Necrotizing Fasciitis: Treatment Concepts & Clinical Outcomes – An Institutional Experience.

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Ajay Raveendranadh, S S Prasad, Vivek Viswanath This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4026886/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Oct, 2024 Read the published version in BMC Surgery → Version 1 posted 8 You are reading this latest preprint version Abstract BACKGROUND: A severe infection of the skin and soft tissues, necrotizing fasciitis (NF), spreads quickly along the deep fascia. This study aimed to characterize the clinicopathological features and analyze the bacteria implicated in antibiotic sensitivity, surgical management, and diagnostic accuracy of the Laboratory risk indicator for Necrotizing Fasciitis (LRINEC) score for Necrotizing Soft Tissue Infection (NSTI) METHODS: This single-center prospective observational study was conducted in the Department of General Surgery, Kasturba Medical College, Manipal, with 171 proven cases of NSTI between 2019 and 2021. Clinico-demographic data and laboratory investigation values were collected at two time points (at admission and 72 hours after admission). Imaging data, LRINEC score, culture results, and antibiotic sensitivity were recorded. Appropriate descriptive and analytical statistics were used for the statistical analysis. RESULTS: Of the 171 patients, 150 were male (87.7%). The mean age was 57.6 ± 13.1 years. The presenting features in all the cases were pain, swelling, and fever. Diabetes mellitus (DM) is the most common comorbidity. The lower extremities were the most commonly affected sites. Streptococcus pyogenes showed significant growth in 25.41% of the samples. Ceftriaxone sensitivity was seen in 41/141. A score of ≥ 8 was obtained n 118/171 (69%) patients, suggesting a higher severity and significant risk for NSTI. The Area Under the Curve of Receiver Operating characteristic Curve (ROC) for establishing diagnostic accuracy for LRINEC was 0.694. Mortality was significantly higher in the patients with higher LRINEC scores and elevated procalcitonin. The mortality rate was higher in patients who underwent surgery within 12 hours. CONCLUSION: Necrotizing fasciitis is a soft tissue infection with a high mortality rate. The clinical features and determinants of mortality in patients with NF are highlighted in this study. At the outset, a high index of suspicion was critical. Using prognostic evaluation techniques in daily clinical practice will assist medical professionals in providing adequate on-time care and significantly lowering mortality. Delay in surgical intervention after admission is one of the most important determinants of mortality and morbidity. LRINEC necrotizing fasciitis NSTI procalcitonin Figures Figure 1 Figure 2 INTRODUCTION Necrotizing soft tissue infection (NSTI) is a unique, deadly, life-threatening disease that mostly destroys the fascial layer, deeper subcutaneous tissue, and sometimes even muscles[ 1 ]. Hippocrates described a clinical case of necrotizing fasciitis, a consequence of erysipelas disease, around 500 BC. This description is similar to the modern understanding of NF[ 2 ]. According to reports, the prevalence of NSTI is 0.40 cases per 100,000 people worldwide, and its yearly incidence is predicted to be between 500 and 1,000 cases. Middle-aged and older individuals are frequently affected by this condition. A 3:1 male-to-female ratio indicates a preponderance in men; this ratio is primarily associated with a higher incidence of Fournier's gangrene in men[ 3 ]. The development of NF is linked to the combined effects of the host's specific characteristics and bacterial virulence factors. Various bacteria, toxins, and enzymes produced play a role in promoting the spread of infection and necrosis[ 4 ]. The prognosis is worse in the presence of coexisting conditions, including diabetes mellitus, immunodeficiency disorders, cirrhosis of the liver, or renal failure[ 5 ]. Although facultative anaerobic and aerobic organisms can induce NSTI, polymicrobial bacteria are the most common cause. Therefore, it is essential to diagnose NF immediately. Given its link to more extensive surgery, greater rates of amputation, and higher fatality rates, any delay might prove catastrophic. In addition, infection may cause systemic inflammatory response syndrome (SIRS) if treatment is not administered. Local pain, swelling, and erythema are the classic triad of symptoms that patients with NSTI typically present with. The most common abnormalities in vital signs were fever and tachycardia (> 100 beats/min), followed by hypotension (SBP 20/min). Skin erythema and these abnormalities are most helpful in differentiating NF from other soft tissue infections. The infected site exhibits tenderness, sclerosis, skin necrosis, and hemorrhagic bullae[ 6 , 7 ]. Under these conditions, laboratory findings are often non-specific. Nonetheless, specific test results can assist physicians to distinguish NSTI from other skin conditions. One such example is the LRINEC proposed by Wong et al.[ 8 ]. In addition to providing early disease detection, this score can aid patient categorization into risk groups and the distribution of diagnostic resources. Plain radiography can reveal the presence of gas within soft tissues despite having limited sensitivity and specificity. Compared with typical radiography, CT and MRI are more specific and sensitive. The degree of gas formation, inflammation, tissue edema, and tissue infection may all be observed on CT scans. Although MRIs is more expensive than CT, it provides more precision. Another practical alternative is ultrasonography, which can help determine the type and severity of infection, particularly in cases where the diagnosis is not entirely clear [ 9 , 10 ]. Successful treatment requires a multidisciplinary approach to intensive care, with active fluid replacement and sepsis management, rigorous surgical debridement, and broad systemic antibiotic drugs[ 11 ]. A comprehensive literature review found a lack of information regarding NSTI in patients from India. In a tertiary center in southern Karnataka, this study aims to characterize the clinicopathological features and analyze the bacteria implicated in the antibiotic sensitivity, surgical management, and diagnostic accuracy of the LRINEC score in NSTI. MATERIALS AND METHODS This single-center prospective observational study was conducted at the Department of General Surgery, Kasturba Medical College, Manipal, between December 2019 and September 2021. The study commenced after obtaining approval from the Institutional Ethics Committee (659/2019), and written informed consent was obtained from all patients. Patients with clinically diagnosed NSTI who were hospitalized or discharged against the institute's recommendations met the inclusion criteria. Two surgeons made the diagnosis. If there was a discrepancy, a third independent surgeon was deemed to have made the diagnosis. Before surgery, an emergency radiograph of the affected region was taken for each patient. Clinical data, including a detailed history, clinical examination findings, and laboratory investigation values, were collected at two time points: one at the time of admission and the other 72 hours after admission. Imaging data, LRINEC score, culture, and antibiotic sensitivity; data on surgical management, including a number of debridements, amputations (if any), and reconstructive surgeries were collected, and duration of hospitalization was