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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 54  |  Issue : 2  |  Page : 52-60

Predictors of mortality in necrotizing fasciitis


Department of General Surgery, Government Medical College, Pali, Rajasthan, India

Date of Submission05-Apr-2020
Date of Decision22-Jun-2020
Date of Acceptance06-Oct-2020
Date of Web Publication20-Mar-2021

Correspondence Address:
Mohan Lal
PR 63 H, Bangur Hospital Campus, Pali, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_43_20

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  Abstract 


Background: Necrotizing fasciitis (NF) is a rapidly progressing life threatening necrosis of the fascia and subcutaneous tissue. This study was done to assess the clinical presentation, laboratory investigations, microbiological characteristics, and major predictors of mortality associated with NF.
Material and Methods: A prospective study was conducted from March 2013 to February 2014. NF patients were categorized into two groups based on their in hospital outcome. Demographic data, clinical features, comorbidities, site of infection with microbiology and laboratory results, and surgical intervention for patients were compared and analyzed. SPSS 26.0 statistics software was used for statistical analysis.
Results: The mean age was 48.6 ± 16.78 years. Fever (P = 0.0177), tachycardia (P = 0.0155), and septic shock (P = 0.0046) were significantly high in nonsurvivors. Diabetes was the most common comorbidity. Renal impairment (P = 0.0229) was significantly high in the nonsurvivor group. The most common site was lower limb/thigh NF. Abdomen/groin NF (P = 0.0158) was significantly high in nonsurvivors. Nonsurvivors had significantly low hemoglobin (P = 0.0027) and serum sodium (P = 0.0023) and had significantly high leukocyte count (P = 0.00001), serum creatinine (P = 0.0000), serum glucose (P = 0.00003), and LRINEC score (P = 0.00002). Polybacterial infections (P = 0.021) were significantly high in nonsurvivors. The frequency of debridement more than 2 (P = 0.0469) and debridement within 24 h of admission (0.0013) were significantly high in survivors. Hospital stay (P = 0.0272) was significantly high in nonsurvivors. Multivariate logistic regression analysis did not show any independent factors associated with mortality
Conclusion: Identification of predictors of mortality can improve the management and outcome of NF.

Keywords: Fournier's gangrene, necrotizing fasciitis, predictor of mortality, predisposing factors


How to cite this article:
Kumar M, Lal M. Predictors of mortality in necrotizing fasciitis. Formos J Surg 2021;54:52-60

How to cite this URL:
Kumar M, Lal M. Predictors of mortality in necrotizing fasciitis. Formos J Surg [serial online] 2021 [cited 2021 Apr 13];54:52-60. Available from: https://www.e-fjs.org/text.asp?2021/54/2/52/311589




  Introduction Top


Necrotizing fasciitis (NF) is a rapidly progressing, life-threatening necrotizing infection of fascia and subcutaneous tissue.[1] Its rarity, vague presentations, and normal overlying skin without clear boundaries between viable and nonviable tissues make NF a major diagnostic challenge.[2],[3] Its rapid progression, septic shock, and high morbidity and mortality (up to 20%–30%) necessitate the early diagnosis and identification of potential risk factors of poor prognosis that typically requires urgent surgical interventions.[1],[4],[5] The present study aims to highlight the clinical and laboratory characteristics and microbiology and determine the various predisposing and prognostic factors associated with mortality in NF patients.


  Subjects and Methods Top


Study design

All patients with provisional diagnosis of NF admitted from March 2013 to February 2014, who had undergone surgery and whose histopathology reports were available, were included in the study. Exclusion criteria include intraoperative and histopathology negative for NF, age below 12 years, arterial or venous ulcer, and refusal to consent. All patients were evaluated on the basis of history, clinical examination, and investigation, and a provisional diagnosis was made. Patients were resuscitated and treated by surgical procedure. Diagnosis was confirmed by surgical exploration and histopathology. Patients were categorized into two groups based on their inhospital outcome. Data included patient's age, gender, comorbidities, clinical features, site and etiology of infection, on-admission laboratory parameters, causative microbiological organisms, the LRINEC score, number/timing/type of surgical intervention, need for amputation, and length of hospital stay and inhospital mortality. This study was approved by the institutional ethics committee (SMSMC/IEC/23: Dated November 6, 2012) and has been performed in accordance with the Declaration of Helsinki. Informed consent was taken from all patients.

