Bacteriology and mortality of necrotizing fasciitis in a tertiary coastal hospital with comparing risk indicators of methicillin-resistant Staphylococcus aureus and Vibrio vulnificus infections: a prospective study

Abstract

Background Vibrio vulnificus has been reported as the leading causative pathogen of necrotizing fasciitis (NF) and related fatality in the coastal area. Necrotizing fasciitis caused by methicillin-resistant Staphylococcus aureus (MRSA) and V. vulnificus have high mortality rates. The purpose of this prospective study was to clarify the clinical characteristics between death and survival NF patients, to investigate bacteriologic profile and mortality of NF patients, and to compare risk indicators of MRSA and V. vulnificus NF patients. Methods This prospective study was conducted in 184 consecutive NF patients over a period of three years in a tertiary coastal hospital. Differences in mortality, laboratory findings, microbiology and clinical outcomes were compared between the death and survival groups, and the V. vulnificus and MRSA subgroups. Results Twenty patients died, resulting in a mortality rate of 10.9%, and there were 108 patients with a monomicrobial infection (58.7%). The death group had a significantly higher incidence of shock at emergency room and bacteremia than did the survival group. Vibrio species (40 cases) and S. aureus (31 cases) were the two major pathogens. Significant differences with respect to hepatic dysfunction, shock, the event with seawater or seafood contact, bacteremia, C-reactive protein, mean platelet counts, and the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score were observes between V. vulnificus and MRSA groups. Conclusions NF patients with both hepatic dysfunction and diabetes mellitus, bacteremia and shock have significantly higher mortality. We should be aware of the increasing incidence of monomicrobial NF and higher mortality rates of Gram-negative pathogens in the warm coastal area. LRINEC score is not a suitable diagnostic indicator for V. vulnificus NF, which is more rapidly progressive and fulminant than MRSA NF. NF needed team works by early suspicion, immediate surgical intervention and aggressive care, which can successfully decrease mortality.

In-hospital mortality associated with necrotizing soft tissue infection due to Vibrio vulnificus: a matched-pair cohort study

“…In our study, in-hospital mortality among patients with V. vulnificus NSTI was 13.3%. Previous studies have reported vulnificus NSTI mortality around 10–13% [ 9 , 15 ], which is comparable to our results. Mortality from NSTI caused by gram-negative or monomicrobial pathogen has been reported to be higher than caused by other pathogens.…”

“…Tsai et.al conducted a study about NSTI patients with V. vulnificus and methicillin-resistant Staphylococcus aureus (MRSA). The incidence of bacteremia was 65% vs 18.75%; V. vulnificus group was also higher than MRSA group [ 9 ]. Immune-compromised and chronic liver disease (chronic hepatitis, liver cirrhosis, and hepatocellular carcinoma) patients with V. vulnificus are more likely to develop blood stream infections [ 6 , 18 , 19 ].…”

“…The RTX toxin may promote the colonization at the primary infection site and cause severe tissue damage by releasing degrading cytotoxins to induce the inflammatory responses, that Vibrio vulnificus can then spread to the blood stream to result in systemic manifestations. Both VVP and VvsA are produced in the interstitial tissues of limbs and cause serious collagenolytic, hemorrhagic, or edematous skin damage in the extremities [ 9 , 20 – 23 ]. The specific toxin of V. vulnificus may explain a relatively higher rate of blood steam infection than other pathogens.…”

“…Mortality from NSTI caused by gram-negative pathogens has been reported to be higher than caused by other pathogens in warm costal area [ 9 ]; however, it remains unclear whether mortality from V. vulnificus NSTI is higher than mortality from non- Vibrio NSTI. Only a few studies have compared mortality between V. vulnificus NSTI and non- Vibrio NSTI; one showed that the clinical features of V. vulnificus infection were more rapidly progressive and fulminant than those of the methicillin-resistant Staphylococcus aureus (MRSA) or MSSA infection [ 10 ], whereas another showed that the laboratory risk indicator for necrotizing fasciitis (LRINEC) score was inaccurate in necrotizing fasciitis caused by V. vulnificus.…”

Cervical Necrotizing Fasciitis: An Uncommon Fulminant Disease Entity

“…They also found that Vibrio vulnificus infection is more rapidly progressing and fulminant than MRSA in causing necrotizing fasciitis. [37] Hsiao et al in 2007 suggested that Aeromonas and Vibrio infection, cancer, hypotension and band form white blood cell count greater than 10% are independent positive predictors while presence of hemorrhagic bullae is an independent negative predictor of mortality in necrotizing fasciitis. [38] Predisposing factors Immuno-compromised individuals are more susceptible to necrotizing fasciitis as compared to healthy individuals.…”