Necrotizing Fasciitis Treatment And Bacterial Isolates Mortality Risk
Necrotizing fasciitis, although rare, is a highly concerning and progressive medical condition. Its rarity doesn’t diminish its potential to become life-threatening due to the systemic toxicity it can unleash on the body. This condition is primarily characterized by a fast-spreading infection within the fascial layers of the body, which are the connective tissues surrounding muscles, nerves, and blood vessels.
The speed at which it can progress makes necrotizing fasciitis particularly alarming, often causing systemic toxicity. This systemic involvement can lead to severe complications. One of them is septic shock, a condition where the body’s response to infection spirals out of control and can be fatal, as well as multi-organ failure, where vital organs like the heart, lungs, and kidneys cease functioning properly.
Necrotizing fasciitis (NF) patients typically experience the classic triad of symptoms: pain, swelling, and erythema (redness). A key indicator of NF is cloudy dishwater-like drainage, resulting from fascial tissue necrosis. Severe pain, often disproportionate to visible redness and swelling, is a consistent early symptom.
To differentiate necrotizing fasciitis from other soft tissue infections, healthcare providers consider four diagnostic clues.
Diagnostic Differentiation For Necrotizing fasciitis
- Tenderness extends beyond the affected area due to enzyme and toxin spread in the fascia.
- Indistinct boundaries of infection.
- Rare lymphangitis, as necrotizing fasciitis primarily affects deep fascia.
- Rapid progression, even with antibiotics.
The finger test involves a local anesthetic and a 2-cm incision to check if the finger can dissect subcutaneous tissue along the deep fascia. Macroscopic signs of necrotizing fasciitis include grey necrotic tissue, fascial edema, thrombosed vessels, watery, foul-smelling fluid, and non-contracting muscles.
Necrotizing fasciitis entails localized fascial infection, possibly leading to blood vessel thrombosis, cutaneous gangrene, and systemic toxicity like septic shock and multi-organ failure, often caused by Group A Streptococcus. Incidence is rare, about 0.24 to 0.4 cases per 100,000 adults, with high mortality linked to certain conditions. Prompt intervention through wide excision, debridement, and antibiotics is crucial.
Dr. Hasan Sadikin General Hospital (RSHS) in Bandung, Indonesia, is a leading referral center with limited necrotizing fasciitis research. This study aims to gather data on bacterial isolates and their link to necrotizing fasciitis mortality from January 2015 to December 2021.
Methods
In this retrospective study, data from 90 patients were collected by reviewing existing medical records.
Inclusion criteria
- Clinical diagnosis of necrotizing fasciitis (NF), is characterized by the presence of the classic triad of symptoms: pain, swelling, and erythema. Notably, the pain should be significantly greater than the swelling or erythema, and tenderness should extend beyond the visibly affected area with unclear boundaries.
- Patients who had received any form of treatment at the hospital.
- Availability of bacterial swab culture examination data.
Exclusion criteria
- Incomplete medical records.
The swab collection method involved several steps. After superficially cleansing wounds with physiological saline, each swab specimen was obtained by gently rotating a sterile swab (bioM’erieux, Marcy l’Etoile, France) across the wound surface with the most exudate, moving from the deepest point towards the wound’s outer edges.
This microbiological sampling took place before any administration of antibiotics. The swab was then placed in a tube containing a transport medium (bioM’erieux/Amies) and subsequently sent to the hospital’s microbiology laboratory for further culture analysis. Additionally, blood specimens were collected from peripheral vein blood draws and placed in a transport medium (bioM’erieux, BacT/Alert).
Statistical Analysis
Demographic data from patients admitted between January 2015 and December 2021 were meticulously recorded for a total of 90 patients with complete medical records. This information encompassed details such as the patient’s age, gender, underlying cause, site of infection, duration of hospitalization, bacterial isolates, prescribed antibiotics, time elapsed before the initial surgical procedure, the nature of surgical interventions, and the mortality rate.
To perform the data analysis, we focused on variables including bacterial isolates, antibiotic usage, surgical procedures, and mortality data. For datasets with sufficient data points (a minimum of five per group), we employed the chi-square test. When the data were not adequate for the chi-square test, we opted for Fisher’s exact test. Furthermore, the analysis of waiting time before the first surgery involved the application of a one-way ANOVA test.
This data transformation and analysis process was executed using SPSS (Statistical Package for the Social Sciences) version 23.
Results
A comprehensive analysis of medical records from 90 patients revealed that the most prevalent site of infection was in the genitalia and inguinal region, accounting for 37% of cases. A significant majority, 85%, of all samples exhibited the presence of gram-negative bacteria. The primary choice for empirical antibiotics was from the Cephalosporin class, comprising 31% of cases. These antibiotics were often combined with nitroimidazole (metronidazole) and quinolones (levofloxacin, ciprofloxacin).
The overall mortality rate stood at 13.3%. Notably, the highest mortality rate was observed in the group of patients infected with gram-negative bacteria (14.2%, 11 out of 77 patients). Patients who received Ceftriaxone-Metronidazole as empirical antibiotics experienced a notably high mortality rate of 28.57% (4 out of 14 patients). The group of patients who did not undergo surgery had a mortality rate of 37% (3 out of 8 patients). In contrast, patients who underwent debridement followed by fasciotomy, skin graft, flap, or amputation did not experience any mortality.
Necrotizing fasciitis (NF) is an aggressive infection known for its rapid spread, leading to the necrosis of skin, subcutaneous tissue, and fascia, often accompanied by thrombosis in the microcirculation of the skin. This condition poses a severe systemic threat, emphasizing its life-threatening potential. The speed of NF’s propagation correlates with the thickness of the subcutaneous layer, as it advances along the fascial plane. NF is also referred to by various terms, such as Meleney ulcer, progressive bacterial synergistic gangrene, Fournier’s gangrene, streptococcal gangrene, flesh-eating bacterial infection, acute dermal gangrene, suppurative fasciitis, and synergistic necrotizing cellulitis.
At our medical center, necrotizing fasciitis exhibited a higher incidence in males (72.2%) compared to females (27.8%), consistent with findings by Shaikh et al., who noted a similar male predominance (74.3%) with a male-to-female ratio of 3:1 in Qatar. Necrotizing fasciitis can affect individuals of all age groups, with middle-aged and elderly patients (over 50 years of age) being more susceptible. The median age of patients in our study was 50 years, ranging from 0 to 76.
In this research, the most common bacteria isolated from patients’ wound samples were gram-negative bacteria (51.2%), with A. baumanii (18.9%), K. pneumoniae (16.7%), and P. aeruginosa (15.6%) being the predominant species. However, it’s worth noting that the prevalence of bacteria causing necrotizing fasciitis can vary by location. Environmental factors in different regions might contribute to these variations, and limited data are available from hot, humid climates in other Southeast Asian cities for a closer comparison.
Conclusion
The study’s findings indicate that the most frequently identified bacterial cause was A. baumanii, but it did not show a significant association with mortality. The researchers strongly advocate early and assertive surgical intervention to decrease the mortality rate attributed to necrotizing fasciitis. This intervention involves source control, deliberate closure of defects, and the prompt administration of empirical antibiotics with a heightened susceptibility to gram-negative bacteria, particularly Meropenem.
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