Definitions

  • Renal impairment: Serum creatinine value >2 mg/dl[6]
  • Rural area: A place with population <5,000, population density <400/km2, and more than “25% of the male working population” is engaged in agricultural pursuits[7]
  • Immunocompromised status: A person is said to be immunocompromised when their immune system is incapable of working at full capacity making them more vulnerable to getting fungal, viral, bacterial, and parasitic infections. Causes include AIDS, chemotherapy, cancer (leukemia and lymphoma), autoimmune diseases, medication (corticosteroid and tumor necrosis factor inhibitor), chronic diseases, and congenital immunodeficiency disorder.[8]


Statistical analysis

Data were presented as proportions, median, or mean, as appropriate. Baseline demographic characteristics, laboratory findings, clinical presentation, bacteriology, and predisposing factors were compared between survivors and nonsurvivors. Analyses were conducted using Student's t-test for continuous variables and Pearson's Chi-square test for categorical variables; Fisher's exact test was used for expected cell frequencies below 5. We performed univariate and multivariate logistic regression analyses to identify predictors of mortality in the overall NF. P < 0.05 was considered statistically significant. All statistical analyses were performed using SPSS 26.0 statistics software (IBM, New York, USA).


  Results Top


Demography

Total 50 patients fulfilled the case definition of NF. Among them, 42 (84%) were survivors and 8 (16%) were nonsurvivors. Males comprised 88% of the study population (44 males), and the average age was 48.6 ± 16.78 years. Thirty-nine patients (78%) were from rural area. The two groups were comparable for gender (88.1% vs. 87.5%; P = 1.00; not significant [NS]), age (48.2 ± 17.16 vs. 50.5 ± 14.40; P = 0.728; NS), and rural background (78.57% vs. 75%; P = 1.00; NS) [Table 1].
Table 1: Comparison of necrotizing fasciitis by outcome

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Clinical findings

The most common symptoms and signs were pain/tenderness (94%), swelling (90%), erythema (90%), fever (62%), and tachycardia (60%). At presentation, all survivors and nonsurvivors had comparable frequency of pain/tenderness (95.23% vs. 87.5%; P = 0.4143; NS), swelling (90.47% vs. 87.5%; P = 1.00; NS), and erythema (92.85% vs. 75%; P = 0.1759; NS). The frequency of fever (100% vs. 54.76%; P = 0.0177; significant [S]), tachycardia (100% vs. 52.38%; P = 0.0155; S), and septic shock (87.5% vs. 30.9%; P = 0.0046; S) were significantly high in nonsurvivors in comparison to survivors [Table 1]

Comorbidities

Diabetes (20%) was the most frequent comorbid condition, followed by hypertension (8%) in NF. The frequency of diabetes mellitus, hypertension, renal impairment, and immunocompromised status was higher among nonsurvivors but significantly higher in case of renal impairment (25% vs. 00%; P = 0.0229; S) only [Table 1].

Precipitating events

The most common precipitating events in NF were boils in 20 patients (40%), posttraumatic injury in the form of minor trauma in 14 patients (28%), and Fournier's gangrene in 10 patients (20%). There was no known cause for NF in 6 patients (12%). Boil was significantly high in the survivor group than the nonsurvivor group (47.61% vs. 00%; P = 0.155; S) [Table 1].

Site of infection

The most common site of NF was lower limb/thigh (44%) followed by perineum and scrotum (20%). The frequency of abdomen/groin NF was significantly high in the nonsurvivor group (50% vs. 9.52%; P = 0.0158; S) in comparison to survivors [Table 1].

