Necrotizing soft tissue infections: review and current concepts in treatment, systems of care, and outcomes

Fournier Gangrene in the Emergency Department: Diagnostic Dilemmas, Treatments and Current Perspectives

Fournier gangrene (FG) is a rare and life-threatening urosurgical emergency characterized most often by a polymicrobial infection of the perineal, genital, or perianal region. FG has an increased incidence in male patients, patients with alcoholism, and patients with immunocompromise including human immunodeficiency virus (HIV) and uncontrolled diabetes. FG often begins as a simple abscess or cellulitis with progression to necrotizing soft tissue infection (NSTI). Delays in diagnosis and treatment confer high mortality. Early recognition and high clinical suspicion are important in making a timely diagnosis, as early manifestations are often subtle. The most significant modifiable risk factor associated with NSTI mortality is delay to surgical intervention. Coordination of both inpatient medical and surgical teams to implement appropriate therapy is vital to successful outcomes. The emergency medicine clinician must be vigilant for this condition and be aware of risk factors, prognostic indicators, and proper treatment protocols to recognize FG early and initiate appropriate management. The objective of this review is to provide updated and relevant information regarding recognition, diagnosis, and management of FG for the emergency medicine provider.

A case report: Community-acquired Pseudomonas aeruginosa necrotizing fasciitis in a morbidly obese diabetic young man can be fatal

We present a case study of a 26-year-old morbidly obese man with a three-day history of right leg pain and swelling. The swelling was associated with low grade fever. He was alert and conscious upon presentation to the hospital. His physical examination showed gross swelling of the entire right lower limb with no systemic manifestations. There was no discharge and bullae from the swelling area of the leg. He had high blood sugar and was newly diagnosed with type 2 diabetes mellitus. He was diagnosed with necrotizing fasciitis. An intravenous imipenem-cilastatin 500 mg every 6 h together with clindamycin 900 mg every 8 h was started empirically. Extensive wound debridement was performed. The swab culture obtained intraoperatively grew Pseudomonas aeruginosa. He required an above knee amputation due to worsening infection despite wound debridement. Post-operatively, he developed acute kidney injury with severe metabolic acidosis, which required daily hemodialysis. However, the patient deteriorated due to septic shock with multi-organ failure, resulting in his death.

Retiform Purpura as a Sign of Necrotizing Cellulitis in an Immunocompetent Boy

Severe group A streptococcus (GAS) infections, particularly necrotizing soft tissue infections (NSTIs), have been associated with the development of streptococcal toxic-shock syndrome (STSS), a systemic illness caused by GAS-derived toxins. Traditional physical examination findings in NSTIs include skin necrosis, crepitus, and hemorrhagic bullae. However, these findings are limited in sensitivity and additional clinical markers may aid in making an early diagnosis of NSTI. We present a case of a superficial infection, specifically GAS necrotizing cellulitis, complicated by STSS in a healthy boy with an associated skin finding of retiform purpura that aided in early diagnosis of a NSTI.

Pediatric necrotizing soft tissue infection after elective surgery: A case report and literature review

INTRODUCTION

Necrotizing soft tissue infections (NSTIs) are rare but often lethal. Early diagnosis and aggressive surgical debridement are essential to achieve the best possible outcome.

CASE PRESENTATION

A 12-year old boy was diagnosed with a necrotizing soft tissue infection following elective revision surgery for functional impairment resulting from scar tissue of the neck. Fever and inflammation of the surgical wound manifested 24-36 hours postoperatively. Antibiotic therapy with amoxicillin-clavulanic acid was initiated, but the patient was unresponsive. Ultrasonography, a wound culture and surgical exploration confirmed the diagnosis. The culture was positive for a Streptococcus pyogenes infection and antibiotic treatment was switched to penicillin and clindamycin. Following the diagnosis, surgical debridement was performed subcutaneously, and only necrotic tissue was removed to preserve as much skin tissue as possible. After eradication of the infection, vacuum-assisted closure of the wound was used to close the subcutaneous space. The patient was discharged after 40 days.

CONCLUSION

In this patient, we treated a necrotizing soft tissue infection with antibiotics, skin sparing surgeries and negative pressure wound therapy (NPWT). We used ultrasonography as imaging technique to help with the diagnosis. The extensiveness of surgical debridement was rather limited. We focused on opening all affected fascial layers. The surgical debridement was subcutaneous, and only necrotic tissue was removed. Because of the location in the neck, we tried to avoid an aggressive skin debridement to preserve as much skin tissue as possible. Negative pressure wound therapy is not frequently used in this context but it contributed to an enhanced wound healing. Ultrasonography for diagnosing NSTIs is useful, but the clinical findings and an explorative surgery will remain most important.

Management and postoperative use of double-cannula irrigation-drainage tube in cervical necrotizing fasciitis: a Chinese single-institution experience of 46 patients

PURPOSE

This study aimed to analyze a Chinese institution's experience with managing cervical necrotizing fasciitis (CNF) and observe the effects of a new therapeutic approach for postoperative drainage system.

METHODS

A retrospective study was established including a total of 46 CNF patients who underwent surgical debridement between April 2006 and April 2018. Analyses of demographic data, etiology, comorbidity, microbiology, complications, treatment methods, duration of treatment, and treatment outcomes were obtained.

RESULTS

There were 16 kinds of microbes cultured in 29 patients. Diabetic patients were more commonly infected by microbes (P < 0.05). There was a significant reduction in the number of operative time (P < 0.05) and length of hospitalization (P < 0.01) with postoperative therapy of double-cannula irrigation-drainage (DCID) system.

CONCLUSION

CNF management includes controlling for comorbidities especially glycemic control and reasonable utilization of antibiotics and aggressive postoperative therapy. DCID system can effectively reduce operative frequency and duration of hospitalization.

Necrotizing fasciitis associated with malignancy

Necrotizing fasciitis (NF) is a rare soft-tissue condition with a high mortality rate even with treatment. Diagnosis is challenging due to an absence of specific symptoms at the early stages of clinical presentation. NF is typically associated with traumatic injuries, superficial skin breakdown, and surgical procedures. Diabetes mellitus and immunosuppression also increase the risk of developing NF. NF predominantly occurs in the lower extremities, the peritoneum, and the perineum. Treatments include antimicrobials, supportive care, and surgical source control. It is important for clinicians to recognize the association of spontaneous atraumatic NF caused by Clostridium septicum with malignancy, so they can maintain a high index of suspicion and provide timely interventions to optimize patient outcomes.

