Factors Associated with Mortality and Amputation Caused by Necrotizing Soft Tissue Infections of the Upper Extremity: A Retrospective Cohort Study

Abstract Background It is unclear what the exact short-term outcomes of necrotizing soft tissue infections (NSTIs), also known and necrotizing fasciitis of the upper extremity, are and whether these are comparable to other anatomical regions. Therefore, the aim of this study is to assess factors associated with mortality within 30-days and amputation in patients with upper extremity NSTIs. Methods A retrospective study over a 20-year time period of all patients treated for NSTIs of the upper extremity was carried out. The primary outcomes were the 30-day mortality rate and the amputation rate in patients admitted to the hospital for upper extremity NSTIs. Results Within 20 years, 122 patients with NSTIs of the upper extremity were identified. Thirteen patients (11%) died and 17 patients (14%) underwent amputation. Independent risk factors for mortality were an American Society of Anesthesiologists (ASA) classification of 3 or higher (OR 9.26, 95% CI 1.64–52.31) and a base deficit of 3 meq/L or greater (OR 10.53, 95% CI 1.14–96.98). The independent risk factor for amputation was a NSTI of the non-dominant arm (OR 3.78, 95% CI 1.07–13.35). Length of hospital stay was 15 (IQR 9–21) days. Conclusion Upper extremity NSTIs have a relatively low mortality rate, but a relatively high amputation rate compared to studies assessing NSTIs of all anatomical regions. ASA classification and base deficit at admission predict the prognosis of patients with upper extremity NSTIs, while a NSTI of the non-dominant side is a risk factor for limb loss.

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Necrotizing Soft-Tissue Infections in the Feet of Patients With Diabetes: Outcome of Surgical Treatment and Factors Associated With Limb Loss and Mortality

The International Journal of Lower Extremity Wounds ◽

10.1177/1534734609344106 ◽

2009 ◽

Vol 8 (3) ◽

pp. 141-146 ◽

Cited By ~ 35

Author(s):

Javier Aragón-Sánchez ◽

Yurena Quintana-Marrero ◽

Jose L. Lázaro-Martínez ◽

Maria J. Hernández-Herrero ◽

Esther García-Morales ◽

...

Keyword(s):

Surgical Treatment ◽

Soft Tissue ◽

Limb Loss ◽

Soft Tissue Infections ◽

Factors Associated ◽

Patients With Diabetes ◽

Necrotizing Soft Tissue Infections ◽

Diabetes Outcome

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Predictors of Mortality and Limb Loss in Necrotizing Soft Tissue Infections of the Upper Extremity

The Journal Of Hand Surgery ◽

10.1016/j.jhsa.2009.08.018 ◽

2009 ◽

Vol 34 (10) ◽

pp. 1900-1901 ◽

Cited By ~ 8

Author(s):

Ian R. Sunderland ◽

Jeffrey B. Friedrich

Keyword(s):

Soft Tissue ◽

Upper Extremity ◽

Limb Loss ◽

Soft Tissue Infections ◽

Predictors Of Mortality ◽

Necrotizing Soft Tissue Infections

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Hyperbaric Oxygen Therapy in Patients with Necrotizing Soft Tissue Infections: No Impact on Mortality or Amputation Rate

Journal of Surgical Research ◽

10.1016/j.jss.2011.11.971 ◽

2012 ◽

Vol 172 (2) ◽

pp. 348

Author(s):

P.R. Massey ◽

J.V. Sakran ◽

B. Sarani ◽

C.A. Sims ◽

J.L. Pasucal ◽

...

Keyword(s):

Soft Tissue ◽

Hyperbaric Oxygen ◽

Hyperbaric Oxygen Therapy ◽

Oxygen Therapy ◽

Amputation Rate ◽

Soft Tissue Infections ◽

Necrotizing Soft Tissue Infections

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Advanced Age is Not an Independent Risk Factor for In-Hospital Mortality in Patients with Necrotizing Soft Tissue Infections (NSTI)

Journal of the American College of Surgeons ◽

10.1016/j.jamcollsurg.2019.08.1329 ◽

2019 ◽

Vol 229 (4) ◽

pp. e220

Author(s):

Mahsa Shariat ◽

Sameer Hirji ◽

Manuel Castillo-Angeles ◽

Barbara U. Okafor ◽

Deepika Nehra ◽

...

Keyword(s):

Risk Factor ◽

Soft Tissue ◽

Hospital Mortality ◽

Independent Risk Factor ◽

Advanced Age ◽

Soft Tissue Infections ◽

Necrotizing Soft Tissue Infections

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Advanced Age is Not an Independent Risk Factor for In-Hospital Mortality in Patients with Necrotizing Soft Tissue Infections

Journal of the American College of Surgeons ◽

10.1016/j.jamcollsurg.2019.08.1006 ◽

2019 ◽

Vol 229 (4) ◽

pp. e106

Author(s):

Mahsa Shariat ◽

Sameer Hirji ◽

Manuel Castillo-Angeles ◽

Barbara U. Okafor ◽

Deepika Nehra ◽

...

