients (65.5%) had some other medical comorbid besides diabetes. Patients who had amputation due to DFI at 30 days post-admission had higher LRINEC scores on admission as compared to those patients who did not have amputation (Median 8 vs. 2, p <0.001). The cut-off point of LRINEC score ≥6.5 at admission had sensitivity of 74% and specificity of 94% in predicting amputation. CONCLUSION: The LRINEC score may be used as an objective scoring system to predict the risk of amputation in patients with moderate to severe DFI in indoor clinical settings. KEY WORDS: Diabetic foot, LRINEC score, Limb loss, Necrotising fasciitis.

A case study of abdominal wall and limb necrotizing fasciitis: an extremely rare post -operative complication.

INTRODUCTION: Infectious affections are the most frequent post-operative complications, the rate have been reducing due to the administration of perioperative antibiotics and they are rarely serious. They are usually associated to pelvic collections, fistulas, urinary tract stenosis and, exceptionally, necrotizing fasciitis (FN) and pelvic organ necrosis. There is no well-codified treatment. CASE PRESENTATION: A 42-year-old female patient, was referred to our department for a stage IIIC2 adenocarcinoma of the uterine cervix. Two months after surgery, the patient presented with fever. Abdominal CT scan revealed a recto-vaginal fistula. The patient underwent a surgical evacuation of the collection and a bypass colostomy. Post-operative period was marked by the occurrence of an extensive necrosis to pelvic organs and medial left leg's thigh compartments muscles. She also presented a thrombosis of the left external iliac vein and artery. Given the septic conditions, a revascularization procedure was not feasible. A bilateral ureterostomy was required and a ligature of the left external iliac vessels. Then she received palliative treatment.she died one month after surgery because of multivisceral failure due to sepsis. CONCLUSION: Necrotizing fasciitis is extremely rare and serious condition, the diagnosis is clinical and radiological, CT scan is helpful for the. There are predisposing factors such as diabetes, neoadjuvant radiotherapy or chemotherapy. The prognosis can be improved with rapid management and appropriate medical and surgical excisions of necrotic tissue, and antibiotic therapy adapted to the suspected germs, essentially anaerobic ones.

Laparoscopic treatment of a patient with multiple organ dysfunction syndrome induced by necrotising fasciitis.

Necrotising fasciitis (NF) is an uncommon surgical emergency that threatens the life and health of patients. We report the treatment of a 76-year-old female patient with NF. The patient developed NF due to chronic poor glycaemic control, which further progressed to multiple organ dysfunction syndrome due to the severity of the hyperglycaemia. After resuscitation at the intensive care unit, surgical treatment was recommended and the patient underwent laparoscopic surgery. She had an uneventful post-operative recovery with aggressive anti-inflammatory therapy, glycaemic control and systemic nutritional support. There were no recurrences during the next 6 months of follow-up. NF should be diagnosed and treated as early as possible to gain valuable treatment time for the patient. Laparoscopic surgery is a treatment option.

IDENTIFICATION OF POTENTIALLY MODIFIABLE FACTORS TO IMPROVE RECOGNITION AND OUTCOME OF NECROTIZING SOFT-TISSUE INFECTIONS.

ABSTRACT: Background : Necrotizing soft-tissue infections (NSTIs) present a surgical emergency of increasing incidence, which is often misdiagnosed and associated with substantial mortality and morbidity. A retrospective multicenter (11 hospitals) cohort study was initiated to identify the early predictors of misdiagnosis, mortality, and morbidity (skin defect size and amputation). Methods : Patients of all ages who presented with symptoms and were admitted for acute treatment of NSTIs between January 2013 and December 2017 were included. Generalized estimating equation analysis was used to identify early predictors (available before or during the first debridement surgery), with a significance level of P < 0.05. Results : The median age of the cohort (N = 216) was 59.5 (interquartile range = 23.6) years, of which 138 patients (63.9%) were male. Necrotizing soft-tissue infections most frequently originated in the legs (31.0%) and anogenital area (30.5%). More than half of the patients (n = 114, 54.3%) were initially misdiagnosed. Thirty-day mortality was 22.9%. Amputation of an extremity was performed in 26 patients (12.5%). Misdiagnosis was more likely in patients with a higher Charlson Comorbidity Index (ß = 0.20, P = 0.001), and less likely when symptoms started in the anogenital area (ß = -1.20, P = 0.003). Besides the established risk factors for mortality (septic shock and age), misdiagnosis was identified as an independent predictor of 30-day mortality (ß = 1.03, P = 0.01). The strongest predictors of the final skin defect size were septic shock (ß = 2.88, P < 0.001) and a skin-sparing approach to debridement (ß = -1.79, P = 0.002). Conclusion : Recognition of the disease is essential for the survival of patients affected by NSTI, as is adequate treatment of septic shock. The application of a skin-sparing approach to surgical debridement may decrease morbidity.

