Predictors for gram-negative monomicrobial necrotizing fasciitis in southern Taiwan

Abstract

Background: Necrotizing fasciitis (NF) is a rare and life-threatening necrotizing skin and soft-tissue infection. Infectious pathogens of NF must be detected early and treated rapidly to prevent loss of limb or a fatal outcome. This study aimed to detect more reliable predictors between gram-negative and gram-positive monomicrobial NF of limbs. Methods: A total of 100 patients with limb monomicrobial NF were diagnosed prospectively from April 2015 to July 2018. These monomicrobial NF pathogens can be divided into gram-negative and gram-positive groups according to the result of Gram staining and final bacterial reports. Data such as demographics, seawater or seafood contact history, infectious location, comorbidities, presenting signs and symptoms, and laboratory findings were recorded and compared. Results: A total of 55 patients were infected with gram-negative organisms and 45 patients with gram-positive organisms. Among the 55 cases of monomicrobial gram-negative NF, 48 (87.3%) were caused mainly by Vibrio spp. (38, 69.1%) and Aeromonas spp. (10, 18.2%). A higher incidence of chronic kidney disease, cerebrovascular accident, tachypnea, and septic shock; a higher rate of band forms of leukocytes of more than 3%, serum lactate of more than 20 mg/dL, and C-reactive protein level of less than 150 mg/dL; prolonged prothrombin time; and a lower fibrinogen level were observed in patients with gram-negative infection. In a multivariate analysis, a higher incidence of seawater or seafood contact history (odds ratio [OR]: 66.301; 95% confidence interval [CI]: 7.467-588.702), a higher rate of hyperlactatemia (OR: 7.904; 95% CI: 1.231-50.744), and a low fibrinogen level (OR: 1.013; 95% CI: 1.004-1.023) indicated gram-negative infection. Conclusions: In southern Taiwan, NF of limbs mainly affected the lower limbs, exhibited monomicrobial infection, and was predominated by gram-negative bacteria. Gram-negative monomicrobial NF of limbs often occurred in individuals with the more seawater or seafood contact history, hyperlactatemia, and low fibrinogen levels.

Patients with Monomicrobial Aeromonas Necrotizing Fasciitis Had Higher Mortality Rates Than Those of Vibrio vulnificus Infections

“…We have set up the team "Vibrio necrotizing soft tissue infection (NSSTI) Treatment and Research (VTR) Group", which consists of professional staff working in various departments, including emergency medicine, orthopedic surgery, infectious diseases, intensive care unit (ICU), plastic surgery, and hyperbaric oxygen treatment center. Our team has successfully decreased the mortality rate of Vibrio NF from 38-13% (4,(10)(11)(12)(13)(14)(16)(17)(18)(19). However, we observed that the patients with monmicrobial necrotizing fasciitis caused by Aeromonas hydrophila and Aeromonas sobria still had the highest mortality rates up to 50% even we performed early diagnosis and immediately surgical interventions (4,12,14,16).…”

“…Monomicrobial gram-negative necrotizing fasciitis had been reported to have more fulminant clinical cources and higher motality than gram-positive necrotizing fasciitis in the past decade (4)(5)(6)(7)(8)(9)(10)(11). Vibrio vulnificus, Aeromonas hydrophila, and Klebsiella pneumoniae were the most frequently reported gram-negative aerobic pathogens of necrotizing fasciitis in southwest Taiwan (4, 8, 10-21).…”

“…Recent literatures revealed that monomicrobial necrotizing fasciitis caused by gram-negative pathogens, such as Vibrio vulnificus, Klebsiella pneumoniae, Aeromonas hydrophila, Pseudomonas spp. and Escherichia coli, could cause fulminant clinical courses and fatal syndrome (4)(5)(6)(7)(8)(9)(10)(11)(12).…”

“…Nearly fifty patients with necrotizing fasciitis are admitted to our institution annually, and Vibrio vulnificus are the most frequent causative organism of monmicrobial necrotizing fasciitis (4,(10)(11)(12)(13)(14)16). We have set up the team "Vibrio necrotizing soft tissue infection (NSSTI) Treatment and Research (VTR) Group", which consists of professional staff working in various departments, including emergency medicine, orthopedic surgery, infectious diseases, intensive care unit (ICU), plastic surgery, and hyperbaric oxygen treatment center.…”

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

“…Monomicrobial infection was diagnosed by isolating single pathogenic bacteria, and polymicrobial infections were diagnosed by isolating more than one pathogenic bacterium from soft tissue lesions and/or blood collected immediately after the patient’s arrival at the ED or during surgery [ 13 , 24 , 31 ].…”