Determinants of mortality for necrotizing soft-tissue infections

Musculoskeletal infections in children

Serious musculoskeletal infections in children include osteomyelitis, septic arthritis, pyomyositis, and necrotizing fasciitis. The epidemiology, pathophysiology, and microbiology of each of these infections are reviewed. Specific diagnostic studies and management strategies are discussed. Prompt recognition and treatment is emphasized to prevent potential long-term sequelae.

Rapidly progressive soft tissue infections

Skin and soft tissue infections are among the most common reasons for people to seek medical advice. They also represent one of the most common indications for antimicrobial therapy and account for approximately 7-10% of hospitalisations in North America. Although non-limb and non-life threatening infections may be treated on an out-patient basis with oral antibiotics, patients with more serious acute skin and soft tissue infections may require admission to hospital for management; this decision is especially true if the infection is rapidly progressive. We provide a concise overview of the differential diagnosis and approach to management of community-acquired rapidly progressive skin and soft tissue infections.

Necrotising fasciitis: clinical features in patients with liver cirrhosis

Necrotising fasciitis is a fulminant and life-threatening infection. It is associated with a high mortality rate and is often seen in the aged and immunocompromised patients. Liver cirrhosis is regarded as a risk factor of necrotising fasciitis. From January 1995 to December 2003, 17 cirrhotic patients who had been admitted to our hospital for necrotising fasciitis were identified. The infection all developed in the lower extremities. Only six patients survived, and the overall case fatality rate was 64.7%. The cases were divided into two groups: survivors and nonsurvivors. Comparisons were made on age, gender, presenting symptoms, underlying medical diseases, laboratory data and clinical course. Underlying diabetes mellitus and grade C liver cirrhosis were the only statistically significant factors that led to poor prognosis (p< 0.05).

[Skin and soft tissue infections]

Infection can involve all layers of soft tissue. The severity of infection can range from a simple cutaneous infection to widespread necrosis of the skin, muscle, and fascia. While infections of soft tissue are common, and can usually be managed using conservative therapy or local surgery, clinicians should be aware of less commonly seen invasive infections that need immediate radical surgical débridement to treat the source adequately, contributing to improved survival.

Necrotizing fasciitis: analysis of 48 cases in South Auckland, New Zealand

BACKGROUND

To assess the presentation, management and risk factors for mortality in necrotizing fasciitis at Middlemore Hospital in South Auckland, New Zealand.

METHODS

A retrospective review of the medical records of patients presenting to Middlemore Hospital over a 6-year period (1997-2002) with a diagnosis of necrotizing fasciitis.

RESULTS

Forty eight patients were identified. There were 27 men and 21 women whose age ranged from 19 to 80 years (median 51 years) at presentation. Maori and Pacific Islanders accounted for 64% of total admissions despite making up only 31% of the referral population. Streptococcus Pyogenes was the most common bacterial isolate (54%). 31% of patients had polymicrobial infections. Sixty-two per cent of cases involved extremities. The median number of operations and length of stay were 4 and 31 days, respectively. Overall mortality was 29%. In multivariate analysis, delay in surgical intervention (P = 0.015) and diabetes mellitus (P = 0.023) were found to be associated with increased mortality. Ethnicity, sex, type of pathogen, site of infection and increasing age did not affect mortality.

CONCLUSION

Necrotizing fasciitis remains a significant problem in our community especially in the Maori and Pacific population. Early surgical debridement decreases mortality rates.

Treatment options in the management of necrotising fasciitis caused by Group A Streptococcus

Invasive Group A Streptococcus (GAS) disease is a serious condition that has multiple manifestations. A particularly severe form of invasive GAS disease is necrotising fasciitis (NF). The case-fatality rate of GAS NF is approximately 20%. Penicillin remains the antibiotic of choice when treating invasive GAS infections. Epidemiological studies have shown that clindamycin is effective in the treatment of deep infections that are caused by GAS. Clinicians should consider adding clindamycin to the beta-lactam antibiotic regimen when NF or myositis is present. Intravenous immunoglobulin appears to be a promising adjunctive therapy in the management of GAS NF. Consultations with surgeons and infectious disease specialists are imperative.

Necrotizing fasciitis during de novo minimal change nephrotic syndrome in a kidney transplant recipient

Skin infections and particularly necrotizing fasciitis (NF) represent a rare but serious complication after transplantation. Optimal management depends on prompt diagnosis with identification of the causative organisms to allow appropriate antibiotic therapy in association with surgical debridement. We report a case of a methicillin-resistant Staphylococcus aureus (MRSA) NF as the single pathogen in a renal transplant recipient, during the course of a de novo minimal-change nephrotic syndrome, treated with high-dose steroids. Antibiotic therapy together with surgical debridement and discontinuation of immunosuppressive treatment led to a complete recovery, despite persistence of the nephrotic syndrome. The development of de novo minimal-change nephrotic syndrome after renal allograft transplantation should alert physicians to the possibility of MRSA NF during an increase in the immunosuppressive regimen.