Clostridial Gas Gangrene - A Rare but Deadly Infection: Case series and Comparison to Other Necrotizing Soft Tissue Infections

Objective

Clostridial gas gangrene (GG) or clostridial myonecrosis is a very rare but life‐threatening necrotizing soft tissue infection (NSTI) caused by anaerobic, spore‐forming, and gas‐producing clostridium subspecies. It is the most rapidly spreading and lethal infection in humans, also affecting muscle tissue. The high mortality, of up to 100%, in clostridial GG is mediated by potent bacterial exotoxins. Necrotizing fasciitis (NF) is an important differential diagnosis, most often caused by group A streptococci, primarily not affecting musculature but the subcutaneous tissue and fascia. In the early stages of the infection, it is difficult to distinguish between GG and NF. Therefore, we compare both infection types, identify relevant differences in initial clinical presentation and later course, and present the results of our patients in a retrospective review.

Methods

Patients diagnosed with GG from 2008 to 2018 in our level one trauma center were identified. Their charts were reviewed retrospectively and data analyzed in terms of demographic information, microbiological and histological results, therapeutic course, outcome, and mortality rates. The laboratory risk indicator for NF (LRINEC) score was applied on the first blood work acquired. Results were compared to those of a second group diagnosed with NF.

Results

Five patients with GG and nine patients with NF were included in the present study. Patients with GG had a mortality rate of 80% compared to 0% in patients with NF. In eight patients with NF, affected limbs could be salvaged; one NF underwent amputation. LRINEC did not show significant differences between the groups; however, C‐reactive protein was significantly increased (P = 0.009) and hemoglobin (Hb) was significantly decreased (P = 0.02) in patients with GG. Interleukin‐6 and procalcitonin levels did not show significant difference. Patients with GG were older (70.2 vs 50 years). Of the isolated bacteria, 86% were sensitive to the initial calculated antibiotic treatment with ampicillin‐sulbactam or imipenem plus metronidazole plus clindamycin.

Conclusion

Both GG and NF need full‐scale surgical, antibiotic, and intensive care treatment, especially within the first days. Among patients with NSTI, those with clostridial GG have a significantly increased mortality risk due to early septic shock caused by clostridial toxins. In the initial stages, clinical differences are hardly detectable. Immediate surgical debridement is the key to successful therapy for NSTI and needs to be performed as early as possible. However, patients should be treated in a center with an experienced interdisciplinary intensive care team based on a predetermined treatment plan.

[Necrotizing fasciitis-a surgical emergency]

Necrotizing fasciitis is a fulminant and potentially life-threatening infection of the skin and soft tissue. It is usually caused by a combination of different bacteria and is often due to assumed minor trauma. Clinically, only relatively insignificant skin changes are initially present, such as blistering or erythema. They are often accompanied by excessive pain. In the further course, the massive systemic reaction becomes predominant. The diagnosis of necrotizing fasciitis is primarily clinical, which can be supported by laboratory parameters (LRINEC score) and computed tomography imaging. Decisive for the prognosis is the immediate initiation of surgical treatment by radical debridement. Additionally, the calculated administration of a combination of different antibiotics should be initiated. As part of the further complex intensive care treatment, a regular reevaluation of the wounds is carried out. Multiple débridements are always necessary until plastic surgery for defect coverage can be carried out.

Plastic Surgery Complications: A Review for Emergency Clinicians

The number of aesthetic surgical procedures performed in the United States is increasing rapidly. Over 1.5 million surgical procedures and over three million nonsurgical procedures were performed in 2015 alone. Of these, the most common procedures included surgeries of the breast and abdominal wall, specifically implants, liposuction, and subcutaneous injections. Emergency clinicians may be tasked with the management of postoperative complications of cosmetic surgeries including postoperative infections, thromboembolic events, skin necrosis, hemorrhage, pulmonary edema, fat embolism syndrome, bowel cavity perforation, intra-abdominal injury, local seroma formation, and local anesthetic systemic toxicity. This review provides several guiding principles for management of acute complications. Understanding these complications and approach to their management is essential to optimizing patient care.

Necrotizing fasciitis: A comprehensive review

Necrotizing soft-tissue infections (NSTIs) are rare but rapidly progressive, life-threatening bacterial infections with high morbidity and mortality. NSTIs include necrotizing forms of fasciitis, myositis, and cellulitis. This article focuses on necrotizing fasciitis (NF) and discusses NF classifications, clinical features, diagnostic approaches, evidence-based treatments, and nursing interventions.

Vacuum sealing drainage with instillation in the treatment of necrotising soft-tissue infection: a retrospective analysis

Objective:

Necrotising soft-tissue infection is a rare but life-threatening infectious disease with high morbidity and mortality. It is typically caused by toxin-producing bacteria and characterised clinically by a very rapid progression of the disease with significant local tissue destruction. In this study, we intend to explore effective wound management to control the invasive infection and to decrease the high mortality.

Method:

This retrospective analysis explored the wound management and mortality in patients with necrotising soft-tissue infection. Extensive debridement, vacuum sealing drainage (VSD) with normal saline instillation combined with broad-spectrum or sensitive antibiotics, and supportive therapies were used.

Results:

All 17 patients included in the analysis survived. The microbiology of 11 patients was found to be polymicrobial. Of the patients, 14 were discharged with completely healed wounds and three were transferred to a local hospital after the systemic and invasive wound infection was controlled.

Conclusion:

Our experiences revealed the outstanding effect of VSD with instillation in removing the debris of necrotising tissue on the wound bed, in the continual and complete drainage of wound exudates, and in prompting wound healing.

Antifungal Therapy in Fungal Necrotizing Soft Tissue Infections

BACKGROUND

Necrotizing soft tissue infections (NSTIs) are life-threatening surgical emergencies associated with high morbidity and mortality. Fungal NSTIs are considered rare and have been largely understudied. The purpose of this study was to study the impact of fungal NSTIs and antifungal therapy on mortality after NSTIs.

METHODS

A retrospective chart review was performed on patients with NSTIs from 2012 to 2018. Patient baseline characteristics, microbiologic data, antimicrobial therapy, and clinical outcomes were collected. Patients were excluded if they had comfort care before excision. The primary outcome measured was in-hospital mortality.

RESULTS

A total of 215 patients met study criteria with a fungal species identified in 29 patients (13.5%). The most prevalent fungal organism was Candida tropicalis (n = 11). Fungal NSTIs were more prevalent in patients taking immunosuppressive medications (17.2% versus 3.2%, P = 0.01). A fungal NSTI was significantly associated with in-hospital mortality (odds ratio, 3.13; 95% confidence interval, 1.16-8.40; P = 0.02). Furthermore, fungal NSTI patients had longer lengths of stay (32 d [interquartile range, 16-53] versus 19 d [interquartile range, 11-31], P < 0.01), more likely to require initiation of renal replacement therapy (24.1% versus 8.6%, P = 0.02), and more likely to require mechanical ventilation (64.5% versus 42.0%, P = 0.02). Initiation of antifungals was associated with a significantly lower rate of in-hospital mortality (6.7% versus 57.1%, P = 0.01).