recorded. Patients were categorized as having a low (points ≤ 5; 75% probability for presence of NSTI) of NSTI based on the results of six laboratory tests (C-reactive protein, total white blood cell count, Hemoglobin, Sodium level, serum creatinine, and glucose level). This score should encourage early detection and distinguish it from other serious soft tissue infections that require alternative treatment approaches[ 12 ]. Emergency surgical debridement was planned for all patients. A daily dressing was applied to the wound until reconstructive surgery was performed. Pus and tissue samples were sent for culture sensitivity. All patients were started on injectable amoxicillin clavulanate, metronidazole, and amikacin, and were switched to empirical broad-spectrum antibiotics that were focused on the culture. Supportive therapy, such as blood product transfusion, blood sugar management, nutritional support, and fluid and electrolyte balance maintenance, was administered when necessary. In certain instances, resuscitation with intravenous fluids and colloids is required. Statistical analysis: Statistical analysis was performed using IBM SPSS (Statistical Package for Social Sciences) version 20. The analysis included a frequency table, bar, pie chart, and association of variables based on the Chi-square test, and if any cell frequency was < 5, Fisher’s exact test was used (for higher order than 2 × 2 table). All quantitative variables were estimated using mean ± SD and median (interquartile range). All statistical tests were seen at a two-tailed significance level of p < 0.05. RESULTS This study included all patients who satisfied the eligibility criteria during the study period. A total of 171 adult patients with a mean age of 57.6 ± 13.1 years and a majority (55%) of patients aged 51–70 years with a male: female ratio of 50:7. Clinical characteristics included signs and symptoms at the site of involvement and the vitals observed. Other clinicopathological tables have listed in Table 1 . Table 1 Clinico-demographic details of patients with NSTI (N = 171) Variable Observation Gender distribution [n(%)] Male 150 (87.7%) Female 21 (12.3%) Age distribution [n(%)] 70 years 24 (14%) Distribution of comorbidities [n(%)] Diabetes mellitus 99 (57.9%) Hypertension 76 (44.4%) Ischemic heart disease 12 (7.01%) Chronic liver disease 7 (4.09%) Peripheral occlusive arterial disease 3 (1.75%) Site of involvement [n(%)] Left foot 24 (14%) Right foot 16 (9.4%) Left leg 24 (14%) Right leg 28 (16.4%) Left lower limb 29 (17%) Right lower limb 29 (17%) Scrotum 16 (9.4%) Right and left upper limb 5 (3%) Presenting symptoms [n(%)] Pain 171 (100%) Swelling 168 (98.2%) Fever 90 (52.6%) Signs at presentation [n(%)] Erythema/ discolouration 171 (100%) Soft-tissue oedema 170 (99.4%) Bullae 158 (92.4%) Vital signs on examination [n(%)] Pulse rate ≥ 90 beats/minute 70 (40.9%) Hypotension Systolic blood pressure < 90 mmHg 10 (5.8%) Afebrile ( 20/min) 68 (39.8%) There were four cases in total when a culture swab was submitted to a patient. In total, 324 culture samples were collected during the study. A total of 181 of the 324 samples sent indicated microbial growth. Significant growth (25.41%) was observed for S. pyogenes. One of our study's patients showed anaerobic growth of Bacteroides fragilis and Pepto-streptococcus anaerobius. Figure 1 depicts the microbiological profiles of the patients are shown in Fig. 1 . Of 181 positive wound culture growths, 141 showed antibiotic sensitivity. Ceftriaxone sensitivity was seen in 41/141 (29.1%) patients, whereas amoxicillin-clavulanic acid sensitivity was seen in of 30/141 (21.3%) patients. Amikacin 13/141 (9.2%), Sulphamethoxole-Trimethoprin 14/141 (9.9%), and Ciprofloxacin 24/141 (17.02%) were among the other antibiotics tested. Teicoplanin was observed in five cases, and Piperacillin-Tazobactam and Clindamycin were observed in six cases. Meropenem (3/141), gentamycin (2/141), Tinidazole, and Metronidazole sensitivity were observed in a single patient. 72 patients (42.1%) underwent radiography of the affected region at admission. Since CT scans delay primary surgical care, none of the patients underwent this procedure. Of the 72 patients who underwent X-ray imaging, 71 (98.6%) had gas shadows and soft tissue edema visible on the images. Procalcitonin levels were checked in 108 of the 171 patients with NSTI diagnoses at the time of admission. Of these, 97/108 (89.8%) received a positive result (> 0.5ng), signifying sepsis and necessitating a blood culture for specific antibiotic treatment. 11/108 (10.2%) had a low procalcitonin level (< 0.5ng). On admission, the LRINEC score was determined for each patient. A score ≥ 8 was obtained in 118/171 (69%) patients, suggesting a higher severity of the condition and a significant risk for NSTI. Seventeen (9.9%) patients had a score ≤ 5, while 36/171 (21.1%) had score between 6–7. We constructed ROC curves to establish a suitable threshold for the diagnostic accuracy of the LRINEC score in the NSTI (Fig. 2 ). The Area Under the Curve was 0.694 (sensitivity: 95.7%; specificity: 77.6%). Thus, the area under the curve (AUC) was significantly greater than 0.5, which can be considered accurate for diagnosis. The surgical details are presented in Table 2 . Of the 171 patients included in our study, 169 underwent debridement at the time of admission. 96 patients underwent definitive surgery involving reconstruction and amputation. Table 2 Surgical description of the study population (N = 171) Variable Observation Debridement carried out [n(%)] Debridement done 169 (98.9%) Debridement not done 2 (1.2%) Number of debridement [n(%)] No debridement (due to death) 2 (1.2%) One debridement 87 (50.9%) Two debridement 62 (36.3%) Three debridement 18 (10.5%) Four debridement 2 (1.2%) Time taken for surgical debridement [n(%)] Median [IQR] time taken for initial debridement (in hours) 12 [6–48] hours Less than 6 hours 18 (10.5%) 6–12 hours 59 (34.5%) 12–24 hours 8 (4.7%) More than 24 hours 84 (49.1%) Definitive surgery [N = 96] [n(%)] Skin graft 45 (26.3%) Secondary suturing 13 (7.6%) Ray amputation 13 (7.6%) Above knee amputation 9 (5.3%) Below knee amputation 16 (9.4%) Duration of hospital stay [n(%)] Less than 7 days 52 (30.4%) 7–15 days 55 (32.2%) 15–30 days 48 (28.1%) More than 30 days 16 (9.4%) Of the 171 patients diagnosed with NSTI, 143/171 (83.6%) had full recovery and were allowed to go home. 28/171 (16.4%) of the patients had succumbed to death. The association between the LRINEC score and various parameters was assessed. The study found that the higher the LRINEC score, the statistical increase in mortality was noted on a chi-square test (p = 0.04). Hence, a cutoff of ≥ 6 had a high sensitivity of 95.7% in predicting mortality. Elevated procalcitonin levels also had a higher mortality (p = 0.031) in the chi-square test. However, no statistical association was noted between the number of days of hospitalization (p = 0.755) and the type of definitive surgery opted for (p = 0.14). With the objective of finding an association between mortality and surgical variables, 87.1% of the patients who underwent surgery recovered well, which was statistically significant (p = 0.008). Furthermore, 82.1% of them who had undergone surgery in less than 12 h recovered well; this association was found to be statistically significant (p = 0.005). DISCUSSION NSTI are rare, life-threatening diseases associated with high mortality and morbidity. The association between high morbidity and mortality urges the need for