The diagnosis of necrotizing fasciitis

PURPOSE OF REVIEW

A delay in the diagnosis and appropriate treatment of necrotizing fasciitis has clearly been demonstrated to increase mortality. However, paucity of specific cutaneous signs makes early recognition extremely difficult. This review highlights recent developments in the approaches to the diagnosis of necrotizing fasciitis.

RECENT FINDINGS

A clinical staging of necrotizing fasciitis is proposed to better define the progression of the disease. Several clinical subtypes of necrotizing fasciitis have been described recently with hyperacute and sub-acute variants. Imaging techniques, such as magnetic resonance imaging and frozen section biopsies, have been reported to be of value in the early recognition of necrotizing fasciitis. However availability and cost limit the routine use of these tests. Several diagnostic adjuncts that have been developed recently to help in early recognition will be discussed. These include the fasciitis LRINEC (laboratory risk indicator for necrotizing fasciitis) score and transcutaneous tissue oxygen saturation monitoring. Some may have the potential for widespread application in the assessment of severe soft tissue infections.

SUMMARY

Delayed recognition, with consequent massive soft tissue loss and sepsis, remains a deadly pitfall in the management of necrotizing fasciitis. With a better understanding of the clinical manifestations and the potential use and limitations of various diagnostic adjuncts available for the assessment of equivocal cases of soft tissue infections, it is hoped that a clear and logical approach to the diagnosis of necrotizing fasciitis may be developed.

Hyperbaric oxygen as adjuvant therapy in the management of necrotizing fasciitis

BACKGROUND

Necrotizing fasciitis (NF) is an uncommon but serious infection of fascia and skin associated with considerable morbidity and mortality. One modality proposed for improving the outcome of this condition is hyperbaric oxygen (HBO) therapy. This is a form of medical treatment that involves intermittent inhalation of 100% oxygen under pressures exceeding the atmosphere. The aim of this article is to review current practice and evidence for the use of HBO as adjunctive therapy in the management of NF.

METHODS

A survey of published English literature through searches of Medline and PubMed was carried out using the following key words: "necrotizing fasciitis," "Fournier's gangrene," "necrotizing soft tissue infections," "hyperbaric oxygen therapy," "and hyperbaric oxygen chambers."

RESULTS

The results of studies on the use of HBO therapy in NF are inconsistent. Some studies have demonstrated that HBO can improve patient survival and decrease the number of debridements required to achieve wound control, whereas others have failed to show any beneficial effect.

CONCLUSIONS

Encouraging results have been achieved with the addition of HBO therapy to standard treatment regimes, thus justifying further research in this field. More robust evidence by way of a prospective randomized trial is necessary before widespread and routine use of HBO in the management of NF can be recommended.

Necrotising fasciitis

Necrotising fasciitis is a rare but life threatening condition that requires immediate action, but uncertainties still hamper prompt diagnosis and treatment

Necrotizing fasciitis caused by community-associated methicillin-resistant Staphylococcus aureus in Los Angeles

BACKGROUND

Necrotizing fasciitis is a life-threatening infection requiring urgent surgical and medical therapy. Staphylococcus aureus has been a very uncommon cause of necrotizing fasciitis, but we have recently noted an alarming number of these infections caused by community-associated methicillin-resistant S. aureus (MRSA).

METHODS

We reviewed the records of 843 patients whose wound cultures grew MRSA at our center from January 15, 2003, to April 15, 2004. Among this cohort, 14 were identified as patients presenting from the community with clinical and intraoperative findings of necrotizing fasciitis, necrotizing myositis, or both.

RESULTS

The median age of the patients was 46 years (range, 28 to 68), and 71 percent were men. Coexisting conditions or risk factors included current or past injection-drug use (43 percent); previous MRSA infection, diabetes, and chronic hepatitis C (21 percent each); and cancer and human immunodeficiency virus infection or the acquired immunodeficiency syndrome (7 percent each). Four patients (29 percent) had no serious coexisting conditions or risk factors. All patients received combined medical and surgical therapy, and none died, but they had serious complications, including the need for reconstructive surgery and prolonged stay in the intensive care unit. Wound cultures were monomicrobial for MRSA in 86 percent, and 40 percent of patients (4 of 10) for whom blood cultures were obtained had positive results. All MRSA isolates were susceptible in vitro to clindamycin, trimethoprim-sulfamethoxazole, and rifampin. All recovered isolates belonged to the same genotype (multilocus sequence type ST8, pulsed-field type USA300, and staphylococcal cassette chromosome mec type IV [SCCmecIV]) and carried the Panton-Valentine leukocidin (pvl), lukD, and lukE genes, but no other toxin genes were detected.

