#Etiology, characteristics, and #outcomes of community-onset #necrotizing #fasciitis in #Korea: A multicenter study (PLoS One, abstract)

[Source: PLoS One, full page: (LINK). Abstract, edited.]


Etiology, characteristics, and outcomes of community-onset necrotizing fasciitis in Korea: A multicenter study

Tark Kim, Seong Yeon Park, Yee Gyung Kwak, Jiwon Jung, Min-Chul Kim, Seong-Ho Choi, Shi Nae Yu, Hyo-Lim Hong, Yong Kyun Kim, Se Yoon Park, Eun Hee Song, Ki-Ho Park, Oh Hyun Cho, Sang-Ho Choi , the Korean SSTI Study Group

Published: June 20, 2019 / DOI: https://doi.org/10.1371/journal.pone.0218668




Necrotizing fasciitis (NF) is a serious skin and soft tissue infection causing high mortality. Investigating region specific epidemiologic factors associated with NF is important for establishing appropriate treatment strategies. This multicenter study was done to provide an update of the microbial etiology, clinical characteristics, and outcomes of NF in Korea.

Materials and methods

A retrospective cohort of adult patients with NF was established using patient data from 13 general hospitals between January 2012 and December 2015 in Korea. We evaluated microbial etiology and clinical characteristics to identify risk factors associated with in-hospital mortality; analyses were performed using binary logistic regression models.


A total of 161 patients with NF were included. The most common underlying disease was diabetes mellitus (66 cases, 41.0%). A total of 148 organisms were isolated from 119 (73.9%) patients. Enteric Gram-negative organisms (36 patients) were the most common pathogen, followed by Staphylococcus aureus (30 patients) and streptococci (28 patients). Methicillin-resistant Staphylococcus aureus (MRSA) was identified in 6.2% (10/161) of patients. Of 37 enteric Gram-negative isolates tested, 26 (70.3%) isolates were susceptible to ceftriaxone. The in-hospital mortality rate was 22.4%. Intensive care unit admission, septic shock, and Gram-negative organism infections were significantly associated with in-hospital mortality, and surgery was not a favorable prognostic factor.


As initial empirical antibiotics, glycopeptides against MRSA and broad-spectrum antibiotics against third-generation cephalosporin-resistant organisms should be considered for patients with community-onset NF in Korea.


Citation: Kim T, Park SY, Kwak YG, Jung J, Kim M-C, Choi S-H, et al. (2019) Etiology, characteristics, and outcomes of community-onset necrotizing fasciitis in Korea: A multicenter study. PLoS ONE 14(6): e0218668. https://doi.org/10.1371/journal.pone.0218668

Editor: Marc O. Siegel, George Washington University, UNITED STATES

Received: December 30, 2018; Accepted: June 6, 2019; Published: June 20, 2019

Copyright: © 2019 Kim et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: TK received the Soonchunhyang University Research Fund. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Keywords: Necrotizing fasciitis; Staphylococcus aureus; Antibiotics; MRSA; S. Korea.


Human #streptococcal necrotizing #fasciitis #histopathology mirrored in a murine model (Am J Pathol., abstract)

[Source: American Journal of Pathology, full page: (LINK). Abstract, edited.]

Human streptococcal necrotizing fasciitis histopathology mirrored in a murine model

Nadia Keller, Federica Andreoni, Claudine Reiber, Helga Luethi-Schaller, Reto Andreas Schuepbach, Holger Moch, Ewerton Marques Maggio, Annelies Sophie Zinkernagel

DOI: https://doi.org/10.1016/j.ajpath.2018.03.009

Publication History: Published online: April 20, 2018 – Accepted: March 26, 2018 – Received in revised form: March 13, 2018 – Received: November 28, 2017



Streptococcal necrotizing fasciitis (NF) causes high morbidity and mortality despite state-of-the-art therapy. Low incidence and rapid disease progression, necessitating immediate initiation of therapy, have proven challenging aspects for setting up prospective randomized trials. This has resulted in little therapeutic progress over the last decade. The validation of reliable murine NF models to study both pathogenesis and optimized therapeutic regimens of streptococcal NF are thus essential. In this study, we characterized a murine NF model and compared the pathology to an in-depth tissue analysis of streptococcal NF in patients. We found that the streptococcal murine NF model closely reflected all histological characteristics encountered in human streptococcal NF. This murine NF model helps understanding human NF pathology better in a time-dependent manner and will allow studying novel therapeutic options in the future.