CONCLUSIONS

Fungal NSTIs are more common in patients taking immunosuppressive medications and are significantly associated with in-hospital mortality. Antifungal therapy is associated with decreased in-hospital mortality in those with fungal NSTIs. Consideration should be given to adding antifungals in empiric treatment regimens, especially in those taking immunosuppressive medications.

Epidermal hepcidin is required for neutrophil response to bacterial infection

Novel approaches for adjunctive therapy are urgently needed for complicated infections and patients with compromised immunity. Necrotizing fasciitis (NF) is a destructive skin and soft tissue infection. Despite treatment with systemic antibiotics and radical debridement of necrotic tissue, lethality remains high. The key iron regulatory hormone hepcidin was originally identified as a cationic antimicrobial peptide (AMP), but its putative expression and role in the skin, a major site of AMP production, have never been investigated. We report here that hepcidin production is induced in the skin of patients with group A Streptococcus (GAS) NF. In a GAS-induced NF model, mice lacking hepcidin in keratinocytes failed to restrict systemic spread of infection from an initial tissue focus. Unexpectedly, this effect was due to its ability to promote production of the CXCL1 chemokine by keratinocytes, resulting in neutrophil recruitment. Unlike CXCL1, hepcidin is resistant to degradation by major GAS proteases and could therefore serve as a reservoir to maintain steady-state levels of CXCL1 in infected tissue. Finally, injection of synthetic hepcidin at the site of infection can limit or completely prevent systemic spread of GAS infection, suggesting that hepcidin agonists could have a therapeutic role in NF.

Severe bacterial skin infections

The severe bacterial diseases discussed herein are those that present dermatological lesions as their initial manifestations, for which the dermatologist is often called upon to give an opinion or is even the first to examine the patient. This review focuses on those that evolve with skin necrosis during their natural history, that is, necrotizing fasciitis, Fournier gangrene, and ecthyma gangrenosum. Notice that the more descriptive terminology was adopted; each disease was individualized, rather than being referred by the generic term "necrotizing soft tissue infections". Due to their relevance and increasing frequency, infections by methicillin-resistant Staphylococcus aureus (MRSA) were also included, more specifically abscesses, furuncle, and carbuncle, and their potential etiologies by MRSA. This article focuses on the epidemiology, clinical dermatological manifestations, methods of diagnosis, and treatment of each of the diseases mentioned.

Reducing Cesarean Delivery Surgical Site Complications

Cesarean delivery (CD) wound complications disrupt the time a mother spends with her newborn. Surgical site infections (SSI) may result in unplanned office visits, emergency room visits, and hospital readmissions. Despite increasing attention to preoperative preparation, the CD SSI rate remains high. Local practices must be evaluated, and new methods to reduce CD SSI must be used.

Spontaneous closure of an extensive postdebridement perineal wound in a newly diagnosed diabetic patient presenting with necrotizing fasciitis

Diabetes mellitus may present for the first time with necrotizing fasciitis. Early treatment of septic shock and immediate surgical debridement reduces mortality. A diverting loop colostomy prevents soiling of extensive postdebridement wound. Local wound care together with good glycemic and infection control leads to spontaneous wound closure.

A case report of iatrogenic gas gangrene post colonoscopy successfully treated with conservative management- is surgery always necessary?

Background

Colonoscopy is a routine procedure in diagnosis and treatment of colonic disease. While generally regarded as a safe procedure, potentially fatal complications can occur. Gas gangrene is one such complication, with very high mortality. There are few cases of gas gangrene occurring after colonoscopy, making it one of the rarer complications of this procedure. There have been no previously reported cases of a patient surviving such an infection and the optimal treatment strategy is contentious. This report describes a case of intramural gas gangrene of the colon, treated conservatively with antibiotic therapy in which the patient survived with full recovery.

Case presentation

A 71-year-old, previously healthy male presented 6 h post apparently uncomplicated colonoscopic polypectomy with rigors, nausea, vomiting and right upper quadrant pain. At presentation he was febrile at 40.1 °C but hemodynamically stable. Abdominal computed tomography revealed substantial colonic thickening and several focal intramural gas bubbles (pneumatosis intestinalis) surrounding the polypectomy site. Within 24 h post procedure he became hypotensive and was admitted to ICU in frank septic shock requiring inotropes, and with demonstrable septic myocardial depression. Bloods showed multi-organ derangement with leukocytosis, lactic acidosis, haemolytic anaemia and hyperbilirubinemia. A diagnosis of presumed Clostridial gas gangrene was made, and treatment was initiated with benzylpenicillin, clindamycin, metronidazole and vancomycin. After 4 days in ICU he was stepped down, and discharged after a further 10 days with no surgical or endoscopic interventions. At three-month review he reported being back to full health.

Conclusions

This case demonstrates that gas gangrene infection is a possible complication of colonoscopic polypectomy. This is a cause of rapid deterioration in post-colonoscopy patients and has been misdiagnosed as colonic perforation in previously reported cases of retroperitoneal gas gangrene. Such misdiagnosis delays antibiotic therapy, which likely plays a role in the high mortality of this condition. Early diagnosis and initiation of antibiotic therapy with benzylpenicillin and clindamycin as seen in this case is essential for patient survival. While surgery is typically performed, non-operative management of pneumatosis intestinalis, and potentially gas gangrene is becoming more common and was utilized effectively in this patient.

Survival and Health-Related Quality of Life after Hospitalization for Necrotizing Soft Tissue Infections of the Upper Extremity: A Long-Term Outcome Study

Introduction The main aim of the study was to investigate the survival and health-related quality of life (HRQoL) after hospitalization for necrotizing soft tissue infections (NSTIs) of the upper extremity.

Materials and Methods A retrospective study with long-term follow-up of patients surviving NSTIs of the upper extremity was performed. Survival and HRQoL after hospital discharge were the primary outcomes. The HRQoL was measured using the 36-item Short Form (SF-36), EuroQoL-5D-5L (EQ-5D), Quick Disability of Shoulder, Arm and Hand (QuickDASH), and numeric rating scales (NRS) for satisfaction with appearance and pain.

