Necrotising fasciitis of the extremities: implementation of new management technologies.
BACKGROUND
Necrotising fasciitis (NF) is potentially life-threatening soft-tissue infection. Early diagnosis and aggressive surgical debridement are critical to decrease mortality and morbidity. The impacts of new management technologies such as hydro-bisturi-assisted debridement (HAD) and negative pressure wound therapy (NPWT) are not yet clear with respect to treatment of NF. The objective of this study was to describe laboratory (including LRINEC score), clinical and microbiological factors, treatment methods and outcomes related to managing necrotising fasciitis, focusing on the implementation of new treatment methods in our centre.


METHODS
From June 2010 to June 2014, adult patients diagnosed with necrotising fasciitis affecting an upper or lower limb that were admitted to our hospital, a referral tertiary care centre, were eligible to participate in this study. Demographic data, clinical features, location of infection, Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score on the day of admission, microbiology and laboratory results, use of HAD, wound management using NPWT, and patient outcomes were retrospectively analysed. A univariate risk factor analysis was performed, in an attempt to define prognostic factors for mortality.


RESULTS
A total of 20 patients satisfied the inclusion criteria. Type II NF (Group A ß-haemolytic streptococci) was found in 8 cases (40%). The average LRINEC score on the day of admission was 6. The lower extremity was affected in 60% of the cases. All patients were treated operatively, with 2.5 interventions on average. Hydro-bisturi was used in the first debridement in 40% of the cases (8 out 20). In 75% of the studied cases, Negative Pressure Wound Therapy (NPWT) was the technique selected for surgical wound management. The global mortality rate was 30%. On univariate analysis, the only factors significantly associated with mortality were high levels of creatinin (p=0.033) and low blood glucose levels (p=0.012). Finally, four amputations were observed in this series.


CONCLUSIONS
We confirm that necrotising fasciitis (NF) of the extremities, despite new advancements in treatment and critical care management, is still a potentially life-threatening soft-tissue infection (30% mortality). New, advanced wound management modalities have been heavily used in management of necrotising fasciitis, but these have not had significant impacts on morbidity and mortality rates.
Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain. Electronic address: pcorona@vhebron.net.
Pablo S
PS
Corona
Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain.
Frank
F
Erimeiku
Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain.
Maria Mercedes
MM
Reverté-Vinaixa
Paediatric Hand Surgery and Microsurgery Unit, Hospital Sant Joan de Deu, Barcelona, Spain.
Francisco
F
Soldado
Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain.
Carles
C
Amat
Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain.
Lluis
L
Carrera
D000368:Aged; D003646:Debridement / Q000295:instrumentation / Q000379:methods / Q000639:trends; D042241:Early Diagnosis; D005121:Extremities / Q000382:microbiology / Q000473:pathology*; D019115:Fasciitis, Necrotizing / Q000150:complications / Q000382:microbiology / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D054843:Negative-Pressure Wound Therapy; D011379:Prognosis; D012017:Referral and Consultation; D012189:Retrospective Studies; D013030:Spain; D016896:Treatment Outcome
Hydro-bisturi debridement; LRINEC; Lower extremity; Necrotising fasciitis; Negative pressure wound therapy; Upper extremity