151
|
Optimal timing of initial debridement for necrotizing soft tissue infection: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2019; 85:208-214. [PMID: 29485428 DOI: 10.1097/ta.0000000000001857] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
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.
Collapse
|
152
|
Keeling PA, Domes CM. A Systematic Review of the Laboratory Risk Indicator for Necrotizing Fasciitis Score and Its Utility in Orthopedics for Diagnosing Necrotizing Fasciitis in Adults. Orthopedics 2019; 42:e288-e294. [PMID: 30964538 DOI: 10.3928/01477447-20190403-07] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 09/12/2018] [Indexed: 02/03/2023]
Abstract
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.].
Collapse
|
153
|
Fadel ZT, Burke E, Joukhadar N, Samargandi OA, Bezuhly M. Effects of seasonal changes in temperature and humidity on incidence of necrotizing soft tissue infections in Halifax, Canada, 2001-2015. Saudi Med J 2019; 40:469-474. [PMID: 31056624 PMCID: PMC6535159 DOI: 10.15537/smj.2019.5.24096] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 03/12/2019] [Indexed: 12/22/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Zahir T Fadel
- Division of Plastic and Reconstructive Surgery, Dalhousie University, Halifax, Nova Scotia, Canada. E-mail.
| | | | | | | | | |
Collapse
|
154
|
Dermatological Disorders following Liver Transplantation: An Update. Can J Gastroenterol Hepatol 2019; 2019:9780952. [PMID: 31058114 PMCID: PMC6463607 DOI: 10.1155/2019/9780952] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 02/24/2019] [Accepted: 03/11/2019] [Indexed: 02/08/2023] Open
Abstract
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.
Collapse
|
155
|
Polzik P, Grøndal O, Tavenier J, Madsen MB, Andersen O, Hedetoft M, Hyldegaard O. SuPAR correlates with mortality and clinical severity in patients with necrotizing soft-tissue infections: results from a prospective, observational cohort study. Sci Rep 2019; 9:5098. [PMID: 30911053 PMCID: PMC6434142 DOI: 10.1038/s41598-019-41688-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 03/13/2019] [Indexed: 01/12/2023] Open
Abstract
Necrotizing soft tissue infections (NSTI) have a 90-day mortality rate of 18–22%. Tools are needed for estimating the prognosis and severity of NSTI upon admission. We evaluated soluble urokinase-type plasminogen activator receptor (suPAR) levels at admission as a prognostic marker of NSTI severity and mortality. In a prospective, observational cohort study, suPAR was measured in 200 NSTI patients. We compared admission suPAR levels in survivors and non-survivors, patients with septic shock and non-shock, amputation and non-amputation, correlations with Simplified Acute Physiology Score II (SAPS II) and the Sequential Organ Failure Assessment (SOFA) score. Admission suPAR levels were higher in septic shock vs. non-septic shock patients (9.2 vs. 5.8 ng/mL, p-value < 0.001) and non-survivors vs. survivors (11 vs. 6.1 ng/mL, p-value < 0.001) and correlated with SAPS II (r = 0.52, p < 0.001) and SOFA score (r = 0.64, p < 0.001). Elevated suPAR upon admission was associated with 90-day mortality (log-rank test p < 0.001), however not after adjustment for age, sex, and SOFA score. The AUC for suPAR and 90-day mortality was 0.77. We found that suPAR is a promising candidate for prognosis and severity in patients with NSTI.
Collapse
Affiliation(s)
- Peter Polzik
- Department of Anesthesiology, Center of Head and Orthopedics, Copenhagen University Hospital (Rigshospitalet), Copenhagen Ø, Denmark.