Results A median of 6.5 years after hospitalization, 81% of the 108 patients survived. The response rate was 45% (n = 38). The SF-36 score was 80 (interquartile range [IQR]: 58–91), the EQ-5D score 1.4 (IQR: 1.2–2.2), the EuroQoL-Visual Analog Scale score 77 (IQR: 67-90), the QuickDASH score 13.6 (IQR: 2.3-30.7), the NRS for satisfaction with appearance 8 (IQR: 7–9), and NRS for pain 1 (IQR: 0-5).

Conclusion Six-and-a-half years after the NSTI, 81% of the patients were still alive. General health prior to the NSTI mainly influenced the risk at secondary mortality. In surviving patients, the HRQoL varied widely, but was adversely affected by female sex, intravenous drug use, NSTI type I or III, and longer length of hospital stay.

Sonographic exploration for fascial exploration (SEFE) in necrotizing fasciitis: a case report

BACKGROUND

Necrotizing skin and soft tissue infections are life-threatening conditions. Reliance on gas in tissue planes leads to worsened outcomes in patients with non-gas forming types of necrotizing fasciitis (NF).

CASE PRESENTATION

We present a case of Group A Strep (GAS) necrotizing fasciitis, which was identified at bedside with point-of-care ultrasound (US) including an area of subfascial fluid. Computerized tomography only revealed diffuse cellulitic changes. Patient was taken to the operating room where fascial exploration was not performed at the concerning area seen on ultrasound and thus falsely negative. The patient subsequently developed multi-system organ failure and required amputation of the limb due to rapid spread of GAS NF.

CONCLUSION

We suggest an US protocol to help identify optimal areas for fascial exploration-sonographic exploration for fascial exploration (SEFE).

Obesity Is Not an Independent Predictor of Necrotizing Soft Tissue Infection Outcomes

Background: Necrotizing soft tissue infections (NSTIs) are a group of rapidly progressive infections of the skin and its underlying tissue. These infections result in substantial morbidity and mortality. The focus of this study was to determine if obesity is associated with a worsened clinical outcome or prolonged hospital course for patients with NSTIs. Patients and Methods: We conducted a retrospective chart review of patients with NSTI presenting to a single tertiary hospital. Fat content, measured with body mass index (BMI) and abdominal fat thicknesses, including subcutaneous and visceral fat, were compared against primary and secondary outcomes of NSTIs. Results: We found that women had a higher mortality rate compared with men (27% vs. 15% mortality). Women also had an increased subcutaneous abdominal fat thickness (55.7 vs. 36.9 mm, p = 0.028). However, no measurements of fat, BMI, subcutaneous fat, or visceral fat differed between survivors and mortalities of NSTIs. In fact, with the exception of a higher BMI in those who developed acute kidney injury (AKI, p = 0.034), we found no correlation between increases in fat measurement and secondary outcome, including propensity to develop sepsis during hospitalization, length of hospital stay, length of intensive care stay, or antibiotic usage. Multivariable logistic regression analysis was conducted, and we found no statistically significant differences in primary or secondary outcomes. Conclusion: Women appear to have a higher mortality in NSTI, although the reasons for this are unclear. Obesity, as measured by BMI, subcutaneous, and visceral fat thicknesses, does not appear to be an independent risk factor.

[Necrotizing fasciitis-a surgical emergency]

Necrotizing fasciitis is a fulminant and potentially life-threatening infection of the skin and soft tissue. It is usually caused by a combination of different bacteria and is often due to assumed minor trauma. Clinically, only relatively insignificant skin changes are initially present, such as blistering or erythema. They are often accompanied by excessive pain. In the further course, the massive systemic reaction becomes predominant. The diagnosis of necrotizing fasciitis is primarily clinical, which can be supported by laboratory parameters (LRINEC score) and computed tomography imaging. Decisive for the prognosis is the immediate initiation of surgical treatment by radical debridement. Additionally, the calculated administration of a combination of different antibiotics should be initiated. As part of the further complex intensive care treatment, a regular reevaluation of the wounds is carried out. Multiple débridements are always necessary until plastic surgery for defect coverage can be carried out.

Prediction of Molecular Mutations in Diffuse Low-Grade Gliomas using MR Imaging Features

Diffuse low-grade gliomas (LGG) have been reclassified based on molecular mutations, which require invasive tumor tissue sampling. Tissue sampling by biopsy may be limited by sampling error, whereas non-invasive imaging can evaluate the entirety of a tumor. This study presents a non-invasive analysis of low-grade gliomas using imaging features based on the updated classification. We introduce molecular (MGMT methylation, IDH mutation, 1p/19q co-deletion, ATRX mutation, and TERT mutations) prediction methods of low-grade gliomas with imaging. Imaging features are extracted from magnetic resonance imaging data and include texture features, fractal and multi-resolution fractal texture features, and volumetric features. Training models include nested leave-one-out cross-validation to select features, train the model, and estimate model performance. The prediction models of MGMT methylation, IDH mutations, 1p/19q co-deletion, ATRX mutation, and TERT mutations achieve a test performance AUC of 0.83 ± 0.04, 0.84 ± 0.03, 0.80 ± 0.04, 0.70 ± 0.09, and 0.82 ± 0.04, respectively. Furthermore, our analysis shows that the fractal features have a significant effect on the predictive performance of MGMT methylation IDH mutations, 1p/19q co-deletion, and ATRX mutations. The performance of our prediction methods indicates the potential of correlating computed imaging features with LGG molecular mutations types and identifies candidates that may be considered potential predictive biomarkers of LGG molecular classification.

Imaging musculoskeletal soft tissue infections

Musculoskeletal soft tissue infections are not uncommonly encountered in both the clinic and Emergency Department setting. The clinical diagnosis is not always evident as these infections can have variable presentations depending on the duration and depth of disease extension through the soft-tissue layers. Imaging often plays an important role in diagnosing the infection, defining the extent of involvement, directing tissue sampling, and in monitoring treatment response. After initial radiographs, ultrasound (US) is often the next modality utilized to evaluate patients with suspected soft tissue infections given its low cost, availability, portability, and potential for real-time guidance of fluid aspiration. The widespread use of cross-sectional imaging with magnetic resonance imaging (MRI) and computed tomography (CT) has greatly increased the radiological diagnosis in conditions where US may be limited. In addition, CT and MRI allow a thorough evaluation of disease extension, including assessment of joint spaces, tendons, and osseous changes indicative of bone involvement. This review will focus on the radiological findings of soft tissue infections on US, CT, and MRI.

Fournier's gangrene mortality: A 17-year systematic review and meta-analysis

BACKGROUND

To provide better management of Fournier's gangrene, mortality-associated comorbidities and common etiologies were identified.

METHODS

A systematic search was conducted using 12 databases, followed by meticulous screening to select relevant articles. Meta-analysis and meta-regression (for possible cofounders) were both done for all possible outcomes.

