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The roles of early surgery and comorbid conditions on outcomes of severe necrotizing soft-tissue infections

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European Journal of Trauma and Emergency Surgery Aims and scope Submit manuscript

Abstract

Purpose

Severe necrotizing soft-tissue infections (NSTIs) require immediate early surgical treatment to avoid adverse outcomes. This study aims to determine the impact of early surgery and comorbid conditions on the outcomes of NSTIs.

Methods

A retrospective cohort study was performed on all subjects presenting with NSTI at an academic medical center between 2005 and 2016. Patients were identified based on ICD codes. Those under the age of 18 or with intraoperative findings not consistent with NSTI diagnosis were excluded.

Results

There were 115 patients with a confirmed diagnosis of NSTI with a mean age of 55 ± 18 years; 41% were females and 55% were diabetics. Thirty percent of patients underwent early surgery (< 6 h). There were no significant differences between groups in baseline characteristics. The late group (≥ 6 h) had prolonged hospital stay (38 vs. 23 days, p < 0.008) in comparison to the early group (< 6 h). With every 1 h delay in time to surgery, there is a 0.268 day increase in length of stay, adjusted for these other variables: alcohol abuse, number of debridements, peripheral vascular disease, previous infection and clinical necrosis. Mortality was 16.5%. Multivariable analysis revealed that alcohol abuse, peripheral vascular disease, diabetes, obesity, hypothyroidism, and presence of COPD were associated with an increase in mortality.

Conclusions

Early surgical intervention in patients with severe necrotizing soft-tissue infections reduces length of hospital stay. Presence of comorbid conditions such as alcohol abuse, peripheral vascular disease, diabetes, obesity and hypothyroidism were associated with increased mortality.

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References

  1. Stevens DL, Bryant AE. Necrotizing soft-tissue infections. N Engl J Med. 2017;377(23):2253–65. https://doi.org/10.1056/NEJMra1600673.

    Article  PubMed  Google Scholar 

  2. Oud L, Watkins P. Contemporary trends of the epidemiology, clinical characteristics, and resource utilization of necrotizing fasciitis in Texas: a population-based cohort study. Crit Care Res Pract. 2015;2015:618067. https://doi.org/10.1155/2015/618067.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Arif N, Yousfi S, Vinnard C. Deaths from necrotizing fasciitis in the United States, 2003–2013. Epidemiol Infect. 2016;144(6):1338–44. https://doi.org/10.1017/S0950268815002745.

    Article  CAS  PubMed  Google Scholar 

  4. Bonne SL, Kadri SS. Evaluation and management of necrotizing soft tissue infections. Infect Dis Clin N Am. 2017;31(3):497–511. https://doi.org/10.1016/j.idc.2017.05.011.

    Article  Google Scholar 

  5. Hadeed GJ, Smith J, O’Keeffe T, et al. Early surgical intervention and its impact on patients presenting with necrotizing soft tissue infections: a single academic center experience. J Emerg Trauma Shock. 2016;9(1):22–7. https://doi.org/10.4103/0974-2700.173868.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Holena DN, Mills AM, Carr BG, et al. Transfer status: a risk factor for mortality in patients with necrotizing fasciitis. Surgery. 2011;150(3):363–70. https://doi.org/10.1016/j.surg.2011.06.005.

    Article  PubMed  Google Scholar 

  7. Wong C-H, Chang H-C, Pasupathy S, Khin L-W, Tan J-L, Low C-O. Necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality. J Bone Jt Surg Am. 2003;85-A(8):1454–60.

    Article  Google Scholar 

  8. Al-Thani H, El-Menyar A, Shaikh N, et al. Risk stratification of necrotizing fasciitis based on the initial procalcitonin concentration: a single center observational study. Surg Infect. 2015;16(6):806–12. https://doi.org/10.1089/sur.2014.249.

    Article  Google Scholar 

  9. Anaya DA, Bulger EM, Kwon YS, Kao LS, Evans H, Nathens AB. Predicting death in necrotizing soft tissue infections: a clinical score. Surg Infect. 2009;10(6):517–22. https://doi.org/10.1089/sur.2008.112.