CONCLUSIONS

Necrotizing fasciitis caused by community-associated MRSA is an emerging clinical entity. In areas in which community-associated MRSA infection is endemic, empirical treatment of suspected necrotizing fasciitis should include antibiotics predictably active against this pathogen.

Idiopathic Necrotizing Fasciitis: Risk Factors and Strategies for Management

The prognosis of necrotizing fasciitis (NF) depends on early diagnosis and management. Idiopathic NF may be more challenging, because it occurs in the absence of a known causative factor. Therefore, our purpose in this study was to identify the distinct features of idiopathic NF that may be important in early recognition of this disease and determine the factors associated with mortality. A retrospective chart review was performed in patients with a diagnosis of NF between 1988 and 2003. Patients were classified as idiopathic and secondary NF, and data were analyzed in terms of etiological and predisposing factors, causative microbiological organisms, and clinical outcome. The study included 98 patients, 63 men and 35 women, with a diagnosis of NF. The median age was 55.5 years (range, 13–80). Idiopathic NF occurred in 60 of 98 patients (61%). The principal anatomic sites of infection for NF were perineal localisation in 55 patients (66%) and extremities in 31 patients (32%). Characteristics that distinguish patients with idiopathic NF from secondary NF were as follows: age older than 55 years ( P = 0.0001), presence of comorbid illnesses like DM ( P = 0.007) or chronic renal failure ( P = 0.041), and perineal localization ( P = 0.008). By logistic regression analysis, independent risk factors for idiopathic NF remained age >55 years and perineal localization as statistically significant factors, when all the significant variables found in univariate analysis were included in the model. The majority of patients (82%) had polymicrobial infections. The mortality rate was 35 per cent. All patients were treated with radical surgical debridement and a combination of antibiotics. Female gender, presence of malignant disease, and diabetes mellitus (DM) were found to be associated with increased mortality as independent factors in logistic regression analysis, when all of these three factors were included in the model. Understanding the distinct clinical characteristics and the factors associated with mortality in patients with NF may lead to rapid diagnosis and improve the survival rates. Therefore, idiopathic NF is a crucial entity that requires serious suspicion for its diagnosis.

Caloric requirements in patients with necrotizing fasciitis

Patients with necrotizing fasciitis (NF) and other soft tissue infections are often treated in burn centers due to the extent of wound care and surgical intervention needed. Sepsis and surgery increase metabolic needs and may limit oral intake and necessitate enteral (TEN) or parenteral (TPN) nutrition. We reviewed the records of patients admitted with necrotizing fasciitis or surgical soft tissue infections from January 1993 to June 1998 who had indirect calorimetry (IC) measurements performed. Records were also reviewed for surgical/medical management and nutritional intervention. Twenty-six patients were admitted with 17 of these having IC measurements (133 total IC measurements). The IC group had more surgeries (mean 4.9 versus 2.7) and 82% required mechanical ventilation (mean 17.9 days). Energy expenditure showed a moderate but significant increase in energy needs (mean 23.8 kcal/kg/day, 124% BEE) with large variations (10.7-42.4 kcal/kg/day, 60%-199% BEE) in individual energy requirements. Caloric intake averaged 73% of needs based on IC (range 53%-104%). Nearly all patients (94%) required TEN (82%) and/or TPN (41%) nutrition for a mean of 24 days (range 1-68 days). NF presents a broad range of metabolic and surgical needs. Our data indicates patients with NF have increased energy requirements and suggests provision of calories at 124% basal or 25 kcal/kg actual wt/d; but due to the large individual variation, routine assessment using IC is recommended. Clinicians need to recognize the likely need for nutritional support and possibly lengthy clinical course for these patients.

Correlation of histopathologic findings with clinical outcome in necrotizing fasciitis

BACKGROUND

Necrotizing fasciitis is an uncommon disease with high morbidity and mortality rates. Little is known about the role of histopathologic examination in disease prognosis.

METHODS

A retrospective study was conducted to determine what correlations, if any, exist between the histopathologic features of resected tissue in patients with necrotizing fasciitis and clinical outcome.