RESULTS

Out of 1186 reports screened, 38 studies were finally included in the systematic review and meta-analysis. A higher risk of mortality was detected in patients with diabetes, heart disease, renal failure, and kidney disease, with risk ratios (RR) and 95% confidence intervals (95% CI) of 0.72 (0.59-0.89), 0.39 (0.24-0.62), 0.41 (0.27-0.63), and 0.34 (95% CI 0.16-0.73), respectively. However, there was no association between mortality rates and comorbid hypertension, lung disease, liver disease, or malignant disease (p > 0.05). The highest mortality rates were due to sepsis (76%) and multiple organ failure (66%), followed by respiratory (19.4%), renal (18%), cardiovascular (15.7%), and hepatic (5%) mortality.

CONCLUSIONS

Modifications to the Fournier's Gangrene Severity Index (FGSI) are recommended, in order to include comorbidities as an important prognostic tool for FG mortality. Close monitoring of the patients, with special interest given to the main causes of mortality, is an essential element of the management process.

Necrotizing Infections of the Hand and Wrist: Diagnosis and Treatment Options

Necrotizing infections of the hand and wrist are important clinical entities because of their rapidly progressive and potentially lethal nature. These infections encompass a spectrum of diseases with overlapping signs and symptoms, which can be subtle and nonspecific. If the brief prodromal period of these infections goes unrecognized, a local area of devitalized tissue can evolve into fulminant infection, multiorgan failure, and potentially death. Early recognition and treatment including administration of broad-spectrum antibiotics and surgical débridement are paramount to improving patient outcomes.

Pyoderma gangrenosum underrepresentation in non-dermatological literature

Background

Pyoderma gangrenosum (PG) is a chronic, ulcerative neutrophilic dermatosis. PG presents a diagnostic challenge, largely due to the many mimicking diseases, the lack of confirmatory laboratory or biological markers, and the absence of widely accepted diagnostic criteria. In particular, PG is often mistaken for necrotizing soft tissue infections (NSTI).

Methods

We reviewed four major textbooks each in general surgery, plastic surgery, trauma surgery, vascular surgery, emergency medicine, and dermatology. We also performed a search of review articles addressing NSTI and necrotizing fasciitis (NF).

Results

Ten out of the 20 non-dermatology textbooks did not list PG anywhere, and only two listed a differential diagnosis for PG. None of the non-dermatology textbooks indicated PG in the NSTI differential diagnosis, while three of the dermatology textbooks included PG in the NSTI differential diagnosis. PG was listed in all of the dermatology textbooks. Only one of the NSTI and NF articles mentioned PG in the differential diagnosis.

Conclusions

There is an underrepresentation in major textbooks of surgery and emergency medicine and in NSTI and NF review articles when it comes to diagnosing PG. This might be leading to trainees and advanced providers in these fields being uninstructed on PG, and likely contributes to PG misdiagnosis and mismanagement. We recommend PG be included in the differential diagnosis of chronic ulcers and NSTI in non-dermatology textbooks. We also suggest adding identification and diagnosis of inflammatory mimickers of NSTI (e.g. PG) in teaching modules in surgical and emergency specialties to address this knowledge gap.

Recurrent Necrotizing Soft Tissue Infections with Atypical Pathogens after Injection Drug Abuse: Another Manifestation of the Opioid Crisis

Background: The United States is in the midst of an opioid crisis. Injection drug use is a major risk factor for necrotizing soft tissue infections (NSTI) by introducing bacteria into the soft tissues. Repetitive infection and atypical pathogens may be tangible manifestations of the opioid crisis. Methods: We describe recidivism in two cases of NSTI involving opioid abuse and atypical pathogens at a single institution and review pertinent international literature. Results: Repetitive NSTI is rare. Patients with chronic injection drug use, however, may be at particular risk of repetitive NSTI and infections with atypical organisms. Conclusions: Care providers must have a heightened awareness of infections with atypical pathogens and risk of repetitive infection in patients with injection drug use. Aggressive surgical management and antibiotic coverage tailored to culture and susceptibility data are necessary for a successful short-term outcome. A successful long-term outcome mandates identification and management of co-existent behavioral health issues.

Systems and Precision Medicine in Necrotizing Soft Tissue Infections

Necrotizing soft tissue infections (NSTI) are multifactorial and characterized by dysfunctional, time dependent, highly varying hyper- to hypo-inflammatory host responses contributing to disease severity. Furthermore, host-pathogen interactions are diverse and difficult to identify and characterize, due to the many different disease endotypes. There is a need for both refined bedside diagnostics as well as novel targeted treatment options to improve outcome in NSTI. In order to achieve clinically relevant results and to guide preclinical and clinical research the vast amount of fragmented clinical and experimental datasets, which often include omics data at different levels (transcriptomics, proteomics, metabolomics, etc.), need to be organized, harmonized, integrated, and analyzed taking into account the Big Data nature of these datasets. In this chapter, we address these matters from a systems perspective and yet personalized approach. The chapter provides an overview on the increasingly more frequent use of Big Data and Artificial Intelligence (AI) to aggregate and generate knowledge from burgeoning clinical and biochemical information, addresses the challenges to manage this information, and summarizes current efforts to develop robust computer-aided clinical decision support systems so to tackle the serious challenges in NSTI diagnosis, stratification, and optimized tailored therapy.

Efficacy of colistimethate sodium as local application in necrotising fasciitis

Necrotising fasciitis (NF) is a rapidly progressive severe soft tissue infection of the deep fascia resulting in the destruction of overlying subcutaneous tissue and skin. We report the case of NF of the lower limb with a poor prognosis due to multidrug-resistant (MDR) Klebsiella pneumoniae (K. pneumoniae) sensitive only to colistin. In view of the worsening condition of the wound, risk of deterioration of renal function and economic constraints, it was decided to start on colistin therapy locally by colistimethate sodium (CMS). The patient responded well to the treatment and got clinically better. Subsequent culture sent for post-treatment showed no growth of the organism. The wound healed with regular dressings by 8 weeks. This was found to be a very cost-effective treatment modality. Local use of CMS was found to be a novel method of achieving infection-free wound especially against MDR K. pneumoniae.

Multidisciplinary treatment of a patient with necrotizing fasciitis caused by Staphylococcus aureus: A case report

BACKGROUND

Necrotizing fasciitis is a severe bacterial skin infection that spreads quickly and is characterized by extensive necrosis of the deep and superficial fascia resulting in the devascularization and necrosis of associated tissues. Because of high morbidity and mortality, accurate diagnosis and early treatment with adequate antibiotics and surgical intervention are vital. And timely identification and treatment of complications are necessary to improve survival of patient.