Funding: Supported by Swiss National Science Foundation SNSF grant no. 310030_146295/1 (A.S.Z.) and PZ00P3_136639 (R.A.S.).

Disclosures: None declared.

Footnote: N.K., F.A., and C.R. contributed equally and E.M.M. and A.S.Z. contributed equally as senior authors.



We thank Pia Fuchs, Susanne Dettwiler, and Fabiola Prutek for excellent technical help.

N.K., F.A., R.A.S., H.M., and A.S.Z. designed research studies. N.K. and A.S.Z. conducted mouse experiments. H.L.S. conducted FISH experiments. N.K., F.A., and A.S.Z. acquired and interpreted data. N.K., F.A., C.R., E.M.M., and A.S.Z. interpreted histology data. C.R. and E.M.M. organized patient data and histology. N.K., F.A., and A.S.Z. wrote the manuscript. C.R., H.L.S., R.A.S., H.M., and E.M.M. critically read the manuscript.

© 2018 Published by Elsevier Inc. on behalf of the American Society for Investigative Pathology.

Keywords: Streptococcus Pneumoniae; Necrotising Fasciitis.


Necrotising #fasciitis as atypical presentation of #infection with emerging #Neisseria meningitidis serogroup W (#MenW) clonal complex 11, the #Netherlands, March 2017 (@eurosurveillanc, abstract)

[Source: Eurosurveillance, full page: (LINK). Abstract, edited.]

Eurosurveillance, Volume 22, Issue 23, 08 June 2017  / Rapid communication

Necrotising fasciitis as atypical presentation of infection with emerging Neisseria meningitidis serogroup W (MenW) clonal complex 11, the Netherlands, March 2017

A Russcher 1 , E Fanoy 2 3 , GD van Olden 4 , AD Graafland 5 , A van der Ende 6 , MJ Knol 3

Author affiliations: 1. Department of Medical Microbiology, Meander Medical Centre, Amersfoort, the Netherlands; 2. Public Health Service Region Utrecht, Zeist, the Netherlands; 3. Centre for Infectious Diseases Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands; 4. Department of Surgery, Meander Medical Centre, Amersfoort, the Netherlands; 5. Department of Intensive Care, Meander Medical Centre, Amersfoort, the Netherlands; 6. Department of Medical Microbiology and the Netherlands Reference Laboratory for Bacterial Meningitis, Academic Medical Center, Amsterdam, the Netherlands

Correspondence: Anne Russcher (a.russcher@meandermc.nl)

Citation style for this article: Russcher A, Fanoy E, van Olden GD, Graafland AD, van der Ende A, Knol MJ. Necrotising fasciitis as atypical presentation of infection with emerging Neisseria meningitidis serogroup W (MenW) clonal complex 11, the Netherlands, March 2017. Euro Surveill. 2017;22(23):pii=30549. DOI: http://dx.doi.org/10.2807/1560-7917.ES.2017.22.23.30549

Received:14 May 2017; Accepted:30 May 2017



In March 2017, a patient with necrotising fasciitis caused by Neisseria meningitidis serogroup W (MenW) clonal complex 11 was diagnosed in the Netherlands. Unusual and severe presentations of MenW infections are common in the current European epidemic. In the Netherlands, the incidence of MenW infections increased 10-fold, from an average of 0.03 per 100,000 population in 2002–2014 to 0.29 in 2016. Awareness of atypical presentations enables timely adequate treatment and public health action.

Keywords: Neisseria Meningitidis; Necrotizing Fasciitis; The Netherlands.


Cross-talk among #flesheating #Aeromonas hydrophila #strains in mixed #infection leading to #necrotizing #fasciitis (Proc Natl Aca Sci USA, abstract)

[Source: Proceedings of the National Academy of Sciences of the United States of America, full page: (LINK). Abstract, edited.]