Keyword(s):

Risk Factor ◽

Soft Tissue ◽

Hospital Mortality ◽

Independent Risk Factor ◽

Advanced Age ◽

Soft Tissue Infections ◽

Necrotizing Soft Tissue Infections

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Risk Factors and Predictors of Mortality in Streptococcal Necrotizing Soft-tissue Infections: A Multicenter Prospective Study

Clinical Infectious Diseases ◽

10.1093/cid/ciaa027 ◽

2020 ◽

Cited By ~ 11

Author(s):

Trond Bruun ◽

Eivind Rath ◽

Martin Bruun Madsen ◽

Oddvar Oppegaard ◽

Michael Nekludov ◽

...

Keyword(s):

Risk Factors ◽

Septic Shock ◽

Soft Tissue ◽

Blunt Trauma ◽

Gene Profiling ◽

Soft Tissue Infections ◽

Lasso Regression ◽

Factors Associated ◽

Necrotizing Soft Tissue Infections ◽

The Impact

Abstract Background Necrotizing soft-tissue infections (NSTI) are life-threatening conditions often caused by β-hemolytic streptococci, group A Streptococcus (GAS) in particular. Optimal treatment is contentious. The INFECT cohort includes the largest set of prospectively enrolled streptococcal NSTI cases to date. Methods From the INFECT cohort of 409 adults admitted with NSTI to 5 clinical centers in Scandinavia, patients culture-positive for GAS or Streptococcus dysgalactiae (SD) were selected. Risk factors were identified by comparison with a cohort of nonnecrotizing streptococcal cellulitis. The impact of baseline factors and treatment on 90-day mortality was explored using Lasso regression. Whole-genome sequencing of bacterial isolates was used for emm typing and virulence gene profiling. Results The 126 GAS NSTI cases and 27 cases caused by SD constituted 31% and 7% of the whole NSTI cohort, respectively. When comparing to nonnecrotizing streptococcal cellulitis, streptococcal NSTI was associated to blunt trauma, absence of preexisting skin lesions, and a lower body mass index. Septic shock was significantly more frequent in GAS (65%) compared to SD (41%) and polymicrobial, nonstreptococcal NSTI (46%). Age, male sex, septic shock, and no administration of intravenous immunoglobulin (IVIG) were among factors associated with 90-day mortality. Predominant emm types were emm1, emm3, and emm28 in GAS and stG62647 in SD. Conclusions Streptococcal NSTI was associated with several risk factors, including blunt trauma. Septic shock was more frequent in NSTI caused by GAS than in cases due to SD. Factors associated with mortality in GAS NSTI included age, septic shock, and no administration of IVIG.

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Time is of the essence when treating necrotizing soft tissue infections: a systematic review and meta-analysis

World Journal of Emergency Surgery ◽

10.1186/s13017-019-0286-6 ◽

2020 ◽

Vol 15 (1) ◽

Cited By ~ 6

Author(s):

Femke Nawijn ◽

Diederik P. J. Smeeing ◽

Roderick M. Houwert ◽

Luke P. H. Leenen ◽

Falco Hietbrink

Keyword(s):

Surgical Treatment ◽

Soft Tissue ◽

Mortality Rate ◽

Meta Analysis ◽

Operating Time ◽

Mortality Rates ◽

Soft Tissue Infections ◽

Included Patient ◽

Necrotizing Soft Tissue Infections ◽

Analysis Models

Abstract Background Although the phrase “time is fascia” is well acknowledged in the case of necrotizing soft tissue infections (NSTIs), solid evidence is lacking. The aim of this study is to review the current literature concerning the timing of surgery in relation to mortality and amputation in patients with NSTIs. Methods A systematic search in PubMed/MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Controlled Register of Trials (CENTRAL) was performed. The primary outcomes were mortality and amputation. These outcomes were related to the following time-related variables: (1) time from onset symptoms to presentation; (2) time from onset symptoms to surgery; (3) time from presentation to surgery; (4) duration of the initial surgical procedure. For the meta-analysis, the effects were estimated using random-effects meta-analysis models. Result A total of 109 studies, with combined 6051 NSTI patients, were included. Of these 6051 NSTI patients, 1277 patients died (21.1%). A total of 33 studies, with combined 2123 NSTI patients, were included for quantitative analysis. Mortality was significantly lower for patients with surgery within 6 h after presentation compared to when treatment was delayed more than 6 h (OR 0.43; 95% CI 0.26–0.70; 10 studies included). Surgical treatment within 6 h resulted in a 19% mortality rate compared to 32% when surgical treatment was delayed over 6 h. Also, surgery within 12 h reduced the mortality compared to surgery after 12 h from presentation (OR 0.41; 95% CI 0.27–0.61; 16 studies included). Patient delay (time from onset of symptoms to presentation or surgery) did not significantly affect the mortality in this study. None of the time-related variables assessed significantly reduced the amputation rate. Three studies reported on the duration of the first surgery. They reported a mean operating time of 78, 81, and 102 min with associated mortality rates of 4, 11.4, and 60%, respectively. Conclusion Average mortality rates reported remained constant (around 20%) over the past 20 years. Early surgical debridement lowers the mortality rate for NSTI with almost 50%. Thus, a sense of urgency is essential in the treatment of NSTI.

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