early diagnosis and identification of potential risk factors for worse outcomes. In the present study, we attempted to enumerate the clinical findings, demographics, and comorbidities of patients with NSTI. The study involved 171 patients diagnosed with NSTI at our institution over a 21-month period. There were 150 (87.7%) male patients, indicating male preponderance. Uncontrolled DM remains a predisposing factor in approximately 40–60% of cases in published data[ 13 ]. In the current study, approximately 57.1% of patients had poorly controlled diabetes. The most common comorbidity among patients with NF is diabetes mellitus, which is associated with longer hospital stays and higher death rates. Individuals with a history of diabetes mellitus showed a rapid increase in both mortality and NF severity. The hyperglycemic state may partially explain this result, which impairs immunity and promotes bacterial proliferation. The other prevalent comorbidity in this study was hypotension, which may result in reduced antimicrobial delivery, tissue oxygenation, and disruption of the microvascular supply[ 14 ]. The classic and frequent manifestations associated with NF usually include pain, tender local swelling, and fever. Of the 171 patients, all presented with pain, 168 (98.2%) with limb edema, and 90 (52.6%) with fever. Other clinical features included erythema in 171 patients, soft-tissue edema in 170 (99.4%), bullae in 158 (92.4%), hypotension in 101 (59.1%), and tachycardia in 161 (94.2%) patients. Goh et al. showed that 88% of the patients had edema, 79% had pain, and 77% had erythema when they first presented clinically. Due to the non-specific nature of these traits, over 75% of the patients had an initial misdiagnosis[ 6 ]. The clinical value of bacterial examination in the management of infections is substantial. Anaerobic and aerobic bacterial infections are typical sources of NSTI. The present study highlighted that the most common organisms isolated were Streptococcus pyogenes (25.4%), Klebsiella pneumoniae (14.3%), and E. Coli (11.6%), which were the predominant gram-negative microorganisms. Wong et al. found that the most frequent cause (53.9%) was polymicrobial synergistic infection, with Enterobacteriaceae and streptococci being the most frequently isolated microorganisms. Monomicrobial NSTI were mostly caused by group A Streptococcus[ 15 ]. Unfortunately, the first stage of NSTI is frequently masked by non-specific manifestations, which prevents effective and timely specific therapy. Consequently, it is crucial to identify and diagnose patients as soon as possible and not depend solely on clinical symptoms. Seventy-two patients underwent X-ray imaging of the afflicted region; of these, 71 (98.6%) exhibited gas shadows and soft tissue edema, indicating a conclusive diagnosis of NSTI. Of the 171 patients included in our study, 169 (98.9%) underwent surgical debridement. The patients underwent surgery after the initial evaluation and resuscitation. NSTI requires complex therapy consisting of early and repeated surgical debridement, broad-spectrum antimicrobial drugs, and intensive care treatment. 77 (45.5%) patients underwent surgical debridement within 12 hours. 92 patients underwent debridement after 12h, mostly due to logistical delays and the need for optimization of patients who were quite sick before surgery. These data suggest that early surgical intervention is crucial in reducing morbidity and mortality in patients with NSTIs. There still needs to be a clear definition of how early we should be. Kobayashi et al. reported significantly lower mortality in the early intervention group (within 12h after diagnosis)[ 16 ]. Elliot and colleagues demonstrated in a group of 198 patients that survivors experienced a reduced duration between admission and first debridement (1·2 versus 3·1 day)[ 17 ]. Similarly, in a group of 89 patients, Wong et al. demonstrated that a delay of > 24h prior to surgery was associated with a higher death rate (relative risk 9·4; p < 0·05)[ 15 ]. NSTIs are rare, but rapidly progressive and potentially lethal bacterial diseases. In our study, 143 (83.6%) patients recovered from the debilitating disease and were discharged home, and 28 (16.4%) patients died. Mortality was significantly lower in patients who underwent early surgical debridement than in those with a delay in surgical treatment (41% vs. 58%, p ≤ 0.005). Elliot et al. reported a mortality rate of 25.3% in 198 patients[ 17 ]. A retrospective study conducted in Thailand by Khamnaun et al. included 1,504 patients with a 19.3% death rate [ 18 ]. The LRINEC score was calculated for all the patients at the time of admission. Among the 171 patients, 154 (90%) had an LRINEC score of ≥ 6. At an LRINEC cutoff score of 6, the model had a sensitivity of 95.7%. In a study conducted by Wong et al. at an LRINEC score cutoff of 6, the model had a positive predictive value of 92.0%[ 15 ]. The AUC in the ROC for our model was 0.694 (95% confidence interval 0.584–0.804) in this study. The curve represents the relationship between the corresponding values of sensitivity and specificity with all possible values of probabilities as a cutoff point to predict the presence of an NSTI. The limitations of this study include its single-center design, limited sample size, and lack of sample size estimation. To obtain more precise statistics, multicenter research and an increase in sample size should be conducted. There was no comparison of the therapeutic effects in this study, nor was there a control group. We were unable to compare the therapeutic results with alternative treatment modalities; instead, we could only objectively summarize the early characteristics and causal aspects of NSTI and disease therapy. CONCLUSION Necrotizing fasciitis is a soft tissue infection with a high mortality rate. This study addressed the clinical characteristics and mortality predictors of patients with NSTIs. The LRINEC score and increased procalcitonin level were risk factors for death in patients with NSTI. Individuals who underwent surgery within 12 hours showed good recovery rates, indicating statistical significance. To minimize morbidity and death, individuals who exhibit any clinical predictors should focus on the disease course and may be subjected to early investigations or careful observation. Furthermore, early diagnosis and prevention of adverse events are the main goals of healthcare promotion. Declarations Ethics Approval and consent to participate: Kasturba Medical College and Kasturba Hospital Institutional Ethics Committee – 659/2019 Consent for publication: Consent from all research participants was taken before publication. Availability of data and material: The data supporting this study's findings are available upon request from the corresponding author (AR). The data are not publicly available because they contain information that could compromise the privacy of research participants. Competing interest: The authors declare no conflicts of interest. Author contributions: AR and PS conceived and designed the study, conducted the research, provided research materials, and collected and organized the data. AR and VV analysed and interpreted the data. All authors critically reviewed and approved the final draft and were responsible for the content and similarity index of the manuscript. Source of funding: This study did not receive specific grant s from public, commercial, or not-for-profit funding agencies. References Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A. Current concepts in the management of necrotizing fasciitis. Front Surg. 2014;1:36. 