| | - Olav Grøndal
- Department of Anesthesiology, Center of Head and Orthopedics, Copenhagen University Hospital (Rigshospitalet), Copenhagen Ø, Denmark
| | - Juliette Tavenier
- Clinical Research Center, Copenhagen University Hospital (Hvidovre), Hvidovre, Denmark
| | - Martin B Madsen
- Department of Intensive Care, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
| | - Ove Andersen
- Clinical Research Center, Copenhagen University Hospital (Hvidovre), Hvidovre, Denmark.,The Emergency Department, Copenhagen University Hospital (Hvidovre), Hvidovre, Denmark
| | - Morten Hedetoft
- Hyperbaric Medicine Center, Department of Anesthesiology, Center of Head and Orthopedics, University Hospital of Copenhagen (Rigshospitalet), Copenhagen, Denmark
| | - Ole Hyldegaard
- Department of Anesthesiology, Center of Head and Orthopedics, Copenhagen University Hospital (Rigshospitalet), Copenhagen Ø, Denmark
| |
Collapse
|
156
|
SAĞKAN ÖZTÜRK A, KÖSE Sİ. Gizli Tehdit: Et Yiyen Zoonoz Bakteriler. KAHRAMANMARAŞ SÜTÇÜ İMAM ÜNIVERSITESI TIP FAKÜLTESI DERGISI 2019. [DOI: 10.17517/ksutfd.438344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
|
157
|
Chang CP, Fann WC, Wu SR, Lin CN, Hsiao CT. Lactate on emergency department arrival as a predictor of in-hospital mortality in necrotizing fasciitis: a retrospective study. J Orthop Surg Res 2019; 14:73. [PMID: 30841912 PMCID: PMC6402084 DOI: 10.1186/s13018-019-1108-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 02/21/2019] [Indexed: 01/01/2023] Open
Abstract
Background Hyperlactatemia is known to be associated with adverse outcome in critical illness. In this study, we attempted to identify if hyperlactatemia on emergency department (ED) arrival is a reliable predictor for in-hospital mortality in necrotizing fasciitis (NF) patients. Method A prospective cohort study of hospitalized patients with NF was conducted in two tertiary teaching hospitals in Taiwan between March 2010 and March 2018. Blood samples were collected in the ED upon arrival, and the lactate levels were determined. Sequential organ failure assessment (SOFA) scores were calculated during the first 24 h after admission. All collected data were statistically analyzed. Result Of the 707 NF patients, 40 (5.66%) died in the hospital. The median (interquartile range) blood lactate level in all NF patients was 3.6 mmol/l (2.2–4.8). The blood lactate level upon ED arrival was significantly associated with mortality (odds ratio [OR] = 1.35; 95% confidence interval [CI], 1.30–1.46; P < 0.001), even after adjustment for age and SOFA score (OR = 1.27; P < 0.001). Multivariate regression analysis showed that a high blood lactate level (OR = 1.17; 95% CI, 1.07–1.29; P = 0.001) and a high SOFA score (OR = 1.15; 95% CI, 1.11–1.20; P < 0.001) were independent risk factors for in-hospital mortality in NF. Blood lactate achieved an area under-the-receiver-operating-characteristic curve (AUC) of 0.79 (P < 0.001) for predicting mortality that was similar to that of SOFA score (AUC = 0.82; P < 0.001). Blood lactate displayed a sensitivity of 62% and a specificity of 86% in predicting mortality at the optimal cutoff value of 5.80 mmol/l. Conclusion In necrotizing fasciitis patients, hyperlactatemia on ED arrival is independently associated with in-hospital mortality. NF patients with hyperlactatemia on ED arrival should be closely monitored for signs of deterioration and consider early and aggressive intervention to prevent mortality.
Collapse
Affiliation(s)
- Chia-Peng Chang
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No.6, Sec. W., Jiapu Rd., Puzi City, Chiayi County, 613, Taiwan, Republic of China
| | - Wen-Chih Fann
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No.6, Sec. W., Jiapu Rd., Puzi City, Chiayi County, 613, Taiwan, Republic of China.,Department of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shu-Ruei Wu
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chun-Nan Lin
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No.6, Sec. W., Jiapu Rd., Puzi City, Chiayi County, 613, Taiwan, Republic of China
| | - Cheng-Ting Hsiao
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No.6, Sec. W., Jiapu Rd., Puzi City, Chiayi County, 613, Taiwan, Republic of China. .,Department of Medicine, Chang Gung University, Taoyuan, Taiwan.