RESULTS

Eighty-two cases of necrotizing fasciitis that occurred between January 1990 and December 2002 were identified. Histopathologic findings were available for review in 63 cases. A novel histopathologic classification scheme, based on hematoxylin-eosin and Gram stain results, was developed. The classification scheme included 3 stages: stage I, characterized by an intense neutrophilic response and an absence of bacteria in infected tissue; stage II, characterized by the presence of a moderate-to-severe neutrophilic response and positive Gram stain results or by minimal to absent neutrophilic response with a negative Gram stain result; and stage III, characterized by the presence of few or no polymorphonuclear leukocytes and a Gram stain result positive for bacteria during histopathologic examination. Patients with stage I findings had a significantly lower risk of death than patients with stage III findings (7.1% vs. 47%; odds ratio [OR], 0.1; 95% confidence interval [CI], 0.01-0.8; P=.03). Patients with stage II findings had a significantly lower mortality rate than patients with stage III findings (14.2% vs. 47%; OR, 0.2; 95% CI, 0.04-0.9; P=.04). Due to the small number of deaths (n=11) in patients for whom histopathologic examination of resected tissue was performed, multivariate analysis was not done.

CONCLUSIONS

Results of this study suggest that histopathologic findings may correlate with clinical outcome in cases of necrotizing fasciitis. Because the histopathologic scheme is based on results of commonly available stains, it could be easily adopted for use in other institutions that could further evaluate its usefulness as a prognostic tool.

Severe soft tissue infections of the extremities in patients admitted to an intensive care unit

This report describes a retrospective analysis of 33 patients admitted to an intensive care unit with suspicion of necrotising fasciitis (NF) of the extremities. The aim of the study was to clarify the clinical presentation of NF in order to determine when early surgery should be considered. Twenty-one patients with surgically confirmed NF were compared to 12 patients with superficial soft tissue infection. At admission, patients with NF were more likely to have skin areas of ischaemia or necrosis, fluid-filled vesicles, and severe sepsis or septic shock.

Clinical significance of untreated Candida species isolated from ascites in cirrhotic patients

The clinical significance of Candida species isolated from cirrhotic ascites is still unknown. We reviewed the clinical and laboratory features of all cirrhotic patients whose ascites samples were positive for Candida species. A total of 21 cirrhotic patients was identified. Patients were regarded as having peritonitis if they had 1 or more clinical symptom(s) or sign(s) in the absence of any other possible explanation. 10 patients (47.6%) were classified into the spontaneous Candida peritonitis (SCP) group, and the remaining 11 patients (52.4%) were classified into asymptomatic candidascites. Mortalities were higher in the SCP group at discharge (50.0% vs 27.3%), 6-month (90% vs 45.5%) and 1-y (100% vs 54.5%) (p=0.007). Receiver-operating characteristic curve analysis revealed that the cut-off value of ascitic fluid polymorphonuclear cell count of 315/mm(3) (0.315 x 10(9)/l) had the highest diagnostic accuracy with both sensitivity and specificity of 1.0. In conclusion, Candida species are associated with a grave outcome when manifested with peritonitis.

Recurrent necrotizing fasciitis caused by methicillin-resistant Staphylococcus aureus

Reported here is a rare case of recurrent necrotizing fasciitis due to methicillin-resistant Staphylococcus aureus (MRSA). A 46-year-old female with poorly controlled diabetes and chronic ingestion of steroid-containing medications was admitted for treatment of necrotizing fasciitis of the right thigh. Three months following hospital discharge she was readmitted with necrotizing fasciitis of the left hand. On both occasions, MRSA was isolated from tissue cultures obtained during surgical debridement. Patients who develop necrotizing fasciitis are predisposed to severe soft tissue infections due to associated comorbid conditions such as diabetes mellitus. Recurrent soft tissue infection in a patient with previous MRSA-related necrotizing fasciitis should therefore be treated with a high index of suspicion.

Source control in the management of severe sepsis and septic shock: An evidence-based review

OBJECTIVE

In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for source control in the management of severe sepsis and septic shock that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and to improve outcome in severe sepsis.

DESIGN

The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee.

METHODS

The modified Delphi methodology used for grading recommendations built on a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along five levels to create recommendation grades from A to E, with A being the highest grade. Pediatric considerations to contrast adult and pediatric management are in the article by Parker et al. on p. S591.

CONCLUSION

Source control represents a key component of success in therapy of sepsis. It includes drainage of infected fluids, debridement of infected soft tissues, removal of infected devices or foreign bodies, and finally, definite measures to correct anatomic derangement resulting in ongoing microbial contamination and to restore optimal function. Although highly logical, since source control is the best way to reduce quickly the bacterial inoculum, most recommendations are, however, graded as D or E due to the difficulty to perform appropriate randomized clinical trials in this respect. Appropriate source control should be part of the systematic checklist we have to keep in mind in setting up the therapeutic strategy in sepsis.