10.3389/fsurg.2014.00036 . Descamps V, Aitken J, Lee MG. Hippocrates on necrotizing fasciitis. Lancet. 1994;344(8921):556. 10.1016/s0140-6736(94)91956-9 . Levine EG, Manders SM. Life-threatening necrotizing fasciitis. Clin Dermatol. 2005 Mar-Apr;23(2):144–7. 10.1016/j.clindermatol.2004.06.014 . Morgan MS. Diagnosis and management of necrotizing fasciitis: a multiparametric approach. J Hosp Infect. 2010;75(4):249–57. 10.1016/j.jhin.2010.01.028 . Roje Z, Roje Z, Matić D, Librenjak D, Dokuzović S, Varvodić J. Necrotizing fasciitis: literature review of contemporary strategies for diagnosing and management with three case reports: torso, abdominal wall, upper and lower limbs. 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Cite Share Download PDF Status: Published Journal Publication published 28 Oct, 2024 Read the published version in BMC Surgery → Version 1 posted Editorial decision: Revision requested 02 May, 2024 Reviews received at journal 02 May, 2024 Reviewers agreed at journal 22 Apr, 2024 Reviewers invited by journal 20 Apr, 2024 Editor assigned by journal 20 Apr, 2024 Editor invited by journal 08 Mar, 2024 Submission checks completed at journal 08 Mar, 2024 First submitted to journal 07 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4026886","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":278131844,"identity":"d7dfa1d9-ced5-4fa5-ac08-8915d0fadcd4","order_by":0,"name":"Ajay Raveendranadh","email":"data:image/png;base64,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","orcid":"","institution":"Kasturba Medical College, Manipal Academy of Higher Education","correspondingAuthor":true,"prefix":"","firstName":"Ajay","middleName":"","lastName":"Raveendranadh","suffix":""},{"id":278131845,"identity":"8aa9d3d6-40eb-4da9-b71a-904557433a7b","order_by":1,"name":"S S Prasad","email":"","orcid":"","institution":"Kasturba Medical College, Manipal Academy of Higher Education","correspondingAuthor":false,"prefix":"","firstName":"S","middleName":"S","lastName":"Prasad","suffix":""},{"id":278131846,"identity":"fcdac23f-d2d9-41e5-8ecd-c05b71ee1603","order_by":2,"name":"Vivek Viswanath","email":"","orcid":"","institution":"Kasturba Medical College, Manipal Academy of Higher Education","correspondingAuthor":false,"prefix":"","firstName":"Vivek","middleName":"","lastName":"Viswanath","suffix":""}],"badges":[],"createdAt":"2024-03-07 15:04:37","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4026886/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4026886/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12893-024-02638-2","type":"published","date":"2024-10-28T15:57:25+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":52537335,"identity":"85a01eb9-ea89-4157-858c-1fcc13e23d4f","added_by":"auto","created_at":"2024-03-12 16:44:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":30218,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMicrobial profile in patients with NSTI (N=181 positive growth samples)\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4026886/v1/929ee9c9ae4433a224102444.png"},{"id":52537336,"identity":"ee64a489-55af-4d3f-a1c1-dac77ab09987","added_by":"auto","created_at":"2024-03-12 16:44:15","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":48048,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eReceiver operating characteristic (ROC) curves for LRINEC for predicting NSTI.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4026886/v1/a424c561f71cb7be44d3cf42.png"},{"id":68207047,"identity":"4c878327-6092-42dd-b48c-6df42e938217","added_by":"auto","created_at":"2024-11-04 16:34:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":487542,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4026886/v1/037908f8-c161-42aa-bfd4-c085a92ce503.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eNecrotizing Fasciitis: Treatment Concepts \u0026amp; Clinical Outcomes – An Institutional Experience.\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eNecrotizing soft tissue infection (NSTI) is a unique, deadly, life-threatening disease that mostly destroys the fascial layer, deeper subcutaneous tissue, and sometimes even muscles[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Hippocrates described a clinical case of necrotizing fasciitis, a consequence of erysipelas disease, around 500 BC. This description is similar to the modern understanding of NF[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. According to reports, the prevalence of NSTI is 0.40 cases per 100,000 people worldwide, and its yearly incidence is predicted to be between 500 and 1,000 cases. Middle-aged and older individuals are frequently affected by this condition. A 3:1 male-to-female ratio indicates a preponderance in men; this ratio is primarily associated with a higher incidence of Fournier's gangrene in men[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe development of NF is linked to the combined effects of the host's specific characteristics and bacterial virulence factors. Various bacteria, toxins, and enzymes produced play a role in promoting the spread of infection and necrosis[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The prognosis is worse in the presence of coexisting conditions, including diabetes mellitus, immunodeficiency disorders, cirrhosis of the liver, or renal failure[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Although facultative anaerobic and aerobic organisms can induce NSTI, polymicrobial bacteria are the most common cause.\u003c/p\u003e \u003cp\u003eTherefore, it is essential to diagnose NF immediately. Given its link to more extensive surgery, greater rates of amputation, and higher fatality rates, any delay might prove catastrophic. In addition, infection may cause systemic inflammatory response syndrome (SIRS) if treatment is not administered. Local pain, swelling, and erythema are the classic triad of symptoms that patients with NSTI typically present with. The most common abnormalities in vital signs were fever and tachycardia (\u0026gt;\u0026thinsp;100 beats/min), followed by hypotension (SBP\u0026thinsp;\u0026lt;\u0026thinsp;100 mmHg) and tachypnea (\u0026gt;\u0026thinsp;20/min). Skin erythema and these abnormalities are most helpful in differentiating NF from other soft tissue infections. The infected site exhibits tenderness, sclerosis, skin necrosis, and hemorrhagic bullae[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUnder these conditions, laboratory findings are often non-specific. Nonetheless, specific test results can assist physicians to distinguish NSTI from other skin conditions. One such example is the LRINEC proposed by Wong et al.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In addition to providing early disease detection, this score can aid patient categorization into risk groups and the distribution of diagnostic resources. Plain radiography can reveal the presence of gas within soft tissues despite having limited sensitivity and specificity. Compared with typical radiography, CT and MRI are more specific and sensitive. The degree of gas formation, inflammation, tissue edema, and tissue infection may all be observed on CT scans. Although MRIs is more expensive than CT, it provides more precision. Another practical alternative is ultrasonography, which can help determine the type and severity of infection, particularly in cases where the diagnosis is not entirely clear [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Successful treatment requires a multidisciplinary approach to intensive care, with active fluid replacement and sepsis management, rigorous surgical debridement, and broad systemic antibiotic drugs[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA comprehensive literature review found a lack of information regarding NSTI in patients from India. In a tertiary center in southern Karnataka, this study aims to characterize the clinicopathological features and analyze the bacteria implicated in the antibiotic sensitivity, surgical management, and diagnostic accuracy of the LRINEC score in NSTI.