| |
Collapse
|
158
|
Tessler RA, Vanhoy S, Bergus K, Fong C, Bulger EM, Rivara FP, Vavilala MS. Higher LRINEC Scores and Escalation of Anesthesia Care in Necrotizing Soft Tissue Infection. J Surg Res 2019; 238:119-126. [PMID: 30769248 DOI: 10.1016/j.jss.2019.01.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 10/21/2018] [Accepted: 01/11/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score may distinguish necrotizing soft tissue infection (NSTI) from non-NSTI. The association of higher preoperative LRINEC scores with escalations of intraoperative anesthesia care in NSTI is unknown and may be useful in communicating illness severity during patient handoffs. MATERIALS AND METHODS We conducted a retrospective cohort study of first operative debridement for suspected NSTI in a single referral center from 2013 to 2016. We assessed the association between LRINEC score and vasopressors, blood products, crystalloid, invasive monitoring, and minutes of operative and anesthesia care. RESULTS We captured 332 patients undergoing their first operative debridement for suspected NSTI. For every 1-point higher LRINEC score, there was a higher risk of norepinephrine and vasopressin use (relative risk [RR] = 18%, 95% confidence interval [CI] [10%, 26%] and [10%, 27%], respectively), packed red blood cell use (RR = 28% [95% CI 13%, 45%]), and additional crystalloid (17.57 mL/h [95% CI 0.37, 34.76]). Each additional LRINEC point was associated with longer anesthesia (3.42 min, 95% CI 0.94, 5.91) and operative times (2.35 min, 95% CI 0.29, 4.40) and a higher risk of receiving invasive arterial monitoring (RR 1.11, 95% CI 1.05, 1.18). The negative predictive value for an LRINEC score < 6 was > 90% for use of vasopressors and packed red blood cells. CONCLUSIONS Preoperative LRINEC scores were associated with escalations in intraoperative care in patients with NSTI. A low score may predict patients unlikely to require vasopressors or blood and may be useful in standardized handoff tools for patients with NSTI.
Collapse
Affiliation(s)
- Robert A Tessler
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington; Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Steve Vanhoy
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Katherine Bergus
- University of Washington, School of Medicine, Seattle, Washington
| | - Christine Fong
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Eileen M Bulger
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington; Department of Surgery, University of Washington, Seattle, Washington
| | - Frederick P Rivara
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington
| | - Monica S Vavilala
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| |
Collapse
|
159
|
Nawijn F, Wassenaar ECE, Smeeing DPJ, Vlaminckx BJM, Reinders JSK, Wille J, Leenen LPH, Hietbrink F. Exhaustion of the immune system by Group A Streptococcus necrotizing fasciitis: the occurrence of late secondary infections in a retrospective study. Trauma Surg Acute Care Open 2019; 4:e000272. [PMID: 30899798 PMCID: PMC6407531 DOI: 10.1136/tsaco-2018-000272] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 11/18/2018] [Accepted: 11/19/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Necrotizing fasciitis is a potentially lethal condition for which early and adequate treatment with surgical debridement and broad-spectrum intravenous antibiotics are essential for survival. It is hypothesized that Group A Streptococcus (GAS) necrotizing fasciitis causes exhaustion of the immune system, making these patients more susceptible for late secondary infections. METHODS A retrospective study was conducted of all patients with necrotizing fasciitis between 2002 and 2016. Patients with necrotizing fasciitis based