Laboratory findings

The frequency of initial blood investigations such as hemoglobin (9.3 ± 1.40 vs. 11.6 ± 1.94; P = 0.0027; S) and serum sodium (125.0 ± 3.85 vs. 133.8 ± 7.49; P = 0.0023; S) was significantly low and leukocyte count (25.3 ± 4.55 vs. 17.4 ± 2.96.; P = 0.0000; S), serum creatinine (1.95 [1.7–8] vs. 1.2 [0.8-1.8]; P = 0.0000; S), and serum glucose (115.3 ± 40.52 vs. 86.8 ± 4.85; P = 0.0000; S) was significantly high in the nonsurvivor group in comparison to the survivor group. Bilirubin, platelet count, and C-reactive protein (CRP) were comparable among survivors and nonsurvivors. In addition, nonsurvivors had significantly high median LRINEC score (12 [7–13] vs. 7 [6–11]; P = 0.0000; S] in comparison to the survivor group [Table 1].

Microbiological findings

Out of 50 cases, 44 (88%) were positive for wound culture and was comparable in both the groups. We found type 1 (polybacterial) NF in 24 patients (48%) and type 2 (monobacterial) NF in 20 patients (40%). Streptococcus pyogenes (44%) and Staphylococcus aureus (28%) were the predominant Gram-positive microorganisms. Escherichia coli (28%) and Klebsiella (16%) were the predominant Gram-negative microorganisms. The frequency of type 1 NF was significantly high in nonsurvivors (87.5% vs. 40.5%; P = 0.021; S) in comparison to the survivor group. The frequency of all individual bacteria, Gram-positive bacteria, Gram-negative bacteria, and type 2 NF was comparable in both the groups [Table 1]. The culture and sensitivity report of NF is shown in [Table 2].
Table 2: Culture and sensitivity report in necrotizing fasciitis patients

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Management and outcomes

The average number of surgeries performed in NF was 2.72 ± 0.645. Debridement more than two was done in 60% of the patients. Seventy-six percent of the patients underwent surgery within 24 h of admission. The median length of hospital stay was 14.5 days (ranged 2–73) in NF. The number of surgeries (2.80 ± 0.671 vs. 2.25 ± 0.462; P = 0.0292; S), more than two debridement (66.66% vs. 25%; P = 0.0469; S) and earlier surgery within 24 h of admission for NF (85.7% vs. 25%; P = 0.0013; S) were significantly high in survivors than the nonsurvivor group. The length of hospital stay (21 [12–73] vs. 14 [2–62]; P = 0.0272; S) was significantly high in nonsurvivors than the survivor group. Need for amputation was 16% in NF and was comparable in both the groups. Nonsurvivors received a combination of antibiotics (>2 antibiotics) comparable to survivors (37.5% vs. 50%; P = 0.7041; NS) [Table 1].

The mortality rate was 16% in the present study. [Table 3] shows the major causes of mortality which mainly involved septic shock (50%) and end-stage renal disease (25%) as major causes. The proportion of mortality based on the bacteriology results is given in [Table 4].
Table 3: Major causes of mortality (n=8) in necrotizing fasciitis patients

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Table 4: Mortality based on the bacteriology results

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[Table 5] compares the comorbidities with microbiological data and antibiotics used. None of the comorbidities showed a significant association with types of microorganisms and combination of antibiotics used except end-stage renal failure and trauma patients. A significantly higher frequency of end-stage renal failure and trauma patients was prescribed more than two antibiotic combinations.
Table 5: Comparison of comorbidities with microbiological data and antibiotics

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Predictors of mortality

Univariate logistic regression analysis showed that patients with fever, tachycardia, septic shock, prior renal failure, abdominal-groin site, hemoglobin <10 g/dl, white blood cell (WBC) >14000/mm3, serum sodium <130 mEq/L, serum creatinine >1.2 mg/dl, serum glucose >110 g/dl, LRINEC score >7, debridement <3, operation after 24 h, and polybacterial infection had a significantly higher risk of inhospital mortality. Multivariate logistic regression analysis did not show any of the above factors to be independently associated with mortality [Table 6].
Table 6: Univariate-multivariate analysis for predictors of mortality