    Article  Google Scholar 

  10. Anaya DA, McMahon K, Nathens AB, Sullivan SR, Foy H, Bulger E. Predictors of mortality and limb loss in necrotizing soft tissue infections. Arch Surg Chic Ill 1960. 2005;140(2):151–7. https://doi.org/10.1001/archsurg.140.2.151. discussion 158.

    Article  Google Scholar 

  11. Bair M-J, Chi H, Wang W-S, Hsiao Y-C, Chiang R-A, Chang K-Y. Necrotizing fasciitis in southeast Taiwan: clinical features, microbiology, and prognosis. Int J Infect Dis IJID Off Publ Int Soc Infect Dis. 2009;13(2):255–60. https://doi.org/10.1016/j.ijid.2008.04.015.

    Article  Google Scholar 

  12. Childers BJ, Potyondy LD, Nachreiner R, et al. Necrotizing fasciitis: a fourteen-year retrospective study of 163 consecutive patients. Am Surg. 2002;68(2):109–16.

    PubMed  Google Scholar 

  13. Dworkin MS, Westercamp MD, Park L, McIntyre A. The epidemiology of necrotizing fasciitis including factors associated with death and amputation. Epidemiol Infect. 2009;137(11):1609–14. https://doi.org/10.1017/S0950268809002532.

    Article  CAS  PubMed  Google Scholar 

  14. Eggerstedt M, Gamelli RL, Mosier MJ. The care of necrotizing soft-tissue infections: patterns of definitive intervention at a large referral center. J Burn Care Res Off Publ Am Burn Assoc. 2015;36(1):105–10. https://doi.org/10.1097/BCR.0000000000000203.

    Article  Google Scholar 

  15. El-Menyar A, Asim M, Mudali IN, Mekkodathil A, Latifi R, Al-Thani H. The laboratory risk indicator for necrotizing fasciitis (LRINEC) scoring: the diagnostic and potential prognostic role. Scand J Trauma Resusc Emerg Med. 2017;25(1):28. https://doi.org/10.1186/s13049-017-0359-z.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Ertl CW, Carpp NC, Johnson J, Burke L. Evaluation of factors associated with death in patients with necrotizing fasciitis of the abdominal wall. Surg Infect. 2017;18(2):176–80. https://doi.org/10.1089/sur.2016.167.

    Article  Google Scholar 

  17. Faraklas I, Stoddard GJ, Neumayer LA, Cochran A. Development and validation of a necrotizing soft-tissue infection mortality risk calculator using NSQIP. J Am Coll Surg. 2013;217(1):153–60.e3. https://doi.org/10.1016/j.jamcollsurg.2013.02.029. discussion 160–161.

    Article  PubMed  Google Scholar 

  18. Frazee BW, Fee C, Lynn J, et al. Community-acquired necrotizing soft tissue infections: a review of 122 cases presenting to a single emergency department over 12 years. J Emerg Med. 2008;34(2):139–46. https://doi.org/10.1016/j.jemermed.2007.03.041.

    Article  PubMed  Google Scholar 

  19. Golger A, Ching S, Goldsmith CH, Pennie RA, Bain JR. Mortality in patients with necrotizing fasciitis. Plast Reconstr Surg. 2007;119(6):1803–7. https://doi.org/10.1097/01.prs.0000259040.71478.27.

    Article  CAS  PubMed  Google Scholar 

  20. Gunter OL, Guillamondegui OD, May AK, Diaz JJ. Outcome of necrotizing skin and soft tissue infections. Surg Infect. 2008;9(4):443–50. https://doi.org/10.1089/sur.2007.053.

    Article  Google Scholar 

  21. Hansen MB. Biomarkers of necrotising soft tissue infections aspects of the innate immune response. Dan Med J. 2017;64(7):1–17.

    Google Scholar 

  22. Hansen MB, Rasmussen LS, Garred P, Bidstrup D, Madsen MB, Hyldegaard O. Pentraxin-3 as a marker of disease severity and risk of death in patients with necrotizing soft tissue infections: a nationwide, prospective, observational study. Crit Care Lond Engl. 2016;20:40. https://doi.org/10.1186/s13054-016-1210-z.