A case of necrotizing fasciitis of the breast following lumpectomy and oncoplastic closure.

BACKGROUND: NF is a life-threatening soft tissue infection that most commonly occurs in the lower extremity. While presenting symptoms such as erythema, severe pain, sepsis, and wound crepitation are well documented, diagnosis of NF of the breast often is obscured by a low clinical index of suspicion due to its relative rarity as well as by the breast parenchyma that physically separates the underlying fascia and overlying skin. Several risk factors have previously been identified, such as underlying infection, diabetes, advanced age, and immunosuppression. However, the gross morbidity and high mortality associated with NF warrant continued surveillance of contributing factors across any anatomic location. Fifteen cases in the literature document the development of NF following breast surgery. CASE REPORT: The authors of this case report aim to expand on the current literature through the presentation of a unique case of NF of the breast following right breast lumpectomy and oncoplastic closure with left reduction mammaplasty in an immunocompromised patient found to have concurrent perforated sigmoid diverticulitis. CONCLUSION: This case exemplifies how frequent postoperative surveillance, a low threshold for intervention, and efficient coordination of care are vital to minimizing the morbidity and mortality risks associated with NF of the breast.

Validating the laboratory risk indicator for necrotizing fasciitis (LRINEC) score: a prospective cohort study in a resource limited setting.

BACKGROUND: Necrotising fasciitis is a rare and fulminant soft tissue infection. Prompt surgical debridement of the involved soft tissues and necrotic fascia is its definitive treatment, with any delay associated with increased mortality. The LRINEC score is a scoring system initially designed to aid in early diagnosis of necrotising fasciitis to facilitate early surgical intervention. This score utilizes common biochemical tests to produce a score of 0-13, stratifying patients into risk categories. METHODS: A prospective cohort study was designed including all patients presenting with severe soft tissue infection from June 2011 to January 2014. Exclusion criteria included: less than 15 years or above 90 years, antibiotics within 48 h of presentation or prior debridement of their soft tissue infection. All patients underwent routine blood investigations, required for calculation of the LRINEC score. RESULTS: The positive predictive value of the LRINEC score was 95.42%, whilst the negative predictive value was 81.16%. There was a statistically significant correlation between white cell count, serum creatinine, blood glucose level and positive histopathology. The mortality rate for patients with histopathologically-confirmed necrotising fasciitis was 10%. CONCLUSION: The LRINEC score is a clinical adjunct to risk stratify patients presenting to the emergency department with soft tissue infections. It utilizes common blood tests commonly to calculate a score, which risk stratifies patients. The use of this scoring system can facilitate better allocation of resources and aids in the decision to transfer patients in rural or regional settings, which are often complicated by being a resource limited environment.

Dilute Povidone-Iodine Solution Soaking Is Ineffective in Improving Outcomes of Necrotizing Fasciitis Caused by Diabetic Foot.

ABSTRACT: Wound soaking is a physical debridement method that helps reduce bacterial colonization and consequently promotes wound healing. Although soaking in povidone-iodine solution was ineffective in reducing bacterial colonization in acute trauma wounds, there is still a lack of evidence supporting the efficacy of this method in treating severe soft tissue infection. This study aimed to explore the effects of wound soaking in 1% dilute povidone-iodine solution on necrotizing fasciitis caused by diabetic foot ulcers. We retrospectively reviewed and finally included 153 patients who were admitted because of diabetic foot ulcers after undergoing fasciotomy for necrotizing infection from January 2018 to December 2021. Results showed no statistical difference in the outcomes between patients in the soaking and nonsoaking groups. End-stage renal disease (P = 0.029) and high serum C-reactive protein level (P = 0.007) were the only independent factors for below-knee amputation in the univariate and multivariate logistic regression analyses. Therefore, soaking diabetic wounds with severe infection in 1% dilute povidone-iodine solution may not reduce the hospital length of stay, risk of below-knee amputation, and readmission rate.

An unexpected case of thoracic necrotising fasciitis.