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003eThis single-center prospective observational study was conducted at the Department of General Surgery, Kasturba Medical College, Manipal, between December 2019 and September 2021. The study commenced after obtaining approval from the Institutional Ethics Committee (659/2019), and written informed consent was obtained from all patients.\u003c/p\u003e \u003cp\u003ePatients with clinically diagnosed NSTI who were hospitalized or discharged against the institute's recommendations met the inclusion criteria. Two surgeons made the diagnosis. If there was a discrepancy, a third independent surgeon was deemed to have made the diagnosis. Before surgery, an emergency radiograph of the affected region was taken for each patient. Clinical data, including a detailed history, clinical examination findings, and laboratory investigation values, were collected at two time points: one at the time of admission and the other 72 hours after admission. Imaging data, LRINEC score, culture, and antibiotic sensitivity; data on surgical management, including a number of debridements, amputations (if any), and reconstructive surgeries were collected, and duration of hospitalization was recorded. Patients were categorized as having a low (points\u0026thinsp;\u0026le;\u0026thinsp;5; \u0026lt;50% probability for the presence of NSTI), medium (Points 6\u0026ndash;7; 50\u0026ndash;75% probability for presence of NSTI), or high risk (points\u0026thinsp;\u0026ge;\u0026thinsp;8; \u0026gt;75% probability for presence of NSTI) of NSTI based on the results of six laboratory tests (C-reactive protein, total white blood cell count, Hemoglobin, Sodium level, serum creatinine, and glucose level). This score should encourage early detection and distinguish it from other serious soft tissue infections that require alternative treatment approaches[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEmergency surgical debridement was planned for all patients. A daily dressing was applied to the wound until reconstructive surgery was performed. Pus and tissue samples were sent for culture sensitivity. All patients were started on injectable amoxicillin clavulanate, metronidazole, and amikacin, and were switched to empirical broad-spectrum antibiotics that were focused on the culture. Supportive therapy, such as blood product transfusion, blood sugar management, nutritional support, and fluid and electrolyte balance maintenance, was administered when necessary. In certain instances, resuscitation with intravenous fluids and colloids is required.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis:\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed using IBM SPSS (Statistical Package for Social Sciences) version 20. The analysis included a frequency table, bar, pie chart, and association of variables based on the Chi-square test, and if any cell frequency was \u0026lt;\u0026thinsp;5, Fisher\u0026rsquo;s exact test was used (for higher order than 2 \u0026times; 2 table). All quantitative variables were estimated using mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD and median (interquartile range). All statistical tests were seen at a two-tailed significance level of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThis study included all patients who satisfied the eligibility criteria during the study period. A total of 171 adult patients with a mean age of 57.6\u0026thinsp;\u0026plusmn;\u0026thinsp;13.1 years and a majority (55%) of patients aged 51\u0026ndash;70 years with a male: female ratio of 50:7. Clinical characteristics included signs and symptoms at the site of involvement and the vitals observed. Other clinicopathological tables have listed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinico-demographic details of patients with NSTI (N\u0026thinsp;=\u0026thinsp;171)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObservation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eGender distribution [n(%)]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e150 (87.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (12.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAge distribution [n(%)]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;30 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (4.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e31\u0026ndash;50 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (26.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e51\u0026ndash;70 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94 (55%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;70 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (14%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDistribution of comorbidities [n(%)]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e99 (57.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76 (44.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIschemic heart disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (7.01%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic liver disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (4.09%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeripheral occlusive arterial disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1.75%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSite of involvement [n(%)]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft foot\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (14%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight foot\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (9.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft leg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (14%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight leg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (16.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft lower limb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (17%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight lower limb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (17%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScrotum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (9.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight and left upper limb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePresenting symptoms [n(%)]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e171 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSwelling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e168 (98.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90 (52.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSigns at presentation [n(%)]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eErythema/ discolouration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e171 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSoft-tissue oedema\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e170 (99.