    Article  Google Scholar 

  23. Hua C, Sbidian E, Hemery F, et al. Prognostic factors in necrotizing soft-tissue infections (NSTI): a cohort study. J Am Acad Dermatol. 2015;73(6):1006.e8–12.e8. https://doi.org/10.1016/j.jaad.2015.08.054.

    Article  Google Scholar 

  24. Huang K-F, Hung M-H, Lin Y-S, et al. Independent predictors of mortality for necrotizing fasciitis: a retrospective analysis in a single institution. J Trauma. 2011;71(2):467–73. https://doi.org/10.1097/TA.0b013e318220d7fa (discussion 473).

    Article  PubMed  Google Scholar 

  25. Jabbour G, El-Menyar A, Peralta R, et al. Pattern and predictors of mortality in necrotizing fasciitis patients in a single tertiary hospital. World J Emerg Surg WJES. 2016;11:40. https://doi.org/10.1186/s13017-016-0097-y.

    Article  PubMed  Google Scholar 

  26. Kao LS, Lew DF, Arab SN, et al. Local variations in the epidemiology, microbiology, and outcome of necrotizing soft-tissue infections: a multicenter study. Am J Surg. 2011;202(2):139–45. https://doi.org/10.1016/j.amjsurg.2010.07.041.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Keeley J, Kaji A, Kim D, et al. Predictors of mortality in necrotizing soft tissue infection. Am Surg. 2014;80(10):989–93.

    PubMed  Google Scholar 

  28. Keung EZ, Liu X, Nuzhad A, Adams C, Ashley SW, Askari R. Immunocompromised status in patients with necrotizing soft-tissue infection. JAMA Surg. 2013;148(5):419–26. https://doi.org/10.1001/jamasurg.2013.173.

    Article  PubMed  Google Scholar 

  29. Krieg A, Dizdar L, Verde PE, Knoefel WT. Predictors of mortality for necrotizing soft-tissue infections: a retrospective analysis of 64 cases. Langenbecks Arch Surg. 2014;399(3):333–41. https://doi.org/10.1007/s00423-014-1162-1.

    Article  PubMed  Google Scholar 

  30. Moore SA, Levy BH, Prematilake C, Dissanaike S. The prediction predicament: rethinking necrotizing soft tissue infections mortality. Surg Infect. 2015;16(6):813–21. https://doi.org/10.1089/sur.2015.002.

    Article  Google Scholar 

  31. Mulla ZD, Gibbs SG, Aronoff DM. Correlates of length of stay, cost of care, and mortality among patients hospitalized for necrotizing fasciitis. Epidemiol Infect. 2007;135(5):868–76. https://doi.org/10.1017/S0950268806007448.

    Article  CAS  PubMed  Google Scholar 

  32. Nisbet M, Ansell G, Lang S, Taylor S, Dzendrowskyj P, Holland D. Necrotizing fasciitis: review of 82 cases in South Auckland. Intern Med J. 2011;41(7):543–8. https://doi.org/10.1111/j.1445-5994.2009.02137.x.

    Article  CAS  PubMed  Google Scholar 

  33. Pakula AM, Kapadia R, Freeman B, Skinner RA. A 3-year experience with necrotizing fasciitis: favorable outcomes despite operative delays in a busy acute care hospital. Am Surg. 2012;78(10):1059–62.

    PubMed  Google Scholar 

  34. Proud D, Bruscino Raiola F, Holden D, Paul E, Capstick R, Khoo A. Are we getting necrotizing soft tissue infections right? A 10-year review. ANZ J Surg. 2014;84(6):468–72. https://doi.org/10.1111/ans.12412.

    Article  PubMed  Google Scholar 

  35. Psoinos CM, Flahive JM, Shaw JJ, et al. Contemporary trends in necrotizing soft-tissue infections in the United States. Surgery. 2013;153(6):819–27. https://doi.org/10.1016/j.surg.2012.11.026.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Schwartz S, Kightlinger E, de Virgilio C, et al. Predictors of mortality and limb loss in necrotizing soft tissue infections. Am Surg. 2013;79(10):1102–5.

