Is Necrotizing Fasciitis in the United States Becoming a New Neglected Disease With Very High Mortality? An Affirmative Answer

The study by Khan et al. published on this issue of our journal [1] provides a comprehensive analysis of necrotizing fasciitis (NF)-related mortality with alarming trends in the United States from 2003 to 2020. This research is particularly significant given the severe and rapidly progressing nature of NF, which demands urgent surgical intervention, while simultaneously proving resuscitation and medical care. The study reveals a dramatic increase by 120.6% in NF-related deaths over the study period, with the age-adjusted mortality rate (AAMR) rising from 0.44 per 100,000 in 2003 to 0.71 per 100,000 in 2020. This upward trend is particularly pronounced after 2014, highlighting a critical period where mortality rates began to escalate sharply. Furthermore, this study underscores significant disparities in NF-related mortality based on sex, race/ethnicity, and geographic region. Males consistently exhibited higher mortality rates than females, with a notable surge in AAMR post-2015. Racial disparities are stark, with American Indian or Alaska Native populations experiencing the highest mortality rates, followed by the African American population. These findings point to underlying systemic issues, including healthcare access inequities and the prevalence of chronic conditions that exacerbate NF outcomes. Geographically, the West recorded the highest AAMR, whereas the Northeast had the lowest. This regional discrepancy was reported by others as well [2]. Urban-rural analysis revealed that large central metropolitan areas had consistently higher mortality rates, whereas smaller metropolitan and noncore areas experienced sharper increases. These variations suggest that regional healthcare infrastructure, environmental factors, and socioeconomic conditions play crucial roles in NF mortality. The study identifies several possible contributing factors to the rising NF mortality rates, including chronic conditions like diabetes and obesity, and healthcare access issues. The opioid epidemic is also highlighted as a significant risk factor, particularly among injection drug users who are more susceptible to severe bacterial infections. To address these challenges, the authors advocate for public health interventions focusing on early diagnosis, timely treatment, and addressing healthcare inequities. Enhancing awareness among healthcare providers and the public is essential for improving NF outcomes. Additionally, targeted efforts to improve healthcare access and quality in underserved regions could mitigate the disparities observed in this study. Although the study conducted by Khan et al. [1] offers an important insight into the mortality trends associated with necrotizing fasciitis (NF), it is important to emphasize certain limitations (some of them outlined by the authors). These limitations are inherent to all major databases, such as National Inpatient Sample (NIS) and others that lack detailed granular clinical data which may influence the interpretation of its findings. However, in my opinion, the most important limitations of this study are the unknown facts: the number of patients that had surgery, how the diagnosis of NF was determined and the time to surgery in patients with NF or more broadly necrotizing soft tissue infections, who did the first surgical intervention, and where it was done (surgeons or emergency medicine providers). These are important questions, since there is a major clinical variability in managing NF across different healthcare settings. Assuming that all patients with NF are seen by the surgeon, one crucial aspect that remains unknown in the available data is the timing of surgical intervention. Delays to initial surgery can markedly affect patient outcomes, and without this information, it poses a limitation in assessing the full impact of timely treatment on mortality rates [3, 4]. Geographic limitations also come into play; the findings may not be generalizable across all regions. Urban areas often have different healthcare resources and disease prevalence compared to their rural counterparts, potentially skewing the data interpretations for specific demographics. Lastly, as public health policies, treatment protocols, and awareness of NF have evolved over the years, these changes may not be adequately reflected in the mortality rates observed in the study. In summary, these limitations warrant careful consideration when interpreting the results of the study. Understanding the broader implications for public health interventions aimed at reducing mortality from necrotizing fasciitis requires the acknowledgment of these constraints. As a practicing surgeon in the Southwestern part of the United States, our dedicated EGS service sees almost weekly 1–2 major necrotizing soft tissue infections, including NF, that have been neglected by patients with major comorbidities, mostly diabetes and obesity, but often neglected and unrecognized by medical providers, who fail to appreciate adequately this potentially deadly conditions from 41 up to 96% [5]. These patients often present with septic shock and multiple organ failure. Nonetheless, the diagnosis of necrotizing fasciitis is not an easy one to make, particularly in nonwhite skin, so one must have a particularly high index of suspicion. Other important management issue is the lack of intensive care facilities, as these patients often need multiple returns to the operating room and need major ICU care. Establishment of dedicated emergency surgery in services, where there are no trauma services, will help this neglected disease. From the surgeon's and hospital standpoint, NF should be treated with the emergency like gunshot wound to the abdomen and resuscitation should be done simultaneously while operating and not waste valuable time for “resuscitation only” in the emergency department of ICU. In summary, Khan et al.'s study provide valuable insights into the epidemiology of necrotizing fasciitis in the United States, highlighting the urgent need for systemic changes to reduce mortality rates. By improving timely surgical care (when it does occur), prioritizing equitable healthcare access and enhancing public health strategies, we can combat better this life-threatening condition and improve outcomes for all affected populations. Rifat Latifi: conceptualization, writing – original draft, writing – review and editing. The author declares no conflicts of interest.