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBullae\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e158 (92.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVital signs on examination [n(%)]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulse rate\u0026thinsp;\u0026ge;\u0026thinsp;90 beats/minute\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70 (40.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypotension Systolic blood pressure\u0026thinsp;\u0026lt;\u0026thinsp;90 mmHg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (5.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfebrile (\u0026lt;\u0026thinsp;38.0\u0026deg;C)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e157 (91.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTachypnoea (\u0026gt;\u0026thinsp;20/min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68 (39.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThere were four cases in total when a culture swab was submitted to a patient. In total, 324 culture samples were collected during the study. A total of 181 of the 324 samples sent indicated microbial growth. Significant growth (25.41%) was observed for S. pyogenes. One of our study's patients showed anaerobic growth of Bacteroides fragilis and Pepto-streptococcus anaerobius. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e depicts the microbiological profiles of the patients are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Of 181 positive wound culture growths, 141 showed antibiotic sensitivity. Ceftriaxone sensitivity was seen in 41/141 (29.1%) patients, whereas amoxicillin-clavulanic acid sensitivity was seen in of 30/141 (21.3%) patients. Amikacin 13/141 (9.2%), Sulphamethoxole-Trimethoprin 14/141 (9.9%), and Ciprofloxacin 24/141 (17.02%) were among the other antibiotics tested. Teicoplanin was observed in five cases, and Piperacillin-Tazobactam and Clindamycin were observed in six cases. Meropenem (3/141), gentamycin (2/141), Tinidazole, and Metronidazole sensitivity were observed in a single patient.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e72 patients (42.1%) underwent radiography of the affected region at admission. Since CT scans delay primary surgical care, none of the patients underwent this procedure. Of the 72 patients who underwent X-ray imaging, 71 (98.6%) had gas shadows and soft tissue edema visible on the images. Procalcitonin levels were checked in 108 of the 171 patients with NSTI diagnoses at the time of admission. Of these, 97/108 (89.8%) received a positive result (\u0026gt;\u0026thinsp;0.5ng), signifying sepsis and necessitating a blood culture for specific antibiotic treatment. 11/108 (10.2%) had a low procalcitonin level (\u0026lt;\u0026thinsp;0.5ng).\u003c/p\u003e \u003cp\u003eOn admission, the LRINEC score was determined for each patient. A score\u0026thinsp;\u0026ge;\u0026thinsp;8 was obtained in 118/171 (69%) patients, suggesting a higher severity of the condition and a significant risk for NSTI. Seventeen (9.9%) patients had a score\u0026thinsp;\u0026le;\u0026thinsp;5, while 36/171 (21.1%) had score between 6\u0026ndash;7. We constructed ROC curves to establish a suitable threshold for the diagnostic accuracy of the LRINEC score in the NSTI (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The Area Under the Curve was 0.694 (sensitivity: 95.7%; specificity: 77.6%). Thus, the area under the curve (AUC) was significantly greater than 0.5, which can be considered accurate for diagnosis.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe surgical details are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Of the 171 patients included in our study, 169 underwent debridement at the time of admission. 96 patients underwent definitive surgery involving reconstruction and amputation.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSurgical description of the study population (N\u0026thinsp;=\u0026thinsp;171)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObservation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDebridement carried out [n(%)]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDebridement done\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e169 (98.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDebridement not done\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eNumber of debridement [n(%)]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo debridement (due to death)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOne debridement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87 (50.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTwo debridement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62 (36.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThree debridement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (10.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFour debridement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eTime taken for surgical debridement [n(%)]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian [IQR] time taken for initial debridement (in hours)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 [6\u0026ndash;48] hours\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess than 6 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (10.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;12 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59 (34.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u0026ndash;24 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (4.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore than 24 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84 (49.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDefinitive surgery [N\u0026thinsp;=\u0026thinsp;96] [n(%)]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkin graft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (26.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary suturing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (7.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRay amputation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (7.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbove knee amputation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (5.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBelow knee amputation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (9.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDuration of hospital stay [n(%)]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess than 7 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52 (30.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u0026ndash;15 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (32.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u0026ndash;30 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (28.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore than 30 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (9.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOf the 171 patients diagnosed with NSTI, 143/171 (83.6%) had full recovery and were allowed to go home. 28/171 (16.4%) of the patients had succumbed to death.