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Prospective derivation and validation of a necrotizing soft tissue infections score: An EASTmulticenter trial
Dennis Y Kim1, Amanda Iavasile, Amy H Kaji
1From the Division of Trauma/Acute Care Surgery/Surgical Critical Care (D.Y.K.), Harbor-UCLA Medical Center, Torrance; Western University of Health Sciences (A.I.), Pomona; Department of Emergency Medicine (A.H.K.), Harbor-UCLA Medical Center, Torrance; Division of Trauma, Burns, Critical Care and Acute Care Surgery, Department of Surgery (J.N.), UCI School of Medicine, Irvine; University of Southern California (A.G.), Los Angeles; Division of Acute Care Surgery (K.M., L.P.), Loma Linda University Medical Center, Loma Linda, California; Division of Trauma and Critical Care (J.P.), Northwestern University Feinberg School of Medicine; Surgical Outcomes and Quality Improvement Center, Department of Surgery (C.D.L.), Northwestern Medicine, Chicago, Illinois; Department of Surgery (E.M., T.S.), Beaumont Health, Dearborn, Michigan; Department of Trauma Research (S.S.), Sanford Health, Sioux Falls, South Dakota; Section of Trauma and General Surgery (K.B.), Northern Light Eastern Maine Medical Center, Portland; College of Osteopathic Medicine (N.S.), University of New England, Biddeford, Maine; Department of Surgery (A.C., R.Z.E.), SUNY Upstate Medical University, Syracuse, New York; Olive View-UCLA Medical Center (D.S., R.P.), Olive View-UCLA Education and Research Institute, Sylmar, California; Department of Surgery (M.T.), and Methodist Health Systems CRI, Methodist Dallas Medical Center (H.G.V.), Dallas, Texas; Division of Trauma (D.H., V.P.), University of Tennessee, Chattanooga, Tennessee; Division of Acute Care Surgery (S.W.R., M.M.M.), Atrium Health Carolinas Medical Center, Wake Forest School of Medicine, Charlotte, North Carolina; Division of Burns, Trauma, Acute and Critical Care Surgery (L.D., K.K.), University of Texas Southwestern Medical Center, Dallas, Texas; Division of Trauma/Acute Care Surgery/Surgical Critical Care (C.J.M., A.L.), Spartanburg Regional Medical Center, Spartanburg, South Carolina; Division of Trauma (G.C., B.L.), Mount Sinai Hospital, Chicago, Illinois; and Department of Surgery (C.d.V.), Harbor-UCLA Medical Center, Torrance, California.
Background:
Although several risk indices have been developed to aid in the diagnosis of necrotizing soft tissue infections (NSTIs), these instruments suffer from varying levels of reproducibility and failure to incorporate key clinical variables in model development. The objective of this study was to derive and validate a clinical risk index score, NECROSIS, for identifying NSTIs in emergency general surgery (EGS) patients being evaluated for severe skin and soft tissue infections.
Methods:
We performed a prospective study across 16 sites in the United States of adult EGS patients with suspected NSTIs over a 30-month period. Variables analyzed included demographics, admission vitals and laboratories, physical examination, radiographic, and operative findings. The main outcome measure was the presence of NSTI diagnosed clinically at the time of surgery. Multivariate analysis was performed to identify independent predictors for the presence of NSTI using the Hosmer-Lemeshow test and the Akaike information criteria.
Results:
Of 362 patients, 297 (82%) were diagnosed with an NSTI. Overall mortality was 12.3%. Multivariate analysis identified three independent predictors for NSTI: systolic blood pressure of ≤120 mm Hg, violaceous skin, and white blood cell count of ≥15 × 10 3 /μL. Multivariate modeling demonstrated Hosmer-Lemeshow goodness of fit ( p = 0.9) with a c statistic for the prediction curve of 0.75. Test characteristics of the NECROSIS score were similar between the derivation and validation cohorts.
Conclusion:
NECROSIS is a simple and potentially useful clinical index score for identifying at-risk EGS patients with NSTIs. Future validation studies are warranted.
Level Of Evidence:
Diagnostic Tests or Criteria; Level III.