Determinants of severity for superficial cellutitis (erysipelas) of the leg: a retrospective study

BACKGROUND: Superficial cellulitis (erysipelas) of the leg is a frequent infectious disease with a favorable outcome, whereas some patients present a serious disease. The determinants of severity for superficial cellulitis (erysipelas) of the leg have not yet been clearly established. In order to determine the characteristics of patients presenting with severe superficial cellulitis of the leg, we analyzed patients with favorable and unfavorable outcome. METHODS: The records of 167 patients referred to Rouen University Hospital for non-superficial cellulitis of the leg were analyzed. Two severity groups of patients were retrospectively defined. Patients in the severe group either died secondary to infection during hospital stay or were hospitalized for a duration at least equal to the 90th percentile (i.e., >21 days of hospitalization). The remaining patients were considered as presenting with non-severe cellulitis. Potential determinants of severity were analyzed by univariate and multivariate analysis based on logistic regression. RESULTS: From univariate analysis, the following general factors were positively associated with severity: advanced age, arterial hypertension, diabetes mellitus, elevated leukocytosis, and elevated neutrophilia. The local factors associated with severity were ulcer of the leg and arteriosclerosis obliterans of the leg. From multivariate analysis, only age (P=0.004), diabetes mellitus (P=0.01), and leukocytosis (P=0.04) appeared to be independently associated with severity. A close to significant association was also found with arteriosclerosis obliterans of the leg (P=0.07). Whereas general complications occurred more frequently in the severe group, no such difference was observed for local complications. CONCLUSIONS: Determinants of severity for superficial cellulitis of the leg include high age and associated medical conditions. Aged patients and patients with diabetes mellitus, elevated leukocytosis, or possibly arteriosclerosis obliterans of the leg should preferably be hospitalized for specific care of associated conditions to avoid the occurrence of general complications.

Necrotizing Soft Tissue Infections: Improved Outcomes with Modern Care

The outcome of necrotizing soft tissue infections (NSTI) remains unchanged despite advances in care. Reasons cited are changing patterns of causative factors, delays in diagnosis, and inadequate antibiotic coverage and surgical treatment. To document outcomes of NSTI after aggressive management and to identify risk factors of mortality and prolonged hospital stay, we reviewed all our patients with NSTI admitted from January 2000 to January 2002. Causative factors, comorbid conditions, site of NSTI, physiologic parameters, symptoms, diagnostic tests, therapeutic interventions, and outcomes were analyzed. Patients were treated aggressively with antibiotics, admission to ICU, and frequent surgical debridements. Of 46 patients identified, 28 (61%) were admitted in ICU, and eight (17%) died. The patients who died had higher admission white blood cell counts (46 ± 22 vs 22 ± 10 x 103/mm3, P = 0.01), higher admission pain score (8 ± 1 vs 5 ± 3, P = 0.02), longer intervals from admission to antibiotic administration (16 ± 20 vs 6 ± 12 hours, P = 0.02), and fewer surgical debridements (2.6 ± 1.1 vs 3.6 ± 1.7, P = 0.04). No independent risk factors of mortality or ICU admission were identified. We concluded that severe local pain and a significantly elevated white blood cell count on admission should alert the physician to the presence of severe infection and prompt the initiation of expeditious aggressive treatment.

[Therapeutic management of necrotizing neck infections]

BACKGROUND

Necrotizing neck infections are uncommon soft-tissue infections, usually caused by virulent, toxin producing bacteria. Necrotizing fasciitis represents a special form of necrotizing soft tissue infection with a mortality rate of up to 76% even though aggressive therapy is recommended.

PATIENTS AND METHODS

In the last 2 years we treated four patients with severe necrotizing neck infections and five suffering from necrotizing fasciitis.

RESULTS

Microbiological analysis revealed mixed infections with Candida albicans, Streptococcus pyogenes, Fusobacterium, Proprioni bacteria and Staphylococcus. The surgical management was not only restricted to drainage, but also included functional neck dissection in order minimize the spread of the disease. Eight of our patients recovered completely, but one died due to toxic shock as consequence of a delayed in therapy.

CONCLUSION

Complete recovery of patients suffering from necrotizing fasciitis depends on early and aggressive surgical therapy including neck dissection and drainage as well as an interdisciplinary strategy of conservative therapy. Hyperbaric oxygen should be considered as a treatment adjunct in patients with necrotizing fasciitis if surgery and antibiotic treatment fail.

Four cases of necrotizing fasciitis caused by Klebsiella species

Presented here are four cases of necrotizing fasciitis caused by Klebsiella spp. that were treated at one hospital over a 2-year period. Klebsiella necrotizing fasciitis can occur via direct inoculation, local trauma or, more commonly, hematogenous spread from other septic foci. Early, aggressive, surgical debridement and appropriate antimicrobial treatment are the cornerstones of treatment for this condition. Necrotizing fasciitis due to Klebsiella spp. is unique in that it is commonly associated with multiple septic foci. While liver abscesses and endogenous endophthalmitis are better-known associations of disseminated Klebsiella infection, necrotizing fasciitis is increasingly recognized as one of the manifestations of this syndrome. When treating Klebsiella necrotizing fasciitis, awareness of the potential for multiorgan involvement should prompt a thorough search for associated foci of infection.