Cross-talk among flesh-eating Aeromonas hydrophila strains in mixed infection leading to necrotizing fasciitis [      ]

Duraisamy Ponnusamy a,1, Elena V. Kozlova a,1, Jian Sha a, Tatiana E. Erova a, Sasha R. Azar a, Eric C. Fitts a, Michelle L. Kirtley a, Bethany L. Tiner a, Jourdan A. Andersson a, Christopher J. Grim b, Richard P. Isom c, Nur A. Hasan c,d, Rita R. Colwell c,d,e,2, and Ashok K. Chopra a,2

Author Affiliations: aDepartment of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX 77555; bCenter for Food Safety and Applied Nutrition, Office of Applied Research and Safety Assessment, Food and Drug Administration, Laurel, MD 20708; cCosmosID Inc., Rockville, MD 20850; dCenter for Bioinformatics and Computational Biology, University of Maryland Institute for Advanced Computer Studies, University of Maryland, College Park, MD 20742; eBloomberg School of Public Health, The Johns Hopkins University, Baltimore, MD 21205

Contributed by Rita R. Colwell, December 4, 2015 (sent for review October 6, 2015; reviewed by Joerg Graf, Brigitte Lamy, Mark R. Liles, and Jonathan G. Shaw)



Necrotizing fasciitis (NF) is a rapidly progressing fatal skin and muscle tissue lesion. We studied a human case of NF and found that the infection was caused by multiple strains of A. hydrophila (NF1–NF4). The latter three strains constitute a clonal group, whereas NF1 is phylogenetically distinct. We tested these strains individually in a mouse intramuscular model of infection and observed NF1 to be less virulent than NF2. However, when NF1 and NF2 were mixed, NF1 exhibited more virulence and it decreased NF2 virulence. The cross-talk between NF1 and NF2 was due to the presence of ExoA toxin in NF2, ability of NF1 and NF2 to differentially modulate innate immune mechanism(s), and direct killing of NF2 by NF1.



Necrotizing fasciitis (NF) caused by flesh-eating bacteria is associated with high case fatality. In an earlier study, we reported infection of an immunocompetent individual with multiple strains of Aeromonas hydrophila (NF1–NF4), the latter three constituted a clonal group whereas NF1 was phylogenetically distinct. To understand the complex interactions of these strains in NF pathophysiology, a mouse model was used, whereby either single or mixed A. hydrophila strains were injected intramuscularly. NF2, which harbors exotoxin A (exoA) gene, was highly virulent when injected alone, but its virulence was attenuated in the presence of NF1 (exoA-minus). NF1 alone, although not lethal to animals, became highly virulent when combined with NF2, its virulence augmented by cisexoA expression when injected alone in mice. Based on metagenomics and microbiological analyses, it was found that, in mixed infection, NF1 selectively disseminated to mouse peripheral organs, whereas the other strains (NF2, NF3, and NF4) were confined to the injection site and eventually cleared. In vitro studies showed NF2 to be more effectively phagocytized and killed by macrophages than NF1. NF1 inhibited growth of NF2 on solid media, but ExoA of NF2 augmented virulence of NF1 and the presence of NF1 facilitated clearance of NF2 from animals either by enhanced priming of host immune system or direct killing via a contact-dependent mechanism.

Aeromonas hydrophila – necrotizing fasciitis – mixed infections – intramuscular mouse model – metagenomics



1D.P. and E.V.K. contributed equally to this work.

2To whom correspondence may be addressed. Email: rcolwell@umiacs.umd.edu or achopra@utmb.edu.

Author contributions: J.S., N.A.H., R.R.C., and A.K.C. designed research; D.P., E.V.K., T.E.E., S.R.A., E.C.F., M.L.K., B.L.T., J.A.A., and C.J.G. performed research; E.V.K., E.C.F., R.R.C., and A.K.C. contributed new reagents/analytic tools; D.P., E.V.K., C.J.G., R.P.I., and N.A.H. analyzed data; D.P., J.S., E.C.F., C.J.G., N.A.H., R.R.C., and A.K.C. wrote the paper; and R.R.C. and A.K.C. conceived the idea.

Reviewers: J.G., University of Connecticut; B.L., Universite de Montpellier; M.R.L., Auburn University; and J.G.S., University of Sheffield.

The authors declare no conflict of interest.

This article contains supporting information online at www.pnas.org/lookup/suppl/doi:10.1073/pnas.1523817113/-/DCSupplemental.


Keywords: Research; Abstracts; Necrotizing Fasciitis; Aeromonas hydrophila.