Practice development Innovations


investigated that could be used in conjunction with clinical findings to help make a diagnosis as early as possible[18]


, References


16.McHenry CR, Piotrowski JJ, Petrinic D, Malangoni MA. Determinants of mortality for necrotizing soft-tissue infections. Ann Surg 1995; 221: 558–63; discussion 563–5.


17.Wong CH, Chang HC, Pasupathy S, Khin LW, Tan JL, Low CO. Necrotizing fasciitis: clinical presentation,


microbiology, and determinants of


mortality. J Bone Joint Surg Am 2003; 85: 1454–60.


18.Wong CH, Wang YS. The diagnosis


of necrotizing fasciitis. Curr Opin Infect Dis 2005; 18: 101–6.


19.Yilmazlar T, Ozturk E, Alsoy A, Ozguc H. Necrotizing soft tissue infections: APACHE II Score,


Dissemination, and Survival.World J Surg 2007; 31: 1858–62.


20.Struk DW, Munk PL, Lee MJ, Ho


SG, Worsley DF. Imaging of soft tissue infections. Radiol Clin North Am 2001; 39: 277–305.


21.Wysoki MG, Santora TA, Shah RM,


Friedman AC. Necrotizing fasciitis: CT characteristics. Radiology 1997; 203: 859–63.


22.Becker M, Zbären P, Hermans R,


Becker CD, Marchal F, Kurt AM, Marre’ S, Rüfenacht DA, Terrier F. Necrotizing fasciitis of the head and neck: role of CT in diagnosis and management. Radiology 1997; 202:471–6.


23.Yen ZS, Wang HP, Ma HM, Chen SC, Chen WJ. Ultrasonographic screening of clinically-suspected necrotizing fasciitis. Acad Emerg Med 2002; 9: 1448–51.


24.Majeski J, Majeski E. Necrotizing


fasciitis: improved survival with early recognition by tissue biopsy and


aggressive surgical treatment. South Med J 1997; 90: 1065–8.


25.Stamenkovic I, Lew PD. Early recognition of potentially fatal


necrotizing fasciitis: the use of frozen- section biopsy.N Engl J Med 1984; 310: 1689–93.


26.Marshall JC, Maier RV, Jimenez M, Dellinger EP. Source control in the management of severe sepsis and septic shock: an evidence-based review. Crit Care Med 2004; 32: S513–26.


27.Wong CH, Yam AK, Tan AB, Song C. Approach to debridement in


necrotizing fasciitis. Am J Surg 2008; 196: e19–24.


Figure 2: A40-year-old man who presented with rapidly extending NSTI of the genital and lower abdomen area. Note the fascial necrosis and infection despite normal overlying skin.


including laboratory studies, imaging studies and pathological examination[1]


LABORATORY STUDIES Wall et al[10]


.


n If the score is 5 or less, then the probability of NSTI is low (less than 50%)


n If the score is 6 or 7, then the probability of NSTI is 50–75%


n If the score is 8 or more, then the probability of NSTI is very high (more than 75%).


retrospectively studied the


admission variables for necrotising and non- necrotising infections and reported that a white blood cell count greater than 15,400 x 103


cells/cc, or a serum sodium level less


than 135mmol/L were associated with a necrotising infection. When combined, these two parameters had a very high negative predictive value of 99%, indicating that they are a good tool for ruling out NSTI. However, the positive predictive value was very low (26%) indicating a very low specificity. More recently, a laboratory score was created by Wong et al[17]


to differentiate


between necrotising and non-necrotising infections. Called the 'Laboratory risk indicator for necrotising fasciitis score’ (LRINEC), it identified six independent laboratory variables associated with NSTI and gave each one of them a number of points [Table 1]. The summation of the points gives a score


that ranges between 0–13. Three groups were then identified according to their risk for NSTI:


This tool was found to have a high


positive predictive value (92%) and also a high negative predictive value (96%) for intermediate and high-risk groups[1, 11] Another test, the Acute Physiology, Age


.


and Chronic Health Evaluation (APACHE II) score has been found to be non-specific for NSTI diagnosis, but helpful in predicting the prognosis for people with the infection[9, 19] Yilmazlar et al[19]


. reported that patients who


had an APACHE II score greater than 13 had an 86% mortality rate. All patients who died during the study had an APACHE II score of greater than 20. All of these scores and laboratory


parameters are supposed to aid in diagnosis, but it is important to remember that none of them replace the physical examination and assessment of an expert physician in making an early and accurate diagnosis[9]


.


IMAGING STUDIES X-ray, ultrasound, computerised tomography (CT) scan and magnetic


15


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