Necrotizing soft tissue infection from decubitus ulcer after spinal cord injury

STUDY DESIGN

A case of necrotizing soft tissue infection in a patient with spinal cord injury with extension of infection into the spinal canal and spinal cord is presented.

OBJECTIVE

To review the history, risk factors, pathophysiology, diagnosis, treatment, and morbidity and mortality regarding necrotizing soft tissue infection as they relate to spinal cord injury.

SUMMARY OF BACKGROUND DATA

Necrotizing soft tissue infection related to decubitus ulcers is rare. To our knowledge, this is the first report of this disease related to a sacral decubitus ulcer with extension of the necrotizing infection into the spinal canal.

METHODS

The clinical, radiographic, and pathologic features associated with necrotizing soft tissue infection are presented. The patient presented with a late-stage necrotizing soft tissue infection requiring extensive de-bridement of necrotic tissue, which the patient underwent on admission.

RESULTS

The patent died of refractory septic shock and multiple-organ failure after surgery.

CONCLUSION

Necrotizing soft tissue infections from decubitus ulcers are rare and unpredictable, and ultimately have a progressively aggressive course. The case reported herein is the first report of necrotizing soft tissue infection from a decubitus ulcer in a patient with spinal cord injury with extension into the spinal canal and spinal cord.

Rapidly advancing necrotizing fasciitis caused by Photobacterium (Vibrio) damsela: a hyperaggressive variant

OBJECTIVE

To describe the first case of Vibrio damsela necrotizing fasciitis in New England, emphasizing the importance of very early operative intervention to achieve source control in this extremely aggressive infection.

DESIGN

Case report.

SETTING

Surgical intensive care unit at Tufts-New England Medical Center in Boston, MA.

PATIENT

A 69-yr-old retired fisherman with rapidly progressive necrotizing fasciitis from Photobacterium (Vibrio) damsela infection and ensuing multiple-system organ failure.

INTERVENTIONS

Surgical debridement, ventilator support, vasopressors, continuous veno-venous hemofiltration, and blood product transfusions.

MEASUREMENTS AND MAIN RESULTS

Death.

CONCLUSIONS

A high index of suspicion is necessary for the diagnosis of this specific pathogen and concordant infection. The willingness to surgically debride and amputate without hesitation at a very early point may be the only intervention capable of saving the lives of patients affected by Photobacterium (Vibrio) damsela.

[Necrotizing fasciitis of the thigh]

INTRODUCTION

Necrotizing fasciitis is a rare and severe infectious disease with infectious necrosis often extending in depth to the subcutaneous tissue in the absence of rapid medical-surgical treatment. We report two cases of necrotizing fasciitis of the thigh, which underline the principle clinical and therapeutic characteristics of this often underrated disease.

OBSERVATION

The first case concerns a young 21 year-old woman without remarkable medical history who, following injury from the thorn of a palm tree, developed an aerobic germ necrotizing fasciitis which regressed following medical-surgical treatment. The second case concerned a 46 year-old man suffering from diabetes and arteritis, who having presented an infection following the amputation of the large toes, developed fatal necrotizing fasciitis.

COMMENTS

This disease corresponds to infectious necrosis of the subcutaneous tissue and is essentially characterized by its rapid, occasionally violent, progression. It represents a surgical emergency and requires early and extensive incision in order to avoid severe functional after effects, or even death of the patient. Only enhanced education of the physicians leading to rapid clinical diagnosis will improve the prognosis which still remains fearsome.

Necrotizing soft-tissue infections

It has been more than 130 years since NSTIs were first described. Despite the development of various classification systems and progress in surgical management, these infections continue to have high mortality and pose enormous diagnostic and therapeutic challenges. For optimal outcome, treatment involves rapid institution of appropriate antibiotic coverage and early wide surgical debridement. Recovery requires aggressive resuscitation, postoperative nutritional support and wound care that is similar to the care of burn patients in many respects. The entire therapeutic process requires a well-prepared and coordinated team of health care professionals including EPs, general, orthopedic, and other specialist surgeons, infectious disease consultants, specially trained nursing staff, and physical therapists.

Acute appendicitis with fulminant necrotizing fasciitis in a neonate

The authors report on a neonate who presented with acute appendicitis and who went on to have fatal necrotizing fasciitis. Although recognized in adults, this rare combination of conditions has not been reported previously in the neonate and requires rapid recognition with aggressive medical and surgical intervention.

Cryptococcal Necrotizing Fasciitis With Multiple Sites of Involvement in the Lower Extremities

BACKGROUND

Cryptococcal necrotizing fasciitis that is localized to the lower extremities is very rare.