Necrotising fasciitis (NF) is a life-threatening bacterial infection characterised by rapid tissue destruction, which can have severe consequences if not recognised early and treated promptly. It is most commonly caused by group A streptococcus entering the body through breaks in the skin. This case report describes a patient who presented with systemic signs of infection, including right axillary pain, following a recent intramuscular injection. Clinical examination and radiological findings were consistent with NF, and surgical exploration confirmed the diagnosis of thoracic NF. The patient underwent extensive surgical debridement, intensive care management and subsequent reconstructive surgery. This report highlights the importance of early recognition of NF and that this condition is not limited to the limbs but may also affect the torso. It employs consideration of all portals of potential bacterial entry that may prompt a differential of NF through thorough history taking. This case encourages healthcare professionals to maintain awareness of skin infections as a potential though rare complication of procedures such as injections hence the continued value of aseptic techniques to minimise risk. Finally, it emphasises that prompt diagnosis, appropriate antibiotic therapy and immediate surgical intervention remain crucial in managing NF and improving patient outcomes.

Cervical Necrotizing Fasciitis: A Severe Sequela of Open Mandibular Fracture and Delay in Treatment.

Cervical necrotizing fasciitis (CNF) is a rare condition in the United States, with very few cases reported as a sequela of mandibular fracture. The authors describe the case of a 40-year-old man with poor oral health and no significant past medical history who developed CNF following delayed treatment of an open mandibular fracture, leading to life-threatening septic shock, thrombophlebitis of the internal jugular vein, and septic emboli to the lungs. Successful management of this patient was accomplished by serial surgical debridement, the administration of broad-spectrum antibiotics, and hemodynamic support. Eventual reconstruction was performed with external fixation of the mandible fracture and split-thickness skin grafting for the left neck and chest wound. The authors recommend early treatment of open mandibular fractures for immunocompromised patients or patients with poor oral hygiene to avoid the rare but potentially fatal complication of CNF and highlight external fixation as a useful technique in select cases of complex mandibular fractures.

Early diagnosis of necrotizing fasciitis: Imaging techniques and their combined application.

Necrotizing fasciitis is a clinical, surgical emergency characterized by an insidious onset, rapid progression, and a high mortality rate. The disease's mortality rate has remained high for many years, mainly because of its atypical clinical presentation, which prevents many cases from being diagnosed early and accurately, resulting in patients who may die from uncontrollable septic shock and multi-organ failure. But unfortunately, no diagnostic indicator can provide a certain early diagnosis of NF, and clinical judgement of NF is still based on the results of various ancillary tests combined with the patient's medical history, clinical manifestations, and the physician's experience. This review provides a brief overview of the epidemiological features of NF and then discusses the most important laboratory indicators and scoring systems currently employed to diagnose NF. Finally, the latest progress of several imaging techniques in the early diagnosis of NF and their combined application with other diagnostic indices are highlighted. We point out promising research directions based on an objective evaluation of the advantages and shortcomings of different methods, which provide a basis for further improving the early diagnosis of NF.

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.

Subunit Reconstruction With Local and Regional Flaps of a Total Cervicofacial Defect From Necrotizing Fasciitis.

A 60-year-old woman with a ∼450 cm 2 right cervicofacial defect following successful treatment of necrotizing fasciitis was consulted for reconstruction. She had complete orbital, malar, buccal, labial, submental, and anterolateral neck skin and soft tissue defects and near complete defects of the forehead and nasal sidewall. She underwent reconstruction with a large 24 cm×11 cm supraclavicular, deltopectoral, forehead rotational, and labial advancement flaps with skin grafting of the orbit. Follow-up at 2 months demonstrated complete take of all flaps. The patient was satisfied with her appearance and considered her outcome favorable. She exhibited comparably premorbid speech and oral competence. Large defects of the head and neck require thorough surgical planning and consideration of a subunit reconstruction technique. While free tissue transfer provides a large area of healthy tissue from a suitable donor site, subunit reconstruction with local and regional flaps can provide a superior outcome in the correct patient.

Treatment of Necrotizing Fasciitis With NovoSorb Biodegradable Temporizing Matrix and RECELL Autologous Skin Cell Suspension: A Case Series.