\u003c/p\u003e \u003cp\u003eThe association between the LRINEC score and various parameters was assessed. The study found that the higher the LRINEC score, the statistical increase in mortality was noted on a chi-square test (p\u0026thinsp;=\u0026thinsp;0.04). Hence, a cutoff of \u0026ge;\u0026thinsp;6 had a high sensitivity of 95.7% in predicting mortality. Elevated procalcitonin levels also had a higher mortality (p\u0026thinsp;=\u0026thinsp;0.031) in the chi-square test. However, no statistical association was noted between the number of days of hospitalization (p\u0026thinsp;=\u0026thinsp;0.755) and the type of definitive surgery opted for (p\u0026thinsp;=\u0026thinsp;0.14). With the objective of finding an association between mortality and surgical variables, 87.1% of the patients who underwent surgery recovered well, which was statistically significant (p\u0026thinsp;=\u0026thinsp;0.008). Furthermore, 82.1% of them who had undergone surgery in less than 12 h recovered well; this association was found to be statistically significant (p\u0026thinsp;=\u0026thinsp;0.005).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eNSTI are rare, life-threatening diseases associated with high mortality and morbidity. The association between high morbidity and mortality urges the need for early diagnosis and identification of potential risk factors for worse outcomes. In the present study, we attempted to enumerate the clinical findings, demographics, and comorbidities of patients with NSTI.\u003c/p\u003e \u003cp\u003eThe study involved 171 patients diagnosed with NSTI at our institution over a 21-month period. There were 150 (87.7%) male patients, indicating male preponderance.\u003c/p\u003e \u003cp\u003eUncontrolled DM remains a predisposing factor in approximately 40\u0026ndash;60% of cases in published data[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In the current study, approximately 57.1% of patients had poorly controlled diabetes. The most common comorbidity among patients with NF is diabetes mellitus, which is associated with longer hospital stays and higher death rates. Individuals with a history of diabetes mellitus showed a rapid increase in both mortality and NF severity. The hyperglycemic state may partially explain this result, which impairs immunity and promotes bacterial proliferation. The other prevalent comorbidity in this study was hypotension, which may result in reduced antimicrobial delivery, tissue oxygenation, and disruption of the microvascular supply[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe classic and frequent manifestations associated with NF usually include pain, tender local swelling, and fever. Of the 171 patients, all presented with pain, 168 (98.2%) with limb edema, and 90 (52.6%) with fever. Other clinical features included erythema in 171 patients, soft-tissue edema in 170 (99.4%), bullae in 158 (92.4%), hypotension in 101 (59.1%), and tachycardia in 161 (94.2%) patients. Goh et al. showed that 88% of the patients had edema, 79% had pain, and 77% had erythema when they first presented clinically. Due to the non-specific nature of these traits, over 75% of the patients had an initial misdiagnosis[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe clinical value of bacterial examination in the management of infections is substantial. Anaerobic and aerobic bacterial infections are typical sources of NSTI. The present study highlighted that the most common organisms isolated were Streptococcus pyogenes (25.4%), Klebsiella pneumoniae (14.3%), and E. Coli (11.6%), which were the predominant gram-negative microorganisms. Wong et al. found that the most frequent cause (53.9%) was polymicrobial synergistic infection, with Enterobacteriaceae and streptococci being the most frequently isolated microorganisms. Monomicrobial NSTI were mostly caused by group A Streptococcus[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUnfortunately, the first stage of NSTI is frequently masked by non-specific manifestations, which prevents effective and timely specific therapy. Consequently, it is crucial to identify and diagnose patients as soon as possible and not depend solely on clinical symptoms. Seventy-two patients underwent X-ray imaging of the afflicted region; of these, 71 (98.6%) exhibited gas shadows and soft tissue edema, indicating a conclusive diagnosis of NSTI.\u003c/p\u003e \u003cp\u003eOf the 171 patients included in our study, 169 (98.9%) underwent surgical debridement. The patients underwent surgery after the initial evaluation and resuscitation. NSTI requires complex therapy consisting of early and repeated surgical debridement, broad-spectrum antimicrobial drugs, and intensive care treatment. 77 (45.5%) patients underwent surgical debridement within 12 hours. 92 patients underwent debridement after 12h, mostly due to logistical delays and the need for optimization of patients who were quite sick before surgery. These data suggest that early surgical intervention is crucial in reducing morbidity and mortality in patients with NSTIs. There still needs to be a clear definition of how early we should be. Kobayashi et al. reported significantly lower mortality in the early intervention group (within 12h after diagnosis)[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Elliot and colleagues demonstrated in a group of 198 patients that survivors experienced a reduced duration between admission and first debridement (1\u0026middot;2 versus 3\u0026middot;1 day)[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Similarly, in a group of 89 patients, Wong et al. demonstrated that a delay of \u0026gt;\u0026thinsp;24h prior to surgery was associated with a higher death rate (relative risk 9\u0026middot;4; p\u0026thinsp;\u0026lt;\u0026thinsp;0\u0026middot;05)[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNSTIs are rare, but rapidly progressive and potentially lethal bacterial diseases. In our study, 143 (83.6%) patients recovered from the debilitating disease and were discharged home, and 28 (16.4%) patients died. Mortality was significantly lower in patients who underwent early surgical debridement than in those with a delay in surgical treatment (41% vs. 58%, p\u0026thinsp;\u0026le;\u0026thinsp;0.005). Elliot et al. reported a mortality rate of 25.3% in 198 patients[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. A retrospective study conducted in Thailand by Khamnaun et al. included 1,504 patients with a 19.3% death rate [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe LRINEC score was calculated for all the patients at the time of admission. Among the 171 patients, 154 (90%) had an LRINEC score of \u0026ge;\u0026thinsp;6. At an LRINEC cutoff score of 6, the model had a sensitivity of 95.7%. In a study conducted by Wong et al. at an LRINEC score cutoff of 6, the model had a positive predictive value of 92.0%[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The AUC in the ROC for our model was 0.694 (95% confidence interval 0.584\u0026ndash;0.804) in this study. The curve represents the relationship between the corresponding values of sensitivity and specificity with all possible values of probabilities as a cutoff point to predict the presence of an NSTI.\u003c/p\u003e \u003cp\u003eThe limitations of this study include its single-center design, limited sample size, and lack of sample size estimation. To obtain more precise statistics, multicenter research and an increase in sample size should be conducted. There was no comparison of the therapeutic effects in this study, nor was there a control group. We were unable to compare the therapeutic results with alternative treatment modalities; instead, we could only objectively summarize the early characteristics and causal aspects of NSTI and disease therapy.