Multifocal Necrotizing Fasciitis Linked to Higher ICU Burden

Key Takeaways

• In adults treated at a German trauma center, multifocal necrotizing fasciitis was uncommon and usually presented with synchronous non-contiguous sites.
• Compared with monofocal disease, multifocal necrotizing fasciitis was associated with greater ICU use and more frequent organ-support needs.
• Multifocal disease also tracked with longer ICU and hospital courses and a heavier operative burden.
• Admission LRINEC scores were similar across groups despite higher creatinine and lower glucose in multifocal disease.

Necrotizing fasciitis usually presents in one anatomic region, but some patients present with or soon develop separate non-contiguous foci during the same disease episode. For emergency and acute surgical teams, that pattern can complicate the initial examination and may understate the critical-care and operative burden that follows.

Methodology A retrospective cohort at a German level-one trauma center, reported in the Keßler et al. cohort study of multifocal versus monofocal necrotizing fasciitis, reviewed adults treated for necrotizing fasciitis and classified disease as multifocal when more than one non-contiguous anatomic site was involved without contiguous spread during the same episode. The comparison covered admission Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) scores, microbiology, organ dysfunction, intensive care unit (ICU) course, operative burden, and in-hospital mortality, and the authors described the analyses as exploratory and descriptive.

Results Multifocal necrotizing fasciitis occurred in 5/47 patients (10.6%). Four of five multifocal cases were synchronous, and one developed a second non-contiguous focus after 4 days. Admission LRINEC scores were similar across groups, although creatinine was higher and glucose was lower in multifocal disease.

ICU admission was 100% in multifocal disease versus 57.1% in monofocal disease, with median ICU stays of 17.0 [12.0-31.0] and 1.0 [0.0-5.0] days, respectively. Mechanical ventilation, septic shock, hemodynamic failure, and renal replacement therapy were also more frequent in the multifocal subgroup.

The median number of debridements was 8.0 [8.0-8.0] in multifocal disease versus 5.0 [3.0-7.0] in monofocal disease, and hospital stay and total operations were also higher in the multifocal group. Presumed injection- or intravenous-access-related portals of entry and intravenous drug use were more common among multifocal cases, while type I and type II infections predominated in both groups and Streptococcus pyogenes was the most commonly identified pathogen overall.

In-hospital mortality was 0/5 in multifocal disease versus 11/42 (26.2%) in monofocal disease, although the authors explicitly cautioned against between-group inference from that contrast.

Limitations and Implications Because this was an exploratory single-center German cohort with a very small multifocal subgroup and no multivariable adjustment or multiple-testing correction, the findings are hypothesis-generating rather than practice-defining. Even so, the combination of similar admission LRINEC scores and substantially greater critical-care and operative burden suggests that additional non-contiguous foci may not be apparent from admission scoring alone.

Conclusions In this center's experience, multifocal necrotizing fasciitis was marked less by a clear mortality signal than by heavier intensive care and surgical use. The non-U.S. setting should be kept in mind, but the report supports careful reassessment for additional non-contiguous sites when disease severity seems out of proportion to the initial presentation.

Clinician Questions

How did the German cohort define multifocal necrotizing fasciitis?

In the German trauma-center cohort, multifocal necrotizing fasciitis was defined as involvement of more than one non-contiguous anatomical site without contiguous spread during the same disease episode. Investigators described cases as synchronous when additional foci were present at admission or appeared within hours, and as metachronous when a second non-contiguous focus emerged later in the same episode.

What did the cohort suggest about LRINEC in multifocal necrotizing fasciitis?

In this cohort, admission LRINEC scores were similar in multifocal and monofocal necrotizing fasciitis and did not clearly track with the greater ICU burden seen in multifocal disease. Creatinine was higher and glucose was lower in multifocal necrotizing fasciitis, indicating that the laboratory pattern was not captured by LRINEC alone.

What portal-of-entry pattern was reported in multifocal necrotizing fasciitis at this trauma center?

At this German trauma center, presumed injection- or IV-access-related portals of entry and intravenous drug use were more common among patients with multifocal necrotizing fasciitis, while comorbidities were otherwise broadly similar between groups. The authors said the pattern was compatible with heterogeneous mechanisms, including repeated local inoculation and possible hematogenous spread, rather than proving a single pathway.

Which microbiology pattern was reported in multifocal necrotizing fasciitis in this cohort?

In this cohort, type I and type II necrotizing fasciitis predominated in both multifocal and monofocal disease, with type II disease more frequent in multifocal cases, and Streptococcus pyogenes was the most commonly identified pathogen overall. The authors noted that the pathogen spectrum in this German cohort differed from marine Gram-negative patterns reported elsewhere, without presenting that comparison as evidence for a single cause of multifocal disease.