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  Discussion Top


NF is a relatively uncommon, fulminant, rapidly progressing, life-threatening necrotizing infection of fascia with necrosis of the subcutaneous tissue spreading unrecognized along the fascial planes at a rate of 2–3 cm/h. However, NF as a soft-tissue infection “per se” typically does not cause myonecrosis but does invade the deep fascia and muscle. It is known as flesh-eating bacteria syndrome, gangrenous erysipelas, Fournier's gangrene, hemolytic streptococcal gangrene, synergistic necrotizing cellulitis, Meleney's gangrene, and suppurative fasciitis.[2],[9],[10],[11] The incidence of NF is 500–1000 cases annually with a global prevalence of 0.40 cases per 100,000 populations.[9],[10] The present study is a prospective study of NF cases from a single surgical tertiary care center in Rajasthan that highlights the clinical and laboratory characteristics and assesses the predictors of mortality in NF patients.

NF could occur at any age but is mostly reported within the age range of 32–57 years. Preexisting comorbidities and immunosuppression in advanced age could be cause for high rate of NF associated with advanced age.[1] In the present study, the mean age was 48.6 years similar to prior reports[1],[12],[13] and was comparable between nonsurvivors and survivors similar to a previous study.[14] Male gender in NF ranged from 49% to 88.6% in previous literature. In our study, male gender was 88%, i.e., upper limit of previous literature, but was comparable in both the groups. Indian males are more liable to NF because of their occupation (manual outdoor jobs with increased risk of trauma and exposure to humidity) and associated comorbidities.[2] This ratio is also correlated with the increased incidence of Fournier's gangrene in males with a reported rate of 96%.[9]

Trauma is the most common identifiable etiology in previous literature. The majority of the patients have a history of minor or major traumas, generally involving external injuries and surgical wounds. Fournier's gangrene is often the result of surgical wounds, boil/skin abscess drainage, bedsores, ischiorectal abscess urethral stricture/trauma, and colon perforations.[3],[9] Boil was the most common cause for NF in our study, but it was significantly high in survivor than nonsurvivors.

NF is classified into four types based on causative organism. Type 1 (70%–80%, polymicrobial) occurs commonly in immunocompromised individuals, caused by one anaerobic species with one or more facultative anaerobic streptococci (other than Group A) and members of Enterobacteriaceae, mostly found in the trunk and perineum. Type 2 (20%, usually monomicrobial) occurs in young and healthy patients, caused by beta-hemolytic Streptococcus A (Streptococcus pyogenes), sometimes with S. aureus, mostly found in extremities. It is not easy to manage a fulminant form of NF with methicillin-resistant S. aureus (MRSA), found in 10%–30% of all patients. Types 3 and 4 are caused by marine-related organism (Clostridium species/Vibrio) and fungus Candida, respectively.[9],[10],[11],[15]

In our study, the overall rate of positive wound cultures was 88% and was comparable to previous literature.[1],[3],[14] Patients who had positive blood cultures had higher mortality rate, up to four times.[1] As reported by Goh et al., of the nine studies, five had a higher rate of polymicrobial infection. Previous studies have emphasized the synergistic effects of polymicrobial bacteria in the pathogenesis of NF.[3] Consistent with previous reports, Streptococcus and Staphylococcus were the most common Gram-positive organisms identified in the present study. On the other side, E. coli and Klebsiella were the predominant Gram-negative organisms in the present study.[1],[2],[3],[16]

