title: Analysis of the increasing prevalence of necrotising fasciitis referrals to a regional plastic surgery unit: a retrospective case series.
abstract: Necrotising Fasciitis is a destructive infection of the skin and subcutaneous tissues associated with significant mortality and morbidity. Survival from the condition often necessitates patient referral for appropriate reconstructive surgery and supportive medical management. The aim of our study was to identify emerging patterns, characteristics and outcomes of necrotising fasciitis in Northern Ireland. A retrospective analysis of all patients referred to the Regional Plastic Surgery Service in Belfast between 2007 and 2012 was performed. Forty-six patients were identified with clinical, intraoperative and histopathological confirmation of necrotising fasciitis. Mean patient age was 59.4 years (range 32-88) with a 25:21 male to female ratio. 13 patients died from the disease. Smoking, obesity, diabetes and immunocompromise were the most prevalent co-morbidities identified. 37 patients had no identifiable mechanism of infection initiation in the history. Painful cellulitis (44/46), skin necrosis (26/46), skin blistering (8/46) and subcutaneous emphysema (3/46) were the most common presenting features. The median LRINEC score at presentation was 7 (range 2-12). The mean serum lactate at presentation was 4.0 mmol/L (range 1.6-13.5). LRINEC scores and serum lactate at presentation exhibited diagnostic sensitivities of 65% and 90% respectively. The lower extremity was the most commonly affected anatomical site (16/46). Group A Streptococcus was the most frequently isolated causative bacterium from debrided tissue cultures (16/46). The prevalence of necrotising fasciitis in the population studied is increasing, particularly in relation to patient cases caused by Group A Streptococcal infection. Increasing bacterial virulence and levels of patient immunocompromise may explain this increasing trend. The LRINEC scoring system lacked diagnostic sensitivity. Elevated serum lactate was supported as both a diagnostic and prognostic indicator. The findings of our study are somewhat limited in their application to other regions and highlight the need for a national analysis of necrotising fasciitis in the UK.
authors.affiliation: Northern Ireland Plastic and Maxillofacial Service, Ulster Hospital, Upper Newtownards Road, Belfast, Northern Ireland BT16 1RH, United Kingdom; Regional Burns Unit, Royal Victoria Hospital, Grosvenor Road, Belfast, Northern Ireland BT12 6BA, United Kingdom. Electronic address: nickhodgins@googlemail.com.
authors.forename: N
authors.initials: N
authors.lastname: Hodgins
authors.affiliation: Northern Ireland Plastic and Maxillofacial Service, Ulster Hospital, Upper Newtownards Road, Belfast, Northern Ireland BT16 1RH, United Kingdom; Regional Burns Unit, Royal Victoria Hospital, Grosvenor Road, Belfast, Northern Ireland BT12 6BA, United Kingdom.
authors.forename: L
authors.initials: L
authors.lastname: Damkat-Thomas
authors.affiliation: Northern Ireland Plastic and Maxillofacial Service, Ulster Hospital, Upper Newtownards Road, Belfast, Northern Ireland BT16 1RH, United Kingdom; Regional Burns Unit, Royal Victoria Hospital, Grosvenor Road, Belfast, Northern Ireland BT12 6BA, United Kingdom.
authors.forename: N
authors.initials: N
authors.lastname: Shamsian
authors.affiliation: Microbiology Department, Ulster Hospital, Upper Newtownards Road, Belfast, Northern Ireland BT16 1RH, United Kingdom.
authors.forename: P
authors.initials: P
authors.lastname: Yew
authors.affiliation: Northern Ireland Plastic and Maxillofacial Service, Ulster Hospital, Upper Newtownards Road, Belfast, Northern Ireland BT16 1RH, United Kingdom.
authors.forename: H
authors.initials: H
authors.lastname: Lewis
authors.affiliation: Regional Burns Unit, Royal Victoria Hospital, Grosvenor Road, Belfast, Northern Ireland BT12 6BA, United Kingdom.
authors.forename: K
authors.initials: K
authors.lastname: Khan
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D015415:Biomarkers / Q000097:blood; D015897:Comorbidity; D003646:Debridement; D019115:Fasciitis, Necrotizing / Q000453:epidemiology* / Q000382:microbiology / Q000601:surgery*; D005260:Female; D006801:Humans; D007773:Lactates / Q000097:blood; D008297:Male; D008875:Middle Aged; D009660:Northern Ireland / Q000453:epidemiology; D015995:Prevalence; D019651:Plastic Surgery Procedures; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D016038:Skin Transplantation; D015996:Survival Rate; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents; D015415:Biomarkers; D007773:Lactates
keywords: Fasciitis; Infection; Necrosis; Necrotising fasciitis; Sepsis