CASE SUMMARY

We report a case of necrotizing fasciitis caused by Staphylococcus aureus in a patient using high doses of glucocorticoid and suffering from secondary diabetes mellitus. He was admitted to our hospital due to redness and oedema of the lower limbs. After admission, necrotizing fasciitis caused by Staphylococcus aureus was considered, and he was discharged after B-ultrasound drainage and multiple surgical operations. In the process of treatment, multiple organ functions were damaged, but with the help of multi-disciplinary treatment, the patient got better finally.

CONCLUSION

The key to successful management of necrotizing fasciitis is an early and accurate diagnosis. The method of using vacuum sealing drainage in postoperative patients can keep the wound dry and clean, reduce infection rate, and promote wound healing. Interdisciplinary collaboration is a vital prerequisite for successful treatment.

Factors Associated with Mortality and Amputation Caused by Necrotizing Soft Tissue Infections of the Upper Extremity: A Retrospective Cohort Study

Background

It is unclear what the exact short-term outcomes of necrotizing soft tissue infections (NSTIs), also known and necrotizing fasciitis of the upper extremity, are and whether these are comparable to other anatomical regions. Therefore, the aim of this study is to assess factors associated with mortality within 30-days and amputation in patients with upper extremity NSTIs.

Methods

A retrospective study over a 20-year time period of all patients treated for NSTIs of the upper extremity was carried out. The primary outcomes were the 30-day mortality rate and the amputation rate in patients admitted to the hospital for upper extremity NSTIs.

Results

Within 20 years, 122 patients with NSTIs of the upper extremity were identified. Thirteen patients (11%) died and 17 patients (14%) underwent amputation. Independent risk factors for mortality were an American Society of Anesthesiologists (ASA) classification of 3 or higher (OR 9.26, 95% CI 1.64–52.31) and a base deficit of 3 meq/L or greater (OR 10.53, 95% CI 1.14–96.98). The independent risk factor for amputation was a NSTI of the non-dominant arm (OR 3.78, 95% CI 1.07–13.35). Length of hospital stay was 15 (IQR 9–21) days.

Conclusion

Upper extremity NSTIs have a relatively low mortality rate, but a relatively high amputation rate compared to studies assessing NSTIs of all anatomical regions. ASA classification and base deficit at admission predict the prognosis of patients with upper extremity NSTIs, while a NSTI of the non-dominant side is a risk factor for limb loss.

Necrotizing Soft Tissue Infections: A Focused Review of Pathophysiology, Diagnosis, Operative Management, Antimicrobial Therapy, and Pediatrics

Background: Necrotizing fasciitis is a major health problem throughout the world. The purpose of this review is to assist providers with the care of these patients through a better understanding of the pathophysiology and management options. Methods: This is a collaborative review of the literature between members of the Surgical Infection Society of North America and World Society of Emergency Surgery. Results: Necrotizing fasciitis continues to be difficult to manage with the mainstay being early diagnosis and surgical intervention. Recognition of at-risk populations assists with the initiation of treatment, thereby impacting outcomes. Conclusions: Although there are some additional treatment strategies available, surgical debridement and antimicrobial therapy are central to the successful eradication of the disease process.

Traditional culture methods fail to detect principle pathogens in necrotising soft tissue infection: a case report

OBJECTIVE

Necrotising soft tissue infections (NSTIs) progress rapidly and mortality remains high, ranging from 10% to 30%, representing a significant challenge for health professionals. Early accurate diagnosis is crucial because timely and aggressive surgical intervention remains the number one indicator for a better clinical outcome. Understanding the microbial background of NSTIs would aid early diagnosis.

PRESENTATION

We present a case of NSTI, in a seemingly healthy adult male, originating from a tooth abscess. The NSTI progressed rapidly, and eventually covered the patient's chest and abdominal skin and underlying soft tissue.

RESULTS

Traditional blood and tissue culture only found Group C Streptococcus where 16S sequencing detected abundant Prevotella spp., a more likely causal organisms of the NSTI. The use of antibiotics with the approriate anaerobe coverage, in combination with timely surgical intervention, contributed to the ultimate successful clinical outcome. Complete wound healing and successful graft was achieved within one month of diagnosis of the microbes present.

CONCLUSION

While surgical intervention remains the most important consideration in treatment of NSTI, correct identifcation of the microbial flora could also contribute to successful treatment.

Necrotizing Fasciitis: Low-Dose Radiotherapy as a Potential Adjunct Treatment

Necrotizing fasciitis (NF) is a rapidly spreading bacterial infection causing extensive tissue necrosis and destruction. Despite appropriate therapy, the disease results in significant morbidity/mortality and substantial treatment costs. Several studies published in the early 1900s demonstrated the effective use of low-dose X-ray radiotherapy (RT) for the treatment of many diverse inflammatory conditions and diseases (eg, gas gangrene, sinus infections, arthritis, tendonitis, and serious inflammatory lung conditions). The mechanism by which therapeutic RT doses produce positive patient outcomes is related at least in part to its capacity to induce tissue-based anti-inflammatory responses. This action is due to the polarization of macrophages to an anti-inflammatory or M2 phenotype via optimized low-dose RT. Low-dose RT has the potential to significantly reduce debilitating surgeries and aggressive treatments required for NF, providing a 3-prong benefit in terms of patient mortality, length of hospitalization stays, and cost of health care (both short term and long term). Low cost and easy availability of low-dose RT makes it a potentially useful option for patients of every age-group. In addition, low-dose RT may be a particularly useful option in countries treating many patients who are unable to afford surgeries, antibiotics, and hyperbaric oxygen.

Fournier Gangrene: A Review for Emergency Clinicians

BACKGROUND

Fournier gangrene (FG) is a rare, life-threatening infection that can result in significant morbidity and mortality, with many patients requiring emergency department (ED) management for complications and stabilization.

OBJECTIVE

This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of FG.

DISCUSSION

Although originally thought to be an idiopathic process, FG has been shown to have a strong association for male patients with advanced age and comorbidities affecting microvascular circulation and immune system function, most commonly those with diabetes or alcohol use disorder. However, it can also affect patients without risk factors. The initial infectious nidus is usually located in the genitourinary tract, gastrointestinal tract, or perineum. FG is a mixed infection of aerobic and anaerobic bacterial flora. The development and progression of gangrene is often fulminant and can rapidly cause multiple organ failure and death, although patients may present subacutely with findings similar to cellulitis. Laboratory studies, as well as imaging including point-of-care ultrasound, conventional radiography, and computed tomography are important diagnostic adjuncts, though negative results cannot exclude diagnosis. Treatment includes emergent surgical debridement of all necrotic tissue, broad-spectrum antibiotics, and resuscitation with intravenous fluids and vasoactive medications.