The synergistic action of bacterial virulence and the host factors are implicated in the development of NF. Bacteria produce toxins and enzymes. There is degradation of fat and fascia due to bacterial enzymes such as lipases and hyaluronidase. There is activation of interleukins, tumor necrosis factor-alpha, and gamma-interferon through a triggering mechanism causing capillary thrombosis with tissue necrosis.[9],[11] Endotoxin and exotoxins cause prolonged vasoconstriction in the dermal capillary. These toxins can cause Systemic inflammatory response syndrome (SIRS), septic shock, Multiple Organ Dysfunction Syndromes (MODS), and finally, death. Lymphangitis and lymphadenopathy are rare due to thrombosis of the vessels.[9],[10]

Early-stage NF includes minor trauma, tenderness beyond apparent area of skin involvement and swelling, erythema, local warmth, flu-like symptoms, dehydration, and feeling of worse. Intermediate-stage NF includes blister or bullae (serous fluid), skin fluctuation, and skin induration. Advanced/late-stage NF includes limb swelling with purplish rash, blister filled blackish hemorrhagic fluid, hemorrhagic bullae, crepitus, skin anesthesia, and skin necrosis with dusky discoloration progressing to frank gangrene bluish-white dark mottled flaky wound. In fulminant NF, a patient is critically ill with signs and symptoms of severe septic shock and multiple organ dysfunctions.[1],[3],[5],[10]

A combination of swelling, local pain, and erythema forms a classic triad of symptoms of NF. It is often misdiagnosed as cellulitis or abscess. The most consistent feature of early NF is pain out of proportion to the swelling or erythema. Tachycardia (>100 beats/min) and fever are the most common vital sign abnormalities, followed by hypotension (systolic blood pressure <100 mmHg) and tachypnea (>20/min).[3],[10] In our study, the frequency of this triad was comparable in survivors and nonsurvivors in contrast to earlier reports.

The development of blisters or bullae (serous fluid) in the skin is an intermediary stage and acts as a turning point in disease between early-stage (nonspecific cutaneous features) and late-stage (skin necrosis) NF. There is a moderate positive correlation between presence of bullae with amputation and mortality rates. The diagnosis of NF is clinical, and findings include gray necrotic tissue, thrombosed vessels, fascial edema, foul-smelling fluid “dishwater” pus, noncontracting muscle, and a positive “finger test” characterized by lack of resistance to finger dissection.[3],[11]

Prognosis becomes poorer in the presence of comorbidities, such as diabetes mellitus, liver cirrhosis, immunosuppression, alcohol abuse, and chronic renal failure.[3],[9],[14] Other predisposing factors include malignancy, chronic heart failure, peripheral vascular disease, hypertension, traumatic injuries, advanced age, and obesity.[1],[4],[15] Multiple comorbidities are associated with increased mortality rate on average 64.7%.[10]

Diabetes mellitus was the most common comorbidity for NF in our study similar to prior literature, but its association with higher mortality could not be demonstrated.[3],[9],[10] Diabetes mellitus is associated with prolonged hospitalization, rapid progress of the severity of NF, and mortality. The baseline serum sugar in the current study was significantly higher in nonsurvivors in contrast to a previous study.[1],[5] Hypertension might cause disruption of the microvascular supply and reduction of tissue oxygenation and antimicrobial delivery. There is a high association of hypertension and mortality in NF.[1]

Infection of the lower extremities is the most common site of NF, followed by the abdomen and the perineum. NF of the upper limbs is rare compared to that of the lower limbs.[9],[10] The most common sites involved in our study were lower extremities, perineum/scrotum, and abdominal/groin regions similar to earlier studies.[1],[9],[11]

The site of infection and its expansion also affect mortality. Head-and-neck NF is associated with higher mortality due to nearby vital structures, and there is poor survival with thoracic extension as compared to nonthoracic extension. There is a lower mortality rate in extremity NF in comparison to abdominal and perineal infections. Hence, its extension to the pelvis or trunk is associated with worse prognosis, requiring early, aggressive, and repeated debridement, to achieve better survival rate. Therefore, early identification and diagnosis is mandatory and should not rely only on the clinical signs alone.[1],[9] Although the two groups were comparable for the site of infection, abdomen/groin had a significantly higher frequency in nonsurvivors than survivors similar to prior literature.[1],[9],[12]

