Different types of bullae of limbs with necrotizing fasciitis predict different outcome: a prospective study

Abstract

Study objective Necrotizing fasciitis (NF) is an uncommon life-threatening necrotizing skin and soft tissue infection. Bullae are special skin manifestations of NF. This study was conducted to analyze the differences between different types of bullae of limbs with NF for providing the information to emergency treatment. Methods From April 2015 to August 2018, patients were initially enrolled based on surgical confirmation of limbs with NF. According to the presence of different bullae types, patients were divided into no bullae group (Group N), serous-filled bullae group (Group S), and hemorrhagic bullae group (Group H). Data such as demographics, clinical outcomes, microbiological results, presenting symptoms/signs, and laboratory findings were compared among these groups. Results In total, 187 patients were collected, with 111 (59.4%) patients in Group N, 35 (18.7%) in Group S, and 41 (21.9%) in Group H. Group H had the highest incidence of amputation, required intensive care unit care, and most patients infected with Vibrio species. In Group N, more patients were infected with Staphylococcus spp. than Group H. In Group S, more patients were infected with β-hemolytic Streptococcus than Group H. Patients with bacteremia, shock, skin necrosis, anemia, and longer prothrombin time constituted higher proportions in Group H and S than in Group N. Conclusions In southern Taiwan, patients with NF accompanied by hemorrhagic bullae appear to have more bacteremia, Vibrio infection, septic shock, and risk for amputation. If the physicians at the emergency department can detect for the early signs of NF as soon as possible, and more patient’s life and limbs may be saved.

Rational Use of Ceftriaxone in Necrotizing Fasciitis and Mortality Associated with Bloodstream Infection and Hemorrhagic Bullous Lesions

“…Wang et al reported that 68% patients developed hemorrhagic bullae on the fourth day; however, our patients commonly presented with hemorrhagic bullous skin lesions upon arrival to the ER [ 5 ]. Thus, the appearance of hemorrhagic bullae was an important diagnostic criteria for NF in our institution, especially in those patients with Vibrio and Aeromonas infections [ 7 , 8 , 9 , 12 , 13 , 14 , 15 , 16 , 17 , 18 ]. Many of the literature had proved that Gram-negative NF had a significant higher prevalence of bloodstream infections than Gram-positive NF [ 9 , 13 , 14 , 15 , 28 , 29 , 30 , 31 ].…”

“…Thus, the appearance of hemorrhagic bullae was an important diagnostic criteria for NF in our institution, especially in those patients with Vibrio and Aeromonas infections [ 7 , 8 , 9 , 12 , 13 , 14 , 15 , 16 , 17 , 18 ]. Many of the literature had proved that Gram-negative NF had a significant higher prevalence of bloodstream infections than Gram-positive NF [ 9 , 13 , 14 , 15 , 28 , 29 , 30 , 31 ]. In this study, we demonstrated that Gram-negative NF with hemorrhagic bullae presentation and bacteremia was significantly associated with poor prognosis, which should be considered first when patients are revealed to have quickly progressing and fulminant features at the ER.…”

“…NF requires teams to work towards acting swiftly on early suspicions, conducting immediate surgical interventions, and providing aggressive care, which can successfully decrease mortality; therefore, clinical presentations and laboratory risk indicators are more important for the rapid recognition and management of NF [ 7 , 8 , 9 , 12 , 13 , 14 , 15 , 16 , 17 , 18 ]. In this prospective study, we confirmed that NF patients with any two or more indicators, including a presentation of bacteremia, hemorrhagic bullous lesions, shock at first consultation, fever with a body temperature of > 38.5 °C, band forms of > 0%, and segmented forms of ≦ 74%, at the time of the initial consultation in the ER or ward should be assumed to have the Gram-negative infection first, due to being capable of causing more devastating outcomes.…”

“…Patients with necrotizing fasciitis presenting with bacteremia, hemorrhagic bullae, subcutaneous bleeding, purpura, necrosis, and gangrene need to be diagnosed early at the time of presentation in the emergency room. Hemorrhagic bullae is a special skin sign that can be crucial for identifying and recognizing necrotizing fasciitis; moreover, it can even be the cause of devastating consequences [ 5 , 6 , 7 , 8 , 9 ]. The early recognition and diagnosis of NF using skin bullous lesions, purple skin discoloration, hypotension, and elevated laboratory markers can allow for the initiation of proper treatment strategies to decrease mortality rates [ 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 ].…”

Necrotising fascitis - a life-threatening infection: Case reports and literature review

“…Laboratory tests and radiological imaging have a significant place in the prediction of infection severity and treatment outcome [16,17,18]. This is why scoring systems have been developed as predictors of the severity of infection.…”