OBJECTIVE

We describe a case of a renal transplant recipient who presented with necrotizing fasciitis of the legs caused by Cryptococcus neoformans, a fungus that is rarely associated with this disease.

METHODS

This is a case report with literature review.

RESULTS

The patient was hospitalized, and the site of infection was debrided to the level of the periosteum. Cultures and histopathologic examination of biopsy material revealed an invasive deep-seated infection with a fungal organism that was consistent with C. neoformans. After 21 days on parenteral amphotericin B (Ambisome; Er-Kim Pharmaceuticals) treatment, the patient was switched to oral itraconazole (Itraspor; Janssen-Cilag Pharmaceuticals) 200 mg/day. He was discharged after 30 days of hospitalization with his wounds completely healed. He continued on oral fluconazole for a total course of 6 weeks.

CONCLUSION

Systemic fungal infections continue to be an important cause of morbidity and mortality in transplant recipients. The insidious nature and atypical manifestations of these infections often delay diagnosis and therapy. In immunosuppressed patients, persistent fever that does not respond to antibacterial therapy should alert the physician to the possibility of fungal infection.

Surgical emergencies in the intravenous drug user

Numerous surgical complications arise from parenteral drug use. Some complications have severe sequelae and most prove to be a diagnostic challenge. It is likely that these problems will remain a significant burden on the health care system as a result of continued widespread drug abuse. EPs must always maintain vigilance when evaluating medical complaints in the IVDU.

Necrotizing Soft Tissue Infections

Necrotizing soft tissue infections are characterized by necrosis of skin and associated structures. Despite advances in the diagnosis and treatment of these infections, the mortality remains high. There have been increasing reports of necrotizing fasciitis caused by group A Streptococcus over the past decade. Recent information supports the role of superantigens in the pathogenesis of this infection. The approach to management requires expeditious evaluation with early surgery and appropriate antimicrobial agents. Limited data suggest that surgical debridement may be delayed in selected patients until the patient is stable by the use of intravenous immunoglobulin, which can neutralize superantigens.

Unusual infectious complications of dermatologic procedures

Because dermatologic procedures disrupt skin integrity, they alter the body's protective barrier and predispose individuals to cutaneous infection. Postoperative wound infections--even with common pathogens such as S. aureus--seldom complicate dermatologic procedures; however, unusual infections have been reported to complicate excisions, biopsies, skin grafts, chemical peels, dermabrasion, laser resurfacing, liposuction, blepharoplasty, and injections (eg, with anesthetic solutions or botulinum toxin). Numerous environmental and patient risk factors increase the rate of postoperative wound infections, but otherwise healthy individuals undergoing relatively simple procedures are sometimes affected. Obtaining a thorough patient, history (including history of prior HSV infection or any immunocompromising factors) is crucial. Patients should be warned of potential complications, particularly when they are undergoing cosmetic procedures. It is important to maintain a high index of suspicion for possible wound infection in all patients that extends several months postoperatively. Manifestations of unusual postoperative infections are highly variable, and they might be secondary to bacterial, fungal, viral, or parasitic pathogens. Bacterial lesions are often polymicrobial, and bacterial superinfection can exacerbate other wound complications such as HSV reactivation. Most wound infections remain localized, but occasionally systemic disease occurs. For example, cutaneous diphtheria or rapidly growing mycobacteria rarely disseminate, whereas TSS results in systemic disease caused by toxin release. Some unusual postsurgical infections are self-limited, but they can still be potentially life threatening or disfiguring. Antimicrobial prophylaxis might reduce the risk of wound infection in some cases. Clinicians can better care for patients by becoming familiar with the causes and clinical manifestations of unusual dermatologic postoperative wound infections (Table 1). Following the recognition of an infectious process, appropriate diagnostic procedures allow for pathogen identification and the prompt institution of indicated therapy.

[Necrotizing soft tissue infections: nomenclature and classification]

Terminology used to refer to necrotizing infections is extensive because of the absence of clear definitions and the use of classification systems based on a variety of criteria, including etiologic, microbiologic, anatomic, and clinical aspects. This situation has led to some confusion. In the attempt to unify terminology, it might be more appropriate to use only the terms necrotizing fasciitis and myonecrosis, in which differentiation is mainly anatomical. Another option would be to use only the expression necrotizing soft tissue infections, a non-specific term, since these constitute a group of clinical processes having similar pathophysiologic characteristics and therapeutic principles.

Necrotizing soft tissue infections: are we making any progress?

BACKGROUND

Necrotizing soft tissue infections are a group of diseases with significant associated mortality. A wide spectrum of bacteria can be involved, and diagnosis can be difficult.

METHODS

Review of pertinent literature of the diagnosis and therapy of necrotizing soft-tissue infection.