This case series reviews the management of 2 patients who developed a rare, aggressive soft tissue infection, necrotizing fasciitis treated with a synthetic polyurethane dermal regenerative template, Biodegradable Temporizing Matrix (NovoSorb BTM) in conjunction with an off-label use of RECELL device applying autologous skin cell suspension and a split-thickness skin graft for reconstruction. The clinical relevance describes a non-traditional patient's course of treatment and clinical outcome using BTM and RECELL for necrotizing fasciitis. The 2 patients survived with acceptable outcomes and timely healing despite a high chance of mortality and likely amputation secondary to the extensive surface area and anatomical location of the infection.

Faciocervical Group B Streptococcal Necrotising Fasciitis: a Multidisciplinary Approach Management.

Neonatal necrotising fasciitis secondary to Streptococcus agalactiae, also known as Group B Streptococcus (GBS), is a rare, life-threatening entity with approximately 40 cases reported in the literature.1 GBS soft tissue infection in infancy most commonly affects the face, likely originating from the colonised oral cavity.2 In cases unresponsive to medical management alone, early surgical debridement can be life-saving. We present a case of faciocervical GBS necrotising fasciitis in a male neonate requiring multiple surgical debridements. The resultant soft tissue defect healed with topical negative pressure therapy and eventual placement of a double-layer dermal substitute. Due to his prematurity, the patient was not skin grafted to limit donor site morbidity. After recovering from his life-threatening infection, the patient had intensive scar therapy leading to a favourable cosmetic result with no evidence of function-limiting contracture. Our report draws focus to the need for a multidisciplinary approach incorporating therapy-led scar management early in the postsurgical recovery plan.

[Clinical efficacy of antibiotic bone cement combined with vacuum sealing drainage in treating diabetes mellitus complicated with necrotizing fasciitis].

Objective: To explore the clinical efficacy of antibiotic bone cement combined with vacuum sealing drainage (VSD) in treating diabetes mellitus complicated with necrotizing fasciitis. Methods: The retrospective observational study approach was used. From January 2020 to March 2022, 12 patients with type 2 diabetes complicated with necrotizing fasciitis who met the inclusion criteria were admitted to Wuxi Ninth People's Hospital, including 7 males and 5 females, aged 27 to 76 years. The initial diagnosis of lesions was in the lower limbs. After admission, bedside incision and drainage were performed timely, and a sample of wound exudate was collected for microbial cultivation. At the same time, the comprehensive supportive treatment was performed. At stage Ⅰ, debridement was performed, and the skin and soft tissue defect area was 40 cm×15 cm to 80 cm×25 cm after debridement. The dead space was filled with bone cement containing gentamicin and vancomycin and VSD was performed. After there was no obvious infection on the wound, the antibiotic bone cement was removed and wound repair surgery was performed at stage Ⅱ. The times of debridement, amputation, infection control, wound treatment method and wound healing at stage Ⅱ, total hospitalization day, and recurrence of necrotizing fasciitis during follow-up after the stage Ⅱ surgery. At the last follow-up, the walking function of patients was evaluated according to the scoring standards of American Orthopedic Foot and Ankle Association (AOFAS). Results: Eleven patients had wound infection control with one debridement surgery and did not undergo amputation surgery; one patient had significant foot gangrene, and the infection was controlled after one debridement and amputation of the gangrenous limb. Blood routine and infection indicators gradually returned to normal within 7 days after surgery. At stage Ⅱ, the wounds in 4 patients were sutured directly, the wounds in 6 patients were repaired with full-thickness inguinal skin graft, while the wounds in 2 patients were repaired with pedicled or tongue-shaped flaps at the wound edge. The wounds healed well after surgery, with no ulceration. The total hospitalization day of patients was 20 to 45 days. Follow-up for 3 to 24 months after stage Ⅱ surgery showed no recurrence of necrotizing fasciitis in any patient. At the last follow-up, the walking function was evaluated as excellent in 10 cases and good in 2 cases according to the AOFAS scoring standard. Conclusions: Antibiotic bone cement combined with VSD used in treating type 2 diabetes complicated with necrotizing fasciitis can effectively control infection and reduce the times of debridement, with good wound healing and walking function after surgery.

Investigation of the effects of clinical parameters on mortality in patients with necrotizing fasciitis.

