6. Krieg:Umbruchvorlage 12.01.2009 9:39 Uhr Seite 31 January 28, 2009 EUROPEAN JOURNAL OF MEDICAL RESEARCH 31 tions such as cellulitis and phlegmonia were included in the radiological review. All pathological changes were noted including those of the cutis, subcutis, fasi- acl layers and muscle. In cases which remained unclear despite these examinations suspected foci were ex- posed surgically and the procedure was chosen accord- ing to the clinical aspect of the tissue. If the diagnosis was not adequately established by these methods, a biopsy specimen was analyzed by frozen section or rapid embedding process and measures were taken ac- cordingly, e.g. a mild non mutilating debridement until verification of the diagnosis by histopathological ex- amination. All cases included in this study finally had histopathological verification of the disease. We assessed the value of the different diagnostic procedures performed in each case before radical de- bridement. We also reviewed the medical results for impact of demographic and clinical data as well as lab- oratory findings at the time of admission, comorbidi- ties, site of infection, time from symptoms to admis- sion, number and type of operations, the duration of hospitalization and the length of intensive care unit (ICU) stay as well as days on the respirator. The pa- tients were classified by organisms isolated from swabs or tissue specimens during the first surgical treatment as type I and type II infections according to Giuliano and associates [4]. The physical status of the patients before the first surgical treatment was assessed accord- ing to the criteria of the American Society of Anaes- thesiologists (ASA) [18]. Data analysis was performed using the SPSS 11.5 software package (SPSS Inc., Chicago, IL, USA). Cor- relation between epidemiological, clinical and microbi- ological variables was examined using the nonparamet- ric Mann-Whitney-test. A two-tailed p-value less than 0.05 was considered to indicate statistical significance. RESULTS Twenty-six consecutive patients with necrotizing fasci- itis were treated at our department between 1996 and 2005. Fifteen patients (57.7 %) were transferred to our department from other hospitals and seven patients (26.9 %) from other departments of our university. Only four patients (15.4 %) presented with symptoms directly to our department. There were 8 women and 18 men with a mean age of 51.4 years ± 14 (range 23 to 82 years). In our patient group twenty-four patients (92.3 %) had a mean number of 2.54 ± 1.4 (range 1-6) comorbidities. The most common comorbidities were diabetes, obesity, heart diseases, nicotine- and/or alco- hol-abuse (Table 1). The mean body mass index (BMI) in our study group was 28.7 ± 7.6 (range 18 to 51.6). Six Patients (23.1 %) used corticoids because of chronic inflammatory bowel disease, Felty syndrome, mixed connective tissue disease or polyarthritis. Only two patients (7.7 %) had no relevant comorbidities. The infection was localized in seven patients (26.9 %) at the perineum, in eight patients (30.8 %) at the extremities and eleven patients (42.3 %) had trun- cal involvement (Fig. 1). The port of entry of the in- fection could be identified in only thirteen patients (50 %). In seven cases of postoperative necrotizing fasci- itis re-exploration of the wound established the diag- Table 1. Spectrum of comorbidities in patients (n = 26) with necrotizing fasciitis Comorbidity Diabetes mellitus Obesity Heart disease Alcohol abuse Smoking Steroid usage Asthma/COPD Chronic inflammatory bowel disease Cancer HIV Chronic renal insuficiency Autoimmune hemolytic anemia Peripheral vascular disease Felty syndrom Mixed tissue disease None No. of patients [%] 12 (46.2 %) 8 (30.8 %) 8 (30.8 %) 7 (26.9 %) 9 (34.6 %) 6 (23.1 %) 5 (19.2 %) 3 (11.5 %) 4 (15.4 %) 1 (3.8 %) 1 (3.8 %) 1 (3.8 %) 1 (3.8 %) 1 (3.8 %) 1 (3.8 %) 2 (7.7 %) Fig. 1. Localization of necrotizing fasciitis. nosis. Indications for initial surgery were toxic mega- colon due to ulcerative colitis in one patient, antral re- section due to gastric carcinoid tumour in one patient, intraabdominal adhesions in one patient, in two pa- tients repair of incarcerated hernia and urological op- erations in another two patients. Rare entries included the site of drug injection (one patient, 3.8 %), der- matitis due to infection with scabies norvegica (one patient, 3.8 %) and a chronic non-healing wound after a preceding trauma or chronic venous insufficiency (three patients, 11.5 %). The presenting symptoms and their relative fre- quencies are reported in Table 2. On admission six pa- tients (23.1 %) were classified as ASA II, ten patients (38.5 %) as ASA III, nine patients (34.6 %) as ASA IV