Laboratory results in NF are not specific, but certain laboratory findings such as leukocytosis >15,000/L, blood urea nitrogen >18 mg/dL and serum creatinine >1.2 mg/dL, CRP >16 mg/dL, or creatine kinase >600 IU/L can help to differentiate NF from other skin diseases. LRINEC score is one of many laboratory-based scoring systems proposed for early diagnosis of NF. The Fournier's Gangrene Severity Index is another scoring system to determine the requirement of surgical debridement in Fournier's gangrene.[9]

In the present study, nonsurvivors had significantly lower levels of hemoglobin and serum sodium and had higher serum creatinine, serum glucose, and leukocyte count as compared to survivors similar to prior literature.[1],[4],[17]

Bedside tests, imaging tests or frozen section biopsy are advised in patients with equivocal clinical findings and LRINEC score >5. Computed tomography (CT) and magnetic resonance imaging (MRI) are more sensitive and specific than plain radiography. An MRI has better accuracy than CT. The finger test is a bedside procedure in which gentle probing of the index finger through a 3-cm incision is made down to the deep fascia to look for characteristic “dishwater pus,” along with the lack of bleeding and lack of tissue resistance to blunt finger dissection correlating with NF. Surgical exploration is regarded as the mainstay for investigation and treatment. Incisional biopsy down to the fascial level with an immediate frozen section, culture, and Gram stain is another useful bedside test. Gold standard test for confirmation of NF is a combination of surgical exploration and microbiological and histopathological analysis.[5],[9]

The management of NF consists of broad-spectrum antibiotics, early and aggressive drainage and meticulous debridement, optimal oxygenation of the infected tissue, and resuscitation.[5],[9],[14] Type 1 infection is treated with ampicillin–sulbactam, piperacillin–tazobactam, ticarcillin–clavulanic acid, third- or fourth-generation cephalosporins, or carbapenems. Type 2 infection is treated with first or second generation of cephalosporins. MRSA is treated with vancomycin or daptomycin and linezolid in case of vancomycin resistance.[9]

Early surgical intervention and repeated debridement is lifesaving. Treatment delay of more than 6–12 h or inadequate debridement contributes to morbidity and mortality. The relative risk of death was 7.5 times greater in cases of restricted primary debridement, whereas mortality rate was nine times greater when primary surgery was delayed by 24 h.[3],[9],[10] Pain out of proportion to physical examination and unresolved cellulitis are major diagnostic clues, but lack of specific clinical features in the initial stages of the disease may be the main cause of delayed diagnosis.[1],[18] Goh et al. describe a 71.4% misdiagnosis of NF as cellulitis or abscess in their systematic review illustrating the diagnostic dilemma involved. Securing a diagnosis noninvasively is very difficult.[3],[12] Often, patients seem to be sick to be immediately operated on, so clinicians will attempt resuscitate them first, leading to delayed surgery or misleading clinical presentation. However, it is important to control the source of infection in the management of any critically ill patients.[19] The diagnosis of NF may be delayed because of concurrent use of nonsteroidal anti-inflammatory drugs suppressing fever and presence of diabetes.[3],[20] In Indian scenario, delay in intervention could be due to illiteracy, lack of public awareness, lack of easy availability of health care facility and specialization, poverty, social taboo, etc., in addition to other cause.

Topical negative pressure therapy is helpful in wound management by removing exudates, stimulating angiogenesis, reducing bacterial contamination, reducing the wound size, improving the rate of granulation tissue formation, reducing the required number of surgical interventions, improving healing of skin grafts and flaps, and reducing infection rates. Postoperative management of the surgical wound and proper nutrition is important for the patient's survival.[9],[10] Many patients require reconstructive surgery and skin grafting and blood product transfusion.[1],[21]