on macroscopic findings, positive Gram staining, culture or fresh frozen section of fascia biopsies were included. Patients with necrotizing fasciitis were divided into two groups based on the presence of GAS. Of both groups, clinical course, outcome and occurrence of late secondary infections were analyzed. For the occurrence of secondary infections, pneumonia was chosen as reference for late secondary infections. RESULTS Eighty-one patients with necrotizing fasciitis were included of which 38 (47%) had GAS necrotizing fasciitis and 43 (53%) had non-GAS necrotizing fasciitis. Patients with GAS necrotizing fasciitis were younger (50 vs. 61 years, p=0.023) and more often classified as ASA I (45% vs. 14%, p=0.002) compared with patients with non-GAS necrotizing fasciitis. In-hospital mortality rate for necrotizing fasciitis was 32%. Patients with comorbidities were more likely to die of necrotizing fasciitis compared with patients without comorbidities (OR 7.41, 95% CI 1.58 to 34.63). Twelve patients (39%) with GAS necrotizing fasciitis developed pneumonia compared with four patients (13%) with non-GAS necrotizing fasciitis (p=0.017; OR 4.42, 95% CI 1.124 to 15.79). Median time from diagnosis to development of pneumonia in patients with GAS necrotizing fasciitis was 10 days (IQR 9). CONCLUSION Patients with GAS necrotizing fasciitis have an increased risk to develop late secondary infections during initial treatment for necrotizing fasciitis compared with patients with necrotizing fasciitis without involvement of GAS. This suggests exhaustion of the immune system after severe GAS infection. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Femke Nawijn
- Surgery, Universitair Medisch Centrum Utrecht, Utrecht, Netherlands
| | - Emma C E Wassenaar
- Surgery, Universitair Medisch Centrum Utrecht, Utrecht, Netherlands
- Surgery, Sint Antonius Ziekenhuis, Nieuwegein, Netherlands
| | | | | | | | - Jan Wille
- Surgery, Sint Antonius Ziekenhuis, Nieuwegein, Netherlands
| | - Luke P H Leenen
- Surgery, Universitair Medisch Centrum Utrecht, Utrecht, Netherlands
| | - Falco Hietbrink
- Surgery, Universitair Medisch Centrum Utrecht, Utrecht, Netherlands
| |
Collapse
|
160
|
Greditzer HG, Massel DH, Barrera CM, Emerson CP, Rizzo MG, Ezuddin N, Brasil C, Nuno AU, Jose J. Radiographic Musculoskeletal Findings Indicating Opioid Misuse: An Overview for Orthopedic Surgeons. HSS J 2019; 15:84-92. [PMID: 30863238 PMCID: PMC6384203 DOI: 10.1007/s11420-018-09654-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 11/15/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Given the high prevalence of musculoskeletal conditions in the USA, it is important for orthopedic surgeons to promptly identify patients who may be at risk for opioid misuse. QUESTIONS/PURPOSES The aim of this literature review was to elucidate various musculoskeletal pathologies and complications, as seen on imaging, that may indicate opioid misuse or opioid use disorder. METHODS A literature search was conducted using the PubMed, Scopus, and Cochrane Library databases for articles related to imaging findings associated with chronic opioid use or misuse in orthopedic patients. Two independent reviewers conducted the search utilizing pertinent Boolean operations. RESULTS We reviewed 36 full-text articles and categorized the radiographic evidence of opioid misuse as follows: soft-tissue radiologic findings, cellulitis, necrotizing fasciitis, abscess formation, retained needles, discitis, myopathy and rhabdomyolysis, osteomyelitis, septic arthritis, and septic thrombophlebitis. CONCLUSION Knowledge of the radiologic findings of opioid misuse will assist orthopedic surgeons in making timely diagnoses that may alter therapeutic regimens for their patients.
