High mortality risk of type III monomicrobial gram-negative necrotizing fasciitis: The role of extraintestinal pathogenic Escherichia coli (ExPEC) and Klebsiella pneumoniae

Nai-Chen Cheng; Yin Cheng; Hao-Chih Tai; Kuo-Liong Chien; Szu-Hui Wang; Yi-Hsuan Chen; Chi-Tai Fang; Po-Ren Hsueh

doi:10.1016/j.ijid.2023.04.390

High mortality risk of type III monomicrobial gram-negative necrotizing fasciitis: The role of extraintestinal pathogenic Escherichia coli (ExPEC) and Klebsiella pneumoniae

Int J Infect Dis. 2023 Jul:132:64-71. doi: 10.1016/j.ijid.2023.04.390. Epub 2023 Apr 13.

Authors

Nai-Chen Cheng¹, Yin Cheng¹, Hao-Chih Tai¹, Kuo-Liong Chien², Szu-Hui Wang³, Yi-Hsuan Chen⁴, Chi-Tai Fang⁵, Po-Ren Hsueh⁶

Affiliations

¹ Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.
² Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.
³ Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.
⁴ Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan; Taiwan Centers for Disease Control, Taipei, Taiwan.
⁵ Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan. Electronic address: fangct@ntu.edu.tw.
⁶ Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Laboratory Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; Departments of Laboratory Medicine and Internal Medicine, China Medical University Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan.

PMID: 37059297
DOI: 10.1016/j.ijid.2023.04.390

Abstract

Objectives: The aim of this study was to investigate the prognostic value of reclassified new type III monomicrobial gram-negative necrotizing fasciitis (NF) and the microbial factors associated with an increased risk of mortality.

Methods: This study included 235 NF cases treated at National Taiwan University Hospital. We compared the mortality risk of NF caused by different causal microorganisms and examined the bacterial virulence genes profile and antimicrobial susceptibility pattern associated with an increase in mortality risk.

Results: Type III NF (n = 68) had a mortality risk two-fold higher than type I (polymicrobial, n = 64) or type II (monomicrobial gram-positive, n = 79) NF (42.6% vs 23.4% or 19.0%, P = 0.019 and 0.002, respectively). Mortality differed by causal microorganism (Escherichia coli [61.5%], Klebsiella pneumoniae [40.0%], Aeromonas hydrophila [37.5%], Vibrio vulnificus [25.0%], polymicrobial [23.4%], group A streptococci [16.7%], and Staphylococcus aureus [16.2%], in decreasing rank, P <0.001). Type III NF caused by E. coli, identified as extraintestinal pathogenic E. coli (ExPEC) via virulence gene analyses, was associated with a particularly high mortality risk (adjusted odds ratio: 6.51, P = 0.003) after adjusting for age and comorbidities. Some (38.5%/7.7%) of the E. coli strains were non-susceptible to third/fourth-generation cephalosporins but remained susceptible to carbapenems.

Conclusion: Type III NF, especially cases caused by E. coli or K. pneumoniae, are associated with a comparatively higher mortality risk than type I or type II NF. Wound gram stain-based rapid diagnosis of type III NF may inform empirical antimicrobial therapy to include a carbapenem.

Keywords: Extraintestinal pathogenic Escherichia coli; Klebsiella pneumoniae; Mortality risk; Necrotizing fasciitis; Necrotoxigenic Escherichia coli.

MeSH terms

Anti-Bacterial Agents / pharmacology
Anti-Bacterial Agents / therapeutic use
Carbapenems / pharmacology
Carbapenems / therapeutic use
Escherichia coli / genetics
Escherichia coli Infections* / microbiology
Extraintestinal Pathogenic Escherichia coli*
Fasciitis, Necrotizing* / diagnosis
Humans
Klebsiella pneumoniae / genetics
Streptococcal Infections* / microbiology

Substances

Carbapenems
Anti-Bacterial Agents