CONCLUSIONS

FG requires a high clinical level of suspicion, combined with knowledge of anatomy, risk factors, and etiology for an accurate diagnosis. Although FG remains a clinical diagnosis, relevant laboratory and radiography investigations can serve as useful adjuncts to expedite surgical management, hemodynamic resuscitation, and antibiotic administration.

Transfer Is Associated with a Higher Mortality Rate in Necrotizing Soft Tissue Infections

Background: Necrotizing soft tissue infections (NSTI) are a surgical emergency with significant morbidity and mortality rates. It has been thought that NSTIs are best treated in large tertiary centers. However, the effect of transfer has been under-studied. We examined whether transfer status is associated with a higher mortality rate in NSTIs. Methods: We conducted a retrospective review of patients with an International Classification of Disease (ICD) code associated with NSTI seen from 2012-2015 at two tertiary care institutions. Patients transferred to a tertiary center (T-NSTI) were compared with those who were treated initially at a tertiary center (P-NSTI). The primary endpoint was in-hospital death. Results: A total of 138 patients with NSTI met our study criteria, 39 transfer patients (28.0%) and 99 (72.0%) who were treated primarily at our institutions. The mortality rate was significantly higher for T-NSTI patients than P-NSTI patients (35.9% versus 14.1%; p < 0.01) with an adjusted odds ratio of 5.33 (95% confidence interval 1.02-28.30; p = 0.04). The need for hemodialysis was an independent predictor of in-hospital death. Treatment at a Level 1 trauma center and current smoking status were independent protectors???? of in-hospital death. For the transfer patients, the timing of transfer and debridement status were not different in survivors and non-survivors. However, there was a trend toward a lower in-hospital mortality rate if patients were transferred early without prior debridement than in all other transfers (21.4% versus 40.0%; p = 0.21). The in-hospital mortality rate was significantly lower at the Level 1 trauma center than at the non-trauma tertiary center (15.5% versus 34.3%; p = 0.02). Conclusion: Transfer status is an independent predictor of in-hospital death in patients with NSTI. Larger, multi-institutional studies are needed to elucidate further what factors contribute to the higher mortality rate in these patients.

A 5-Year Evaluation of the Implementation of Triple Diagnostics for Early Detection of Severe Necrotizing Soft Tissue Disease: A Single-Center Cohort Study

BACKGROUND

The standardized approach with triple diagnostics (surgical exploration with visual inspection, microbiological and histological examination) has been proposed as the golden standard for early diagnosis of severe necrotizing soft tissue disease (SNSTD, or necrotizing fasciitis) in ambivalent cases. This study's primary aim was to evaluate the protocolized approach after implementation for diagnosing (early) SNSTD and relate this to clinical outcome.

METHODS

A cohort study analyzing a 5-year period was performed. All patients undergoing surgical exploration (with triple diagnostics) for suspected SNSTD since implementation were prospectively identified. Demographics, laboratory results and clinical outcomes were collected and analyzed.

RESULT

Thirty-six patients underwent surgical exploration with eight (22%) negative explorations. The overall 30-day mortality rate was 25%, with an early, SNSTD-related mortality rate of 11% (n = 3). Of these, one patient (4%) underwent primary amputation, but died during surgery. No significant differences between baseline characteristics were found between patients diagnosed with SNSTD in early/indistinctive or late/obvious stage. Patient diagnosed at an early stage had a significantly shorter ICU stay (2 vs. 6 days, p = 0.031). Mortality did not differ between groups; patients who died were all ASA IV patients.

CONCLUSION

Diagnosing SNSTD using the approach with triple diagnostics resulted in a low mortality rate and only a single amputation in a pre-terminal patient in the first 5 years after implementation. All deceased patients had multiple preexisting comorbidities consisting of severe systemic diseases, such as end-stage heart failure. Early detection proved to facilitate faster recovery with shorter ICU stay.

Group G streptococcus leading to necrotizing soft tissue infection after left lower extremity radiofrequency venous ablation

A 73-year-old morbidly obese woman developed a severe group G Streptococcus (GGS) necrotizing soft tissue infection (NSTI), superimposed by toxic shock-like syndrome after undergoing radiofrequency venous ablation of her left lower extremity. NSTI secondary to GGS are relatively uncommon, with only nine cases described in the literature. We present a case of GGS NSTI, a debilitating wound infection, occurring after radiofrequency venous ablation. Early identification and treatment are imperative to prevent mortality from NSTI and care must be taken when selecting patients for percutaneous endovascular ablation as they are at risk for such infections.

Risk factors of synchronous multifocal necrotizing fasciitis: a case control study in comparison with monofocal necrotizing fasciitis in Taiwan

Background

Monofocal necrotizing fasciitis (MONF) involves a single site in a rapidly progressing infection and necrosis of the fascia and surrounding soft tissue. Synchronous multifocal necrotizing fasciitis (SMNF), the simultaneous development of NF in multiple noncontiguous sites, is rarely reported. This study aimed to compare the clinical characteristics and outcomes between patients with SMNF and MONF, and to determine the risk factors of SMNF.

Methods

Our retrospective case-control study compared the clinical characteristics and outcomes, between January 2006 and January 2013, of patients with SMNF and of patients with MONF of the extremities.

Results

We enrolled 144 patients with NF of the extremities: 19 with SMNF and 125 with MONF. The duration of symptoms before admission was significantly shorter for the former than for the latter (1.7 days vs. 3.3 days, p = 0.001); the prevalence of shock at the initial visit significantly higher (73.7% vs. 36%, p = 0.002); and the total-case postoperative mortality rate significantly higher (68.4% vs. 14.4%, p <  0.001). In further analysis of the total-case mortality, 9 in 13 SMNF deaths (69.2%) within 7 days after fasciotomy were in the majority while 13 with 28-day mortality (72.2%) was the majority of MONF deaths (p <  0.001). SMNF was significantly more likely to involve bacteremia (89.5% vs. 36%, p <  0.001). Independent risk factors for SMNF were liver cirrhosis (LC) (odds ratio [OR] 6.0, p = 0.001) and end-stage renal disease (ESRD) (OR 7.1, p = 0.035). Gram-negative bacteria were most common in SMNF, and Gram-positive bacteria in MONF (83.3% vs. 53.3%, p = 0.005). Vibrio species were the most common single microbial cause (35.4%) of all NF patients and were the overwhelming cause (73.7%) of SMNF. Staphylococcus aureus and group A β-hemolytic streptococcus (45.6%) were the other predominant causes of MONF while both (10.5%) rarely caused multifocal NF.