RESULTS

Mortality and other adverse outcomes are directly related to advanced age, the presence of organ system failure, lactic acidemia, the percentage of body surface area involved with infection, and delays in operative management. Patients usually die early from the consequences of septic shock, whereas late mortality is related to multiple organ failure.

CONCLUSION

Early recognition and treatment can lower mortality from necrotizing soft tissue infection. Prompt operative debridement, broad-spectrum antimicrobials, and physiologic support are important components of treatment.

Cutaneous and subcutaneous infections in newborns due to anaerobic bacteria

This review describes the microbiology and management of the major cutaneous and subcutaneous infections in newborns where anaerobic bacteria predominate: omphalitis, necrotizing fasciitis, breast abscess, and scalp infection following intrauterine fetal monitoring. The predominant bacteria known to cause these infections are group B streptococcus, group D enterococcus, group A streptococcus, Staphylococcus aureus, Enterobacteriaceae, and anaerobic bacteria. All of these agents can colonize or infect the mother and subsequently colonize or infect the fetus or newborn either intrauterinely or during the passage through the birth canal. Infections due to anaerobes are often polymicrobial, and include also aerobic and facultative bacteria. The anaerobes recovered from these infections are Bacteroided fragilis group, Fusobacterium spp., Peptostreptococcus spp. and Clostridium spp. Early recognition and effective medical and surgical therapy are essential to recovery. Managements of these infections include surgical debridement and drainage when appropriate as well as topical and systemic use of antimicrobial agents effective against both aerobic and anaerobic bacteria.

Fournier's gangrene

Fournier's gangrene can still be a life-threatening condition with a high mortality rate. Diagnosis and treatment should be prompt and adequate. Radiological studies may help to define the extent of the disease preoperatively in cases in which this is unclear. Surgery with extensive debridement of all necrotic tissue is the mainstay of treatment.

Necrotizing fasciitis successfully treated with extracorporeal blood oxygenation and ozonization (EBOO)

A case of necrotizing fasciitis in a dialysis patient is described. Since traditional therapies were unsuccessful, extracorporeal blood oxygenation and ozonation (EBOO) was tried. This technique is no longer in the experimental stage and is used routinely in our hospital. Patient condition improved radically after EBOO.

Fatal group A streptococcal necrotizing fasciitis and toxic shock syndrome in a patient with psoriasis and chronic renal impairment

A 78-year-old woman presented with rapid onset of skin pain which evolved into oedema, discoloration and infarction. She was diagnosed with group A beta-haemolytic streptococcus (Streptococcus pyogenes) necrotizing fasciitis and streptococcal toxic shock syndrome. The patient had a past history of psoriasis and end-stage renal impairment. Despite treatment with multiple antibiotics in an intensive care unit, the skin infarction involving the upper trunk continued to expand and the patient died within 24 hours of hospital admission. Group A streptococcus and Staphylococcus aureus were cultured from a tissue biopsy. Renal failure and compromised skin barrier function are known to predispose to invasive streptococcal infections, but necrotizing fasciitis has only rarely been reported in association with psoriasis. This case illustrates the fulminant nature of the infection.

Necrotizing Fasciitis: A Fourteen-Year Retrospective Study of 163 Consecutive Patients

This review was prompted by continued public and professional interest of necrotizing fasciitis as well as worldwide increases in the incidence of streptococcal invasive infections. Our objective was to outline the clinical course of necrotizing fasciitis and delineate factors relating to mortality among 163 diagnosed patients. Over 14 years patients diagnosed with necrotizing fasciitis were reviewed for patient history, comorbid conditions, and progression of clinical course. A logistic regression model was used to identify factors increasing mortality risk among necrotizing fasciitis patients. Nearly 17 per cent of the patients showed no identifiable antecedent trauma. Seventy-one per cent of tissue culture-positive patients (145) had multibacterial infections. Although no streptococcal species were recovered from one-third of these culture-positive patients there was an increase in mortality noted with β- Streptococcus infections. Ninety-six per cent of the patient deaths were correlated with variables organized into the following categories: 1) patient history (intravenous drug use and age <1 or >60 years), 2) comorbid conditions (cancer, renal disease, and congestive heart failure), 3) characteristics of clinical course (trunk involvement, positive blood cultures, peripheral vascular disease, and positive cultures for β -streptococcus or anaerobic bacteria), and 4) quantitative timeline of clinical course (time: injury to diagnosis, diagnosis to treatment). Mortality is correlated to patient history, comorbid conditions, and progression of clinical course. Necrotizing fasciitis can occur idiopathically and is generally a polymicrobial infection that sometimes occurs in the absence of streptococci. Clearly the mortality and morbidity associated with necrotizing fasciitis can be decreased with clinical awareness, early diagnosis, adequate surgical debridement, and intensive supportive care.