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Cervical Necrotizing Fasciitis Across the COVID-19 Pandemic: A Single-Center Exploratory Retrospective Cohort Study
Marko Tarle1,2, Marina Raguž3,4, Igor Čvrljević1,5
1Department of Maxillofacial and Oral Surgery, Dubrava University Hospital, 10000 Zagreb, Croatia.
Journal of Clinical Medicine
|July 28, 2026
Summary
Cervical necrotizing fasciitis (CNF) incidence increased significantly post-pandemic, associated with distinct immunonutritional profiles and altered microbiology. NPAR and CAR/PNI showed promise as biomarkers for differentiating eras.
Area of Science:
- Infectious Diseases
- Immunology
- Oncology
Background:
- Cervical necrotizing fasciitis (CNF) is a rare, aggressive deep-neck infection.
- A potential rise in CNF incidence post-COVID-19 pandemic noted, with limited understanding of host-response biomarkers.
- Need to investigate if the pandemic/post-pandemic era correlates with increased CNF frequency and altered immunonutritional status.
Purpose of the Study:
- To evaluate the association between the pandemic/post-pandemic era and CNF frequency.
- To characterize the immunonutritional profile of CNF patients during different eras.
- To identify potential biomarkers distinguishing CNF cases based on admission era.
Main Methods:
- Retrospective cohort study at a Croatian tertiary referral center.
- CNF patients grouped into pre-pandemic (2010-2019) and pandemic/post-pandemic (2021-2026) eras.
- Comparison of incidence using Poisson rate ratio (IRR); analysis of classical and albumin-integrated immunonutritional biomarkers (NLR, PLR, LMR, SII, AISI, CAR, NAR, NPAR, PNI, CALLY, CAR/PNI, SIRI/albumin, AISI/albumin).
- Statistical analysis included Mann-Whitney U, Fisher's exact tests, Benjamini-Hochberg FDR correction, and ROC analysis.
Main Results:
- CNF incidence increased 2.6-fold in the pandemic/post-pandemic era (IRR=2.58, p=0.021).
- Higher comorbidity (67% vs 27%) and complication (53% vs 27%) rates observed in the later era.
- NPAR (AUC 0.867) and CAR/PNI (AUC 0.855) demonstrated strong discriminatory performance for era classification.
- Microbiology shifted from predominantly Streptococci (82% to 33%) to include atypical organisms (0% to 20%) exclusively post-pandemic.
Conclusions:
- Post-pandemic CNF cases were more frequent, complex, and exhibited a distinct hypoalbuminemic, hyperinflammatory profile with diversified microbiology.
- NPAR and CAR/PNI emerged as promising exploratory biomarkers for era differentiation in CNF.
- Findings are exploratory, hypothesis-generating, and require prospective multicenter validation; 'era' denotes calendar period, not confirmed SARS-CoV-2 infection.