Collapse
Affiliation(s)
- Harry G. Greditzer
- Department of Radiology, Hospital for Special Surgery, 535 East 70th St., New York, NY 10021 USA
| | - Dustin H. Massel
- UHealth Sports Medicine Institute, University of Miami Miller School of Medicine, Coral Gables, FL USA
| | - Carlos M. Barrera
- UHealth Sports Medicine Institute, University of Miami Miller School of Medicine, Coral Gables, FL USA
| | - Christopher P. Emerson
- UHealth Sports Medicine Institute, University of Miami Miller School of Medicine, Coral Gables, FL USA
| | - Michael G. Rizzo
- UHealth Sports Medicine Institute, University of Miami Miller School of Medicine, Coral Gables, FL USA
| | - Nisreen Ezuddin
- Department of Radiology, Jackson Memorial Hospital, 1611 NW 12th St., Miami, FL 33136 USA
| | - Camila Brasil
- Department of Radiology, Jackson Memorial Hospital, 1611 NW 12th St., Miami, FL 33136 USA
| | - Ane Ugarte Nuno
- Department of Radiology, Hospital Donostia, San Sebastian, Spain
| | - Jean Jose
- UHealth Sports Medicine Institute, University of Miami Miller School of Medicine, Coral Gables, FL USA
- Department of Radiology, Jackson Memorial Hospital, 1611 NW 12th St., Miami, FL 33136 USA
| |
Collapse
|
161
|
Negative Pressure Wound Therapy in Necrotizing Fasciitis of the Head and Neck. J Oral Maxillofac Surg 2019; 77:87-92. [DOI: 10.1016/j.joms.2018.08.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/11/2018] [Accepted: 08/14/2018] [Indexed: 01/22/2023]
|
162
|
Barupal SR, Soni ML, Barupal R. Factors Affecting Mortality Following Necrotizing Soft-Tissue Infections: Randomized Prospective Study. J Emerg Trauma Shock 2019; 12:108-116. [PMID: 31198277 PMCID: PMC6557049 DOI: 10.4103/jets.jets_17_18] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background and Aim: Necrotizing soft-tissue infections (NSTIs) are common in the Indian subcontinent and are associated with high morbidity and mortality. The aim of this paper was to correlate clinical factors and Acute Physiology Health and Chronic Health Evaluation (APACHE) II score with mortality following NSTI. Methodology: Patients presenting to our tertiary-care center between November 1, 2014, and December 1, 2016, with NSTI and between the age of 15 and 90 years were included and entered into a prospectively maintained database. Fifty random patients were selected from the database and were divided according to the survival outcome into two groups: Group 1-survivors and Group 2-nonsurvivors. The two groups were compared for clinical factors and APACHE II score to identify the variable which correlated with the survival. Results: Mean age of the study cohort (n = 50, 44 males) was 50.8 ± 17.1 years. Fournier's gangrene was the most common manifestation (64%), followed by lower limb (14%). Infection was leading cause (34%) followed by trauma (16%) and prior surgery (14%). There were 16 in-hospital deaths (32%). Two groups were similar regarding age and sex. At presentation, nonsurvival group had significantly higher body surface area involvement (P = 0.001), anemia (P = 0.023), metabolic acidosis (P < 0.0001), serum creatinine (P = 0.007), and mean APACHE II score (P < 0.001). There was no difference between time from presentation to the first debridement. Conclusions: We found that APACHE II is a significant predictor of mortality. Early diagnosis and prompt aggressive treatment is the only way to improve outcome. Further studies with larger sample size are warranted.
Collapse
Affiliation(s)
- Sukha Ram Barupal
- Department of General Surgery, Ravindra Nath Tagore Medical College, Maharana Bhupal Hospital, Udaipur, Rajasthan, India
| | - Murari Lal Soni
- Department of General Surgery, Jawahar Lal Nehru Medical College, Ajmer, Rajasthan, India
| | - Rekha Barupal
- Department of Dermatology and Venereology, Ravindra Nath Tagore Medical College, Maharana Bhupal Hospital, Udaipur, Rajasthan, India
| |
Collapse
|
163
|
Ray S, Thapa R, Keyel PA. Multiple Parameters Beyond Lipid Binding Affinity Drive Cytotoxicity of Cholesterol-Dependent Cytolysins. Toxins (Basel) 2018; 11:toxins11010001. [PMID: 30577571 PMCID: PMC6356533 DOI: 10.3390/toxins11010001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 12/14/2018] [Accepted: 12/18/2018] [Indexed: 02/06/2023] Open
Abstract
The largest superfamily of bacterial virulence factors is pore-forming toxins (PFTs). PFTs are secreted by both pathogenic and non-pathogenic bacteria. PFTs sometimes kill or induce pro-pathogen signaling in mammalian cells, all primarily through plasma membrane perforation, though the parameters that determine these outcomes are unclear. Membrane binding, calcium influx, pore size, and membrane repair are factors that influence PFT cytotoxicity. To test the contribution of membrane binding to cytotoxicity and repair, we compared the closely related, similarly-sized PFTs Perfringolysin O (PFO) from Clostridium perfringens and Streptolysin O (SLO) from Streptococcus pyogenes. Cell death kinetics for PFO and SLO were different because PFO increased in cytotoxicity over time. We introduced known L3 loop mutations that swap binding affinity between toxins and measured hemolytic activity, nucleated cell death kinetics and membrane repair using viability assays, and live cell imaging. Altered hemolytic activity was directly proportional to toxin binding affinity. In contrast, L3 loop alterations reduced nucleated cell death, and they had limited effects on cytotoxicity kinetics and membrane repair. This suggests other toxin structural features, like oligomerization, drives these parameters. Overall, these findings suggest that repair mechanisms and toxin oligomerization add constraints beyond membrane binding on toxin evolution and activity against nucleated cells.