    PubMed  Google Scholar 

  37. Shaikh N, El-Menyar A, Mudali IN, Tabeb A, Al-Thani H. Clinical presentations and outcomes of necrotizing fasciitis in males and females over a 13-year period. Ann Med Surg 2012. 2015;4(4):355–60. https://doi.org/10.1016/j.amsu.2015.09.005.

    Article  Google Scholar 

  38. Tan JH, Koh BTH, Hong CC, et al. A comparison of necrotising fasciitis in diabetics and non-diabetics: a review of 127 patients. Bone Jt J. 2016;98-B(11):1563–8. https://doi.org/10.1302/0301-620X.98B11.37526.

    Article  CAS  Google Scholar 

  39. Tsai Y-H, Huang K-C, Shen S-H, Hsu W-H, Peng K-T, Huang T-J. Microbiology and surgical indicators of necrotizing fasciitis in a tertiary hospital of southwest Taiwan. Int J Infect Dis IJID Off Publ Int Soc Infect Dis. 2012;16(3):e159–65. https://doi.org/10.1016/j.ijid.2011.11.001.

    Article  Google Scholar 

  40. Tunovic E, Gawaziuk J, Bzura T, Embil J, Esmail A, Logsetty S. Necrotizing fasciitis: a six-year experience. J Burn Care Res Off Publ Am Burn Assoc. 2012;33(1):93–100. https://doi.org/10.1097/BCR.0b013e318239d571.

    Article  Google Scholar 

  41. Wang J-M, Lim H-K. Necrotizing fasciitis: eight-year experience and literature review. Braz J Infect Dis Off Publ Braz Soc Infect Dis. 2014;18(2):137–43. https://doi.org/10.1016/j.bjid.2013.08.003.

    Article  Google Scholar 

  42. Weng C-L, Wang C-H, Chen I-C, et al. Red cell distribution width is an independent predictor of mortality in necrotizing fasciitis. Am J Emerg Med. 2014;32(10):1259–62. https://doi.org/10.1016/j.ajem.2014.08.001.

    Article  PubMed  Google Scholar 

  43. Willis RN, Guidry CA, Horn CB, et al. Predictors of monomicrobial necrotizing soft tissue infections. Surg Infect. 2015;16(5):533–7. https://doi.org/10.1089/sur.2014.189.

    Article  Google Scholar 

  44. Yaghoubian A, de Virgilio C, Dauphine C, Lewis RJ, Lin M. Use of admission serum lactate and sodium levels to predict mortality in necrotizing soft-tissue infections. Arch Surg Chic Ill 1960. 2007;142(9):840–6. https://doi.org/10.1001/archsurg.142.9.840. (discussion 844–846).

    Article  CAS  Google Scholar 

  45. Audureau E, Hua C, de Prost N, et al. Mortality of necrotizing fasciitis: relative influence of individual and hospital-level factors, a nationwide multilevel study, France, 2007–12. Br J Dermatol. 2017. https://doi.org/10.1111/bjd.15615.

    Article  PubMed  Google Scholar 

  46. Hong Y-C, Chou M-H, Liu EH, et al. The effect of prolonged ED stay on outcome in patients with necrotizing fasciitis. Am J Emerg Med. 2009;27(4):385–90. https://doi.org/10.1016/j.ajem.2008.03.010.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, NY, USA

    Rifat Latifi, Apar S. Patel, David J. Samson, Elizabeth H. Tilley, Saranda Gashi & Roberto Bergamaschi

  2. Clinical Research, Trauma Surgery, Hamad General Hospital (HGH), Doha, Qatar

    Ayman El-Menyar

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  1. Rifat Latifi
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  2. Apar S. Patel
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Correspondence to David J. Samson.

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None of the authors have any conflicts to disclose relating to the purpose of this study.

Ethical approval

This study was conducted under the oversight of the New York Medical College Institutional Review Board (IRB number: 12018).

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As this study was retrospective in nature, using existing data from medical records, informed consent was not obtained.

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Latifi, R., Patel, A.S., Samson, D.J. et al. The roles of early surgery and comorbid conditions on outcomes of severe necrotizing soft-tissue infections. Eur J Trauma Emerg Surg 45, 919–926 (2019). https://doi.org/10.1007/s00068-018-0958-z

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  • DOI: https://doi.org/10.1007/s00068-018-0958-z

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