SLR - March 2023 - Melissa R. Fitzgerald, DPM PGYII
Title: The LRINEC Score—An Indicator for the Course and Prognosis of Necrotizing Fasciitis?Reference : Hoesl V, Kempa S, Prantl L, Ochsenbauer K, Hoesl J, Kehrer A, Bosselmann T. The LRINEC Score-An Indicator for the Course and Prognosis of Necrotizing Fasciitis? J Clinical Medicine. 2022 Jun 22;11(13):3583
Level of Evidence: Level III: Retrospective cohort series
Reviewed By: Melissa R. Fitzgerald, DPM PGYII
Residency Program: St. Elizabeth’s Medical Center Brighton, MA
Podiatric Relevance: This study specifically utilizes The Laboratory Risk Indicator for Necrotizing Fasciitis score (LRINEC) and evaluates its role in early diagnosis of necrotizing fasciitis (NF). The aim of this study was to investigate whether the LRINEC is suitable as a progression and prognosis parameter in patients with necrotizing fasciitis. For podiatric surgeons, necrotizing fasciitis is a rare but life-threatening soft tissue infection that commonly affects the lower extremity, with 62.9% of the study participants experiencing NF of the lower extremities. Early recognition and intervention is paramount to decreasing the mortality of this condition.
Methods: In this study, retrospective data was collected for a total of 70 patients over a 10-year span at a single Level-1 trauma center in Germany. For each patient, the LRINEC score was calculated at hospital admission, and again post-operatively after each subsequent surgical intervention for the first 3 debridements. The authors looked at multiple data points, however the authors’ focus was to evaluate the LRINEC score as a prognostic factor for lethality for NF.
Results: The overall lethality of this cohort was found to be 20 out of 70 patients (28.6%). It was determined that a statistically significant decrease in LRINEC score was found after debridement, with an average of 0.663 LRINEC point decrease per debridement and the largest decrease observed after the initial surgical debridement. As the LRINEC score can be used to measure the severity of sepsis, this result supports the use of surgical debridement to improve the overall condition of the patient. However, it is important to note that although NF was histologically confirmed for each of the included 70 patients, 26 patients (37.1%) had a LRINEC score of less than 6 on admission and would therefore have been considered low risk for presence of NF. Therefore, a cut-off value of a LRINEC score of 7 resulted in an optimal sensitivity (70%) and specificity (60%) to predict lethality in patients with NF.
Conclusion: Overall, the surgical treatment of necrotizing fasciitis is of immense importance. It is important to note that the patients in this study received concurrent treatment involving antibiotic therapy and intensive care measures, and the timing of these variables were not considered in the analysis. The authors concluded that this study was able to illustrate that the lethality of necrotizing fasciitis is still very high despite early recognition and timely surgical intervention. After evaluating this article, I felt that although the lethality significantly decreases after the first surgical debridement, the lethality rate is still significantly high for the podiatric surgeon to face. It is essential that early and consistent detection of NF occurs and that such patients receive timely recognition, treatment, and are often re-evaluated by every member of the medical team. The weight of the lethality rate will always be in the back of my mind as a practicing member of the medical team for these patients, and furthermore as the future surgeon driving the surgical debridement. This article serves as a reminder of the importance of appropriately and thoroughly evaluating each patient and the significance of our medical and surgical decision-making on patient outcomes.