Adjuvant hyperbaric oxygen (HBO), as a postoperative newer therapy, decreases morbidity and mortality, reduces the risk of wound infection by increasing ability of neutrophils to kill bacteria, facilitates the synthesis of collagen and angiogenesis by increasing oxygen diffusion, reduces the time to wound stabilization, increases fresh granulation tissue production, and decreases wound complications. However, HBO should not interfere with initiation or repetition or emergency of the surgical intervention.[10]

The reported rate of number of debridement procedures in six of nine studies is 3.2 per patient.[3],[14] In the present study, the number of debridement performed per patient was 2.7, and these were significantly high in survivors in comparison to nonsurvivors similar to previous literature.[1] The number of debridement more than two and earlier surgery within 24 h of admission for NF were significantly high in survivors than in the nonsurvivor group similar to prior literature.[14] The length of hospital stay was significantly high in nonsurvivors than the survivor group.

Although NF is rare, its mortality rate (21·5%) is high ranging from 6% to 76%.[10] The mortality rate (16%) in our study was comparable with average mortality rate in literature.[1],[3],[9],[22],[23] The reported mean amputation rate is 15·9% (range: 4·1–27·8) similar to amputation rate (16%) in our study. It is clear that prompt diagnosis and intervention reduces mortality and 3.2 amputation rates.[3]

In the present study, univariate logistic regression analysis showed that patients with fever, tachycardia, septic shock, prior renal failure, abdominal-groin site, hemoglobin <10 g/dl, WBC >14000/mm3, sodium <130 mEq/L, serum creatinine >1.2 mg/dl, serum glucose >110 g/dl, LRINEC score >7, debridement <3, operation after 24 h, and polybacterial infection had a significantly higher risk of inhospital mortality. Multivariate logistic regression analysis did not show any of the above factors to be independently associated with mortality may be due to small sample size with low mortality rate.

LRINEC score is a useful tool to differentiate life-threatening NF from other soft-tissue infection. A score ≥6 should raise the suspicion of NF and a score of ≥8 is strongly predictive of it.[14],[18] As reported by El-Menyar et al., a LRINEC score of ≥6, ≥8, and ≥ 10 was found in 79.3%, 56.9%, and 13.8% of the patients, respectively, with a mean LRINEC score of 7.4 comparable to 7.9 in our study.[15] As reported by Swain et al., the median LRINEC score in nonsurvivors was 9.0 (range: 6–12) comparable to our study.[24] CRP is an important component of the LRINEC score to distinguish NF from other soft-tissue infections; if patients had an LRINEC score >6 or CRP >150 mg/dL, they are diagnosed with NF. Most of the cases in our study were having high CRP level. A high score of 7 could be due to late presentation of cases in our study having high CRP value (≥150 mg/dl = score 4 and < 150 = score 0) leading to significantly high LRINEC score in our study. Hence, monitoring of CRP is still important.[25]

An earlier study reported that WBC count more than 30 × 103/μl, band Polymorphonuclear leukocytes (PMNs) > 10%, serum creatinine (>2.0 mg/dL), low hemoglobin, hypoalbuminemia, thrombocytopenia, an activated prothrombin time (>60 s), shock, hemorrhagic bullae, extent of the infection, advanced age, heart disease, chronic heart disease, liver cirrhosis, Vibrio and Aeromonas infection, and delay in surgery of more than 24 h were found to be the independent predictors of mortality in NF patients.[1],[4],[9],[19],[26],[27],[28]

Limitation of our study was small population with low mortality rate. A prospective, multicenter registry enrolling all patients with soft-tissue infections could be a valuable tool to enhance the understanding of NF in its early stages.[9] Although mortality rate of NF in our study is comparable to mortality rate of NF in recent literature but mortality rate of NF is still higher in comparison to other diseases as approximately one-sixth of NF patients died in the hospital.


  Conclusion Top


The present study highlights the clinical characteristics and predictors of mortality in NF and provides useful information on the severity and outcome of NF which will guide on-time optimal treatment of NF according to the severity of infection and general status. Identification of predictors of mortality can improve the management and outcome of NF.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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