Abstract
Background
Necrotizing soft tissue infections (NSTI) are frequently encountered, with a high mortality despite advances in health care.
Material and Methods
Patients presenting with NSTI were prospectively followed up in an attempt to identify factors that were significantly associated with mortality.
Results
There were a total of 86 patients [65 males (75.6%) and 21 females (24.4%)] with an overall mortality of 33.7% (29 patients). The average age was 50.37 years and trauma was the commonest aetiology (34 patients, 66.7%). The average duration of symptoms prior to presentation was 10.56 days; the lower limb was most commonly involved (62 patients, 72.09%). Fifty nine patients had comorbidities (commonest being diabetes mellitus in 41). Age above 50 years, symptoms for more than 8.5 days, involved surface area more than 15.5%, of the total body surface, on-admission pulse rate more than 99 beats/minute, systolic blood pressure less than 103 mm Hg, Glasgow scale less than 12, need for inotropes, low hemoglobin, high leukocyte counts, uraemia, deranged coagulation, low serum albumin, and high levels of lactic acid were significant for mortality. On multivariate analysis, only age above 50 years, presence of acidosis and low serum albumin significantly affected survival.
Conclusion
NSTI carry high mortality. The identification of potential risk factors associated with mortality might help in guiding and optimizing the management of patients who present with NSTI.
Key words: Soft tissue, infection, necrosis, gangrene, fasciotomy, debridement, prognosis, death
Ethical Approval — Informed Consent
The authors declare that the study has been approved by the appropriate ethics committee and has therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki. Also all patients gave their written informed consent prior to their inclusion to the study.
Footnotes
Conflict of Interest
The authors declare that there is no conflict of interest.
References
- 1.Loudon I. Necrotizing fasciitis, hospital gangrene, and phagedena. Lancet. 1994;344:1416–19. doi: 10.1016/S0140-6736(94)90574-6. [DOI] [PubMed] [Google Scholar]
- 2.Wilson B. Necrotizing fasciitis. Am Surg. 1952;18:416–31. [PubMed] [Google Scholar]
- 3.McHenry CR, Piotrowski JJ, Petrinic D, et al. Determinants of mortality for necrotizing soft-tissue infections. Ann Surg. 1995;221:558–65. doi: 10.1097/00000658-199505000-00013. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Urbina T, Hua C, Sbidian E, et al. Impact of a multidisciplinary care bundle for necrotizing skin and soft tissue infections: A retrospective cohort study. Ann Intensive Care. 2019;9:123. doi: 10.1186/s13613-019-0598-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Hua C, Bosc R, Sbidian E, et al. Interventions for necrotizing soft tissue infections in adults. Cochrane Database Syst Rev. 2018;5:CD011680. doi: 10.1002/14651858.CD011680.pub2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Naik D, Jebasingh FK, Thomas N, et al. Necrotizing soft tissue infection of the upper extremities in patients with diabetes mellitus in a tertiary care center-a retrospective study. Diabetes Metab Syndr. 2020;14:1071–5. doi: 10.1016/j.dsx.2020.05.032. [DOI] [PubMed] [Google Scholar]
- 7.Barupal SR, Soni ML, Barupal R. Factors affecting mortality following necrotizing soft-tissue infections: Randomized prospective study. J Emerg Trauma Shock. 2019;12:108–16. doi: 10.4103/JETS.JETS_17_18. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Sharma P, Jhanwar A, Sharma D, et al. Necrotizing soft-tissue infections: Our experience at rural tertiary care centre. Int Surg J. 2016;3:1528–33. doi: 10.18203/2349-2902.isj20162741. [DOI] [Google Scholar]
- 9.Hedawoo JB, Sarve GN. Study of surface area involvement as a mortality indicator in necrotizing fasciitis. MedPulse — Int Medical J. 2015;2:442–5. [Google Scholar]
- 10.Shah AK, Kumar NB, Gambhir RPS, et al. Integrated clinical care pathway for managing necrotising soft tissue infections. Indian J Surg. 2009;71:254–7. doi: 10.1007/s12262-009-0076-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Kalaivani V, Hiremath BV, Indumathi VAI. Necrotising soft tissue infection-risk factors for mortality. J Clin Diagn Res. 2013;7:1662–5. doi: 10.7860/JCDR/2013/5535.3240. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Singh G, Chawla S. Aggressiveness — The key to a successful outcome in necrotizing soft tissue infection. MJAFI. 2003;59:21–4. doi: 10.1016/S0377-1237(03)80098-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Singh G, Sinha SK, Adhikary S, et al. Necrotising infections of soft tissues—a clinical profile. Eur J Surg. 2002;168:366–71. doi: 10.1080/11024150260284897. [DOI] [PubMed] [Google Scholar]
- 14.Huang KF, Hung MH, Lin YS, et al. Independent predictors of mortality for necrotizing fasciitis: a retrospective analysis in a single institution. J Trauma. 2011;71:467–73. doi: 10.1097/TA.0b013e318220d7fa. [DOI] [PubMed] [Google Scholar]
- 15.Kobayashi L, Konstantinidis A, Shackelford S, et al. Necrotizing soft tissue infections: Delayed surgical treatment is associated with increased number of surgical debridements and morbidity. J Trauma. 2011;71:1400–5. doi: 10.1097/TA.0b013e31820db8fd. [DOI] [PubMed] [Google Scholar]
- 16.Park SJ, Kim DH, Choi CI, et al. Necrotizing soft tissue infection: Analysis of the factors related to mortality in 30 cases of a single institution for 5 years. Ann Surg Treat Res. 2016;91:45–50. doi: 10.4174/astr.2016.91.1.45. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Ward RG, Walsh MS. Necrotizing fasciitis: 10 years’ experience in a district general hospital. Br J Surg. 1991;78:488–9. doi: 10.1002/bjs.1800780431. [DOI] [PubMed] [Google Scholar]
- 18.Krieg A, Röhrborn A, Schulte Am Esch J, et al. Necrotizing fasciitis: Microbiological characteristics and predictors of postoperative outcome. Eur J Med Res. 2009;14:30–6. doi: 10.1186/2047-783X-14-1-30. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Dworkin MS, Westercamp MD, Park L, et al. The epidemiology of necrotizing fasciitis including factors associated with death and amputation. Epidemiol Infect. 2009;137:1609–14. doi: 10.1017/S0950268809002532. [DOI] [PubMed] [Google Scholar]
- 20.van Stigt SF, de Vries J, Bijker JB, et al. Review of 58 patients with necrotizing fasciitis in the Netherlands. World J Emerg Surg. 2016;11:21. doi: 10.1186/s13017-016-0080-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Elliott DC, Kufera JA, Myers RA. Necrotizing soft tissue infections. Risk factors for mortality and strategies for management. Ann Surg. 1996;224:672–83. doi: 10.1097/00000658-199611000-00011. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Madsen MB, Skrede S, Perner A, et al. Patient’s characteristics and outcomes in necrotising soft-tissue infections: results from a Scandinavian, multicentre, prospective cohort study. Intensive Care Med. 2019;45:1241–51. doi: 10.1007/s00134-019-05730-x. [DOI] [PubMed] [Google Scholar]