• Shannon M Fernando, Alexandre Tran, Wei Cheng, Bram Rochwerg, Kwadwo Kyeremanteng, SeelyAndrew J EAJEDivision of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.Department of Surgery, University of Ottawa, Ottawa,, Kenji Inaba, and Jeffrey J Perry.
• Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada.
• Ann. Surg. 2019 Jan 1; 269 (1): 58-65.

ObjectiveWe sought to summarize accuracy of physical examination, imaging, and Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score in diagnosis of necrotizing soft tissue infection (NSTI) in adults with a soft tissue infection clinically concerning for NSTI.Summary Of Background DataNSTI is a life-threatening diagnosis. Delay to diagnosis and surgical management is associated with increased mortality.MethodsWe searched 6 databases from inception through November 2017. We included English-language studies reporting diagnostic accuracy of testing or LRINEC Score. Outcome was NSTI confirmed by surgery or histopathology. Two reviewers screened all citations and extracted data independently. Summary measures were obtained from the Hierarchical Summary Receiver Operating Characteristic model.ResultsFrom 2,290 citations, we included 23 studies (n = 5982). Of physical examination signs, pooled sensitivity and specificity for fever was 46.0% and 77.0% respectively, for hemorrhagic bullae 25.2% and 95.8%, and for hypotension 21.0% and 97.7%. Computed tomography (CT) had sensitivity of 88.5% and specificity of 93.3%, while plain radiography had sensitivity of 48.9% and specificity of 94.0%. Finally, LRINEC ≥ 6 had sensitivity of 68.2% and specificity of 84.8%, while LRINEC ≥ 8 had sensitivity of 40.8% and specificity of 94.9%.ConclusionsAbsence of any 1 physical examination feature (eg, fever or hypotension) is not sufficient to rule-out NSTI. CT is superior to plain radiography. LRINEC had poor sensitivity, and should not be used to rule-out NSTI. Given the poor sensitivity of these tests, a high clinical suspicion warrants early surgical consultation for definitive diagnosis and management.

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