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eNecrotizing fasciitis is a soft tissue infection with a high mortality rate. This study addressed the clinical characteristics and mortality predictors of patients with NSTIs. The LRINEC score and increased procalcitonin level were risk factors for death in patients with NSTI. Individuals who underwent surgery within 12 hours showed good recovery rates, indicating statistical significance. To minimize morbidity and death, individuals who exhibit any clinical predictors should focus on the disease course and may be subjected to early investigations or careful observation. Furthermore, early diagnosis and prevention of adverse events are the main goals of healthcare promotion.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and consent to participate:\u0026nbsp;\u003c/strong\u003eKasturba Medical College and Kasturba Hospital Institutional Ethics Committee \u0026ndash; 659/2019\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eConsent from all research participants was taken before publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material:\u0026nbsp;\u003c/strong\u003eThe data supporting this study\u0026apos;s findings are available upon request from the corresponding author (AR). The data are not publicly available because they contain information that could compromise the privacy of research\u0026nbsp;participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest:\u003c/strong\u003e The authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u003c/strong\u003e AR and PS conceived and designed the study, conducted the research, provided research materials, and collected and organized\u0026nbsp;the data. AR and VV analysed and interpreted the data. \u0026nbsp;All authors\u0026nbsp;critically reviewed and approved the final draft and were responsible for the content and similarity index of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSource of funding:\u0026nbsp;\u003c/strong\u003eThis study did not receive specific grant\u003cins cite=\"mailto:Paperpal\" datetime=\"2024-03-06T15:50\"\u003es\u003c/ins\u003e from public, commercial, or not-for-profit funding agencies.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMisiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A. Current concepts in the management of necrotizing fasciitis. 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J Trauma. 2011;71(5):1400\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/TA.0b013e31820db8fd\u003c/span\u003e\u003cspan address=\"10.1097/TA.0b013e31820db8fd\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElliott DC, Kufera JA, Myers RA. Necrotizing soft tissue infections. Risk factors for mortality and strategies for management. Ann Surg. 1996;224(5):672\u0026ndash;83. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/00000658-199611000-00011\u003c/span\u003e\u003cspan address=\"10.1097/00000658-199611000-00011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhamnuan P, Chongruksut W, Jearwattanakanok K, et al. Necrotizing fasciitis: risk factors of mortality. Risk Manag Healthc Policy. 2015;8:1\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2147/RMHP.S77691\u003c/span\u003e\u003cspan address=\"10.2147/RMHP.S77691\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"LRINEC, necrotizing fasciitis, NSTI, procalcitonin","lastPublishedDoi":"10.21203/rs.3.rs-4026886/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4026886/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBACKGROUND:\u003c/h2\u003e \u003cp\u003eA severe infection of the skin and soft tissues, necrotizing fasciitis (NF), spreads quickly along the deep fascia. This study aimed to characterize the clinicopathological features and analyze the bacteria implicated in antibiotic sensitivity, surgical management, and diagnostic accuracy of the Laboratory risk indicator for Necrotizing Fasciitis (LRINEC) score for Necrotizing Soft Tissue Infection (NSTI)\u003c/p\u003e\u003ch2\u003eMETHODS:\u003c/h2\u003e \u003cp\u003eThis single-center prospective observational study was conducted in the Department of General Surgery, Kasturba Medical College, Manipal, with 171 proven cases of NSTI between 2019 and 2021. Clinico-demographic data and laboratory investigation values were collected at two time points (at admission and 72 hours after admission). Imaging data, LRINEC score, culture results, and antibiotic sensitivity were recorded. Appropriate descriptive and analytical statistics were used for the statistical analysis.\u003c/p\u003e\u003ch2\u003eRESULTS:\u003c/h2\u003e \u003cp\u003eOf the 171 patients, 150 were male (87.7%). The mean age was 57.6\u0026thinsp;\u0026plusmn;\u0026thinsp;13.1 years. The presenting features in all the cases were pain, swelling, and fever. Diabetes mellitus (DM) is the most common comorbidity. The lower extremities were the most commonly affected sites. Streptococcus pyogenes showed significant growth in 25.41% of the samples. Ceftriaxone sensitivity was seen in 41/141. A score of \u0026ge;\u0026thinsp;8 was obtained n 118/171 (69%) patients, suggesting a higher severity and significant risk for NSTI. The Area Under the Curve of Receiver Operating characteristic Curve (ROC) for establishing diagnostic accuracy for LRINEC was 0.694. Mortality was significantly higher in the patients with higher LRINEC scores and elevated procalcitonin. The mortality rate was higher in patients who underwent surgery within 12 hours.\u003c/p\u003e\u003ch2\u003eCONCLUSION:\u003c/h2\u003e \u003cp\u003eNecrotizing fasciitis is a soft tissue infection with a high mortality rate. The clinical features and determinants of mortality in patients with NF are highlighted in this study. At the outset, a high index of suspicion was critical. Using prognostic evaluation techniques in daily clinical practice will assist medical professionals in providing adequate on-time care and significantly lowering mortality. Delay in surgical intervention after admission is one of the most important determinants of mortality and morbidity.\u003c/p\u003e","manuscriptTitle":"Necrotizing Fasciitis: Treatment Concepts \u0026amp; Clinical Outcomes – An Institutional Experience.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-12 16:44:11","doi":"10.21203/rs.3.rs-4026886/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-02T15:34:13+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-02T15:00:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"dc1e6482-7d45-4262-a236-a6f6f3970adc","date":"2024-04-22T04:39:33+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-04-20T05:19:48+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-20T04:47:38+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-03-08T06:58:26+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-08T06:46:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2024-03-07T14:51:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3a49d4c4-4c81-40eb-96ea-c103c9e75f0c","owner":[],"postedDate":"March 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-11-04T16:24:40+00:00","versionOfRecord":{"articleIdentity":"rs-4026886","link":"https://doi.org/10.1186/s12893-024-02638-2","journal":{"identity":"bmc-surgery","isVorOnly":false,"title":"BMC Surgery"},"publishedOn":"2024-10-28 15:57:25","publishedOnDateReadable":"October 28th, 2024"},"versionCreatedAt":"2024-03-12 16:44:11","video":"","vorDoi":"10.1186/s12893-024-02638-2","vorDoiUrl":"https://doi.org/10.1186/s12893-024-02638-2","workflowStages":[]},"version":"v1","identity":"rs-4026886","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4026886","identity":"rs-4026886","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}