Conclusions

SMNF was more fulminant than was MONF. SMNF was attributable primarily to marine Gram-negative bacteria. Physicians should be aware of SMNF because of its extremely high mortality rate.

Surgical intervention and customised dressings in an extremity wound caused by necrotising fasciitis: a case study

Necrotising fasciitis can result in extensive loss of soft tissue and limb function. Therefore, surgical intervention requires a balance between extensive tissue removal and saving the limb. A 56-year-old male presented with necrotising fasciitis of the upper extremity. Debridement resulted in a full-thickness wound of the forearm and upper arm, an exposed olecranon and two proximally-based skin flaps. Reconstruction required multiple debridements to optimise the wound for skin grafting and to obtain flap adherence to underlying tissues of the upper arm. Conventional dressings over the flaps proved unsuccessful. Therefore, a customised versatile dressing to address each area of the wound was developed. Negative pressure wound therapy (NPWT) was applied over the exposed muscle (no exposed bone or tendon) of the lower arm and anterior upper arm; a hydropolymer foam dressing covered the elbow region. Closed incision negative pressure wound therapy (ciNPT) was applied over the incision on the posterior upper arm. Ultimately, complete wound closure was achieved, with normal/near-normal range of motion for all joints of the affected limb. There was complete take of skin grafts on the wrist, lower arm and anterior upper arm. ciNPT was effective in holding the incision together and promoting healing of the posterior upper arm, and the hydropolymer foam dressing aided with healing and coverage of the elbow region. In this case, healing of a large, complex upper extremity wound and restored limb function were achieved following use of a combination of surgical techniques and customisation of wound therapy modalities.

Optimal timing of initial debridement for necrotizing soft tissue infection: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND

Necrotizing soft tissue infections (NSTI) are rare, life-threatening, soft-tissue infections characterized by rapidly spreading inflammation and necrosis of the skin, subcutaneous fat, and fascia. While it is widely accepted that delay in surgical debridement contributes to increased mortality, there are currently no practice management guidelines regarding the optimal timing of surgical management of this condition. Although debridement within 24 hours of diagnosis is generally recommended, the time ranges from 3 hours to 36 hours in the existing literature. Therefore, the objective of this article is to provide evidence-based recommendations for the optimal timing of surgical management of NSTI.

METHODS

The MEDLINE database using PubMed was searched to identify English language articles published from January 1990 to September 2015 regarding adult and pediatric patients with NSTIs. A systematic review of the literature was performed, and the Grading of Recommendations Assessment, Development and Evaluation framework were used. A single population [P], intervention [I], comparator [C], and outcome [O] (PICO) question was applied: In patients with NSTI (P), should early (<12 hours) initial debridement (I) versus late (≥12 hours) initial debridement (C) be performed to decrease mortality (O)?

RESULTS

Two hundred eighty-seven articles were identified. Of these, 42 papers underwent full text review and 6 were selected for guideline construction. A total of 341 patients underwent debridement for NSTI. Of these, 143 patients were managed with early versus 198 with late operative debridement. Across all studies, there was an overall mortality rate of 14% in the early group versus 25.8% in the late group.

CONCLUSION

For NSTIs, we recommend early operative debridement within 12 hours of suspected diagnosis. Institutional and regional systems should be optimized to facilitate prompt surgical evaluation and debridement.

LEVEL OF EVIDENCE

Systematic review/meta-analysis, level IV.

A Systematic Review of the Laboratory Risk Indicator for Necrotizing Fasciitis Score and Its Utility in Orthopedics for Diagnosing Necrotizing Fasciitis in Adults

Given its association with trauma and surgery, necrotizing fasciitis is a disease orthopedists are likely to encounter. The laboratory risk indicator for necrotizing fasciitis score is an adjunct diagnostic test designed to help diagnose early necrotizing fasciitis infections, but studies evaluating the scoring system have reported conflicting results. The purpose of this systematic review was to provide clarity on the laboratory risk indicator for necrotizing fasciitis score's capabilities and when it is best used. [Orthopedics. 2019; 42(3):e288-e294.].

Effects of seasonal changes in temperature and humidity on incidence of necrotizing soft tissue infections in Halifax, Canada, 2001-2015

OBJECTIVES

To explore weather seasonal variation in Necrotizing soft tissue infections (NSTI) in Halifax, Nova Scotia, Canada could be attributed to changes in environmental factors of temperature and humidity specifically.

METHODS

A retrospective chart review of NSTIs between 2001 and 2015. Regional temperature and humidity data were obtained from the Environment Canada Agency, Halifax, Canada. Chi-square was used for categorical variables and continuous data was used for correlation analyses. Logistic regression was performed to analyze mortality. Results: Of 170 NSTI patients identified, more presented from March to July, especially when the temperature was greater than 10ºC. Higher incidence per 100,000 persons correlated with increased monthly temperatures (p less than 0.01). Monthly NSTI incidence was inversely related to mean humidity (p=0.005). Causative organism was associated with mean weekly temperature (p less than 0.01) but not humidity (p=0.66). Low body mass index, higher American Society of Anesthesiologists class, long intensive care unit stay, and shorter overall hospital stay were associated with mortality. No correlation was identified between temperature and humidity and mortality.

CONCLUSION

This study demonstrates a tendency toward more frequent cases of NSTI with warmer, but less humid weather, without effect on severity or mortality.

Dermatological Disorders following Liver Transplantation: An Update

Patients undergoing liver transplantation (LT) are at a high risk of dermatological complications compared to the general population as a result of long-term use of immunosuppressant. However, the risk is not as high as other solid organ transplantations (SOT), particularly for skin cancer. The liver is considered as an immune privileged organ since it has a low prevalence of humoral rejection in contrast to other SOT, and thus, LT requires a minimal amount of immunosuppressants compared to other SOT recipients. However, because of the large volume of the liver, patients with LT have higher donor lymphocytes that sometimes may trigger graft-versus-host-disease, yet it is rare. On the other hand, the vast majority of the nonspecific dermatological lesions linked with cirrhosis improve after removal of diseased liver or due to the immunosuppressant used after LT. Nevertheless, dermatological infections related to bacteria, viruses, and fungus after LT are not uncommon. Additionally, the incidence of IgE-mediated food allergies develops in 12.2% of LT patients and may present as life-threatening conditions such as urticaria and/or angioedema and hypersensitivity. Moreover, skin malignancies after LT are a matter of concern. Thus, posttransplant dermatological care should be provided to all LT patients for any suspicious dermatological lesions. Our goal is to give an outline of the dermatological manifestation associated with LT for the clinicians by collecting the published data from all archived case reports.