BACKGROUND: Necrotizing fasciitis is a rapidly progressing, potentially fatal soft-tissue infection that spreads through the fascia. Due to the late onset of diagnostic signs during the disease's advanced stage and its rapid progression, it can be challenging to make a prompt diagnosis. However, with a rapid and accurate diagnosis, the progression of the disease can be halted through appropriate early surgical intervention. Even with correct and timely treatment, the mortality rate for necrotizing fasciitis is higher compared to other soft-tissue infections. This study aims to investigate the effects of clinical parameters in patients with necrotizing fasciitis on mortality. METHODS: The study included 37 patients with a necrotizing fasciitis diagnosis between 2009 and 2018. Demographic characteristics of the patients (age, gender, comorbid conditions), duration from diabetes diagnosis if present, blood glucose level at the time of diagnosis, microorganisms isolated from wound cultures, presence of positive blood cultures, administered antibiotic therapy, laboratory risk indicator for necrotizing fasciitis (LRINEC) score at presentation, number and types of surgical procedures performed, length of hospital stay, and mortality rates were retrospectively recorded. Statistical analysis of dependent and independent variables was conducted using t-tests, Mann-Whitney U test, Chi-square test, and Fisher's exact test. RESULTS: Age was found to be an average of 70 in the mortality group, and it is significantly higher compared to the non-mortality group. A high LRINEC score, the presence of comorbidity, and a positive blood culture were also found to be significant in the mortal-ity group. The low number of surgical procedures performed is significantly lower in the mortality group. CONCLUSION: This study highlights the conditions associated with high mortality in patients with necrotizing fasciitis, which is a treatable disease through timely and accurate diagnosis followed by appropriate antibiotic therapy and surgical intervention. It emphasizes the importance of updating the approach for high-risk group patients and aims to provide information that will help lower the threshold for diagnosing necrotizing fasciitis.

Characteristics and management of patients undergoing emergency surgery for diabetic foot attack.

BACKGROUND: Diabetic foot attack (DFA) is considered one of the worst manifestations of diabetic foot. It is necessary to act quickly to prevent amputation and save the patient's life. The aim of this study is to reveal the characteristic features of DFAs and be a guide to healthcare professionals to manage and refer these patients. METHODS: Sixty-five patients with DFAs were analyzed retrospectively. Demographics were collected. All patients' infectious dis-eases Society of America/International Working Group on the Diabetic Foot (IDSA/IWDGF) stages, site ischemia neuropathy, bacterial infection and depth (SINBAD) and laboratory risk indicator for necrotizing fasciitis (LRINEC) scores were calculated. According to these measurements, patients were categorized and statistical results were obtained. RESULTS: We found that patients who underwent emergency surgery due to DFA applied to an average of two hospitals before applying to our facility and the median acceptance time since the beginning of the first complaint was 9 days. All patients were IDSA/IWDGF stages three and four. Most of the patients had SINBAD scores between four and six. 60% of the patients were at high risk for necrotizing fasciitis according to the LRINEC score. 58.2% of patients had periferic arterial stenosis and the amputation rate was 69.2%. 21.3% of the patients were followed in the intensive care unit, and our patients' mortality rate was 4.2%. CONCLUSION: DFA is an emergency surgical condition that requires high clinical suspicion. If not diagnosed and treated with emergency surgery, it has a high mortality and amputation rate. High white blood cell count in patients, local and systemic signs of inflammation, presence of subcutaneous emphysema in the lower extremities on a direct X-ray radiography, and high blood sugar should be considered as warning signs for DFA. Emergency surgical intervention should be performed on these patients, and if the patient is not in a suitable center for emergency surgery, they should be rapidly referred to a center with experienced clinicians.

A rare case of the axillary necrotizing fasciitis.

Necrotizing fasciitis is a rapidly progressive, life-threatening soft tissue infection that needs acute surgical intervention and other types of supportive care. The upper extremities are a less frequent site for this infection than the lower extremities. Axillary necrotizing fasciitis is quite rare and bears a high risk of iatrogenic neurovascular injuries. We report a severe case of a 39-year-old man with a right axillary necrotizing fasciitis caused by Streptococcus pyogenes. While dealing with important nerves and blood vessels at the initial emergency surgery, we marked and preserved them with vascular tapes. The patient underwent several surgical interventions for infection control in addition to supportive care to avoid limb loss and to survive. Intraoperatively, the locations of nerves and vessels could be easily found by checking the vessel tapes. Twelve months after the initial admission, the patient had no symptoms of nerve injuries and resumed work. With necrotizing fasciitis, the risk of an iatrogenic nerve injury exists even if limb amputation is avoided due to repeated debridement. We report that marking and preserving nerves and blood vessels with vascular tapes at the initial surgery may make the subsequent ones easier and may reduce iatrogenic neurovascular injury.