Collapse
Affiliation(s)
- Sucharit Ray
- Department of Biological Sciences, College of Arts and Sciences, Texas Tech University, Box 43131, Lubbock, TX 79409, USA.
| | - Roshan Thapa
- Department of Biological Sciences, College of Arts and Sciences, Texas Tech University, Box 43131, Lubbock, TX 79409, USA.
| | - Peter A Keyel
- Department of Biological Sciences, College of Arts and Sciences, Texas Tech University, Box 43131, Lubbock, TX 79409, USA.
| |
Collapse
|
164
|
Diggs LP, Lobb J, Tu C, Osborn T, Wade TP. Necrotizing Soft Tissue Infection of the Right Lower Extremity after Ingestion of a Foreign Body. Am Surg 2018. [DOI: 10.1177/000313481808401203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Laurence P. Diggs
- Thoracic and Oncologic Surgery Branch Center for Cancer Research National Cancer Institute National Institutes of Health Bethesda, Maryland
| | - Jennifer Lobb
- Department of General Surgery Saint Louis University School of Medicine St. Louis, Missouri
| | - Christin Tu
- Department of General Surgery Saint Louis University School of Medicine St. Louis, Missouri
| | - Tamara Osborn
- Department of General Surgery Saint Louis University School of Medicine St. Louis, Missouri
| | - Terence P. Wade
- Department of General Surgery Saint Louis University School of Medicine St. Louis, Missouri
| |
Collapse
|
165
|
Miranda D, Bulger EM. Novel Immune Therapies in the Management of Streptococcal Sepsis and Necrotizing Soft Tissue Infections. Surg Infect (Larchmt) 2018; 19:745-749. [DOI: 10.1089/sur.2018.225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- David Miranda
- Department of Surgery, University of Washington, Harborview Medical Center, Seattle, Washington
| | - Eileen M. Bulger
- Department of Surgery, University of Washington, Harborview Medical Center, Seattle, Washington
| |
Collapse
|
166
|
Diagnostic Performance of Initial Serum Albumin Level for Predicting In-Hospital Mortality among Necrotizing Fasciitis Patients. J Clin Med 2018; 7:jcm7110435. [PMID: 30423847 PMCID: PMC6262451 DOI: 10.3390/jcm7110435] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 11/04/2018] [Accepted: 11/08/2018] [Indexed: 11/20/2022] Open
Abstract
Background: Hypoalbuminemia is known to be associated with adverse outcomes in critical illness. In this study, we attempted to identify whether hypoalbuminemia on emergency department (ED) arrival is a reliable predictor for in-hospital mortality in necrotizing fasciitis (NF). patients. Method: A retrospective cohort study of hospitalized adult patients with NF was conducted in a tertiary teaching hospital in Taiwan between March 2010 and March 2018. Blood samples were collected in the ED upon arrival, and serum albumin levels were determined. We evaluated the predictive value of serum albumin level at ED presentation for in-hospital mortality. All collected data were statistically analyzed. Result: Of the 707 NF patients, 40 (5.66%) died in the hospital. The mean serum albumin level was 3.1 ± 0.9 g/dL and serum albumin levels were significantly lower in the non-survivor group than in the survivor group (2.8 ± 0.7 g/dL vs. 3.5 ± 0.8 g/dL). In the multivariable logistic regression model, albumin was significantly associated with in-hospital mortality (odds ratio (OR) 0.92, 95% confidence interval (CI) 0.88–0.96, p < 0.001). The area under-the-receiver-operating-characteristic curve (AUC) for in-hospital survival was 0.77 (95% CI 0.72–0.82) and corresponding sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratio were 66%, 74%, 33%, 88%, 2.25, and 0.48, respectively. High sensitivity (96%) for survival was shown at albumin level of 4.0 g/dL and high specificity (91%) for mortality was shown at a level of 2.5 g/dL. Conclusion: Initial serum albumin levels strongly predicted in-hospital mortality among patients with necrotizing fasciitis. NF patients with hypoalbuminemia on ED arrival should be closely monitored for signs of deterioration and early and aggressive intervention should be considered to prevent mortality.
Collapse
|
167
|
Necrotizing fasciitis of chest and right abdominal wall caused by acute perforated appendicitis: Case report. Int J Surg Case Rep 2018; 53:32-34. [PMID: 30368121 PMCID: PMC6205061 DOI: 10.1016/j.ijscr.2018.09.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 09/07/2018] [Accepted: 09/18/2018] [Indexed: 02/01/2023] Open
Abstract
Necrotizing fasciitis is an uncommon infection and it remains a life-threatening condition. Necrotizing fasciitis of chest caused by acute perforated appendicitis causes a fulminant course and high mortality rate. Antibiotic administration, surgery and Hyperbaric oxygen therapy are the appropriate choice for necrotizing fascitis management.
Introduction Necrotizing fasciitis is an uncommon infection characterized by a necrotic infection that rapidly diffuse along the fascia and progresses to systemic sepsis. The combined occurrence of necrotizing fasciitis of the chest wall and acute appendicitis is extremely unusual. Case presentation A 27-year-old man without any significant medical history presented to the emergency department, in the postoperative course of a laparotomy for perforated acute appendicitis, with septic shock and a large erythematous region over the right abdominal wall. Laboratory evaluation revealed leucocytosis and lactic acidosis. A new surgical exploration revealed a purulent peritonitis with necrotizing fasciitis involving the right lower abdomen, right psoas muscle and right retroperitoneum. On intensive care unit, the patient was managed with intravenous antibiotics and surgical debridement. In the following days, the patient developed extension of the necrosis to the right chest wall. A computed tomography scan of the chest showed right-sided pleural effusion with erosive aspect of the ribs. Necrotic tissues were debrided and antibiotic was changed due to wound superinfection with Acinetobacter Baumannii. Discussion Necrotizing fasciitis of chest due to acute appendicitis is extremely unusual. The optimal treatment associates appropriate antibiotics, oxygenation of infected tissue, and surgical debridement. Conclusion Acute appendicitis resulting in necrotizing fasciitis of chest is rare but life-threatening. Early diagnosis and treatment is essential to reduce morbidity and mortality.
Collapse
|
168
|
Westphal LP, Guggenberger R, Ho M, Jung HH, Petersen JA. Lumbosacral plexus palsy and pelvic myositis after gluteal muscle injection. Neurol Clin Pract 2018; 8:e21-e22. [DOI: 10.1212/cpj.0000000000000519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 06/04/2018] [Indexed: 11/15/2022]
|
169
|
Risk factors for mortality in the late amputation of necrotizing fasciitis: a retrospective study. World J Emerg Surg 2018; 13:45. [PMID: 30302124 PMCID: PMC6167772 DOI: 10.1186/s13017-018-0207-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 09/21/2018] [Indexed: 11/17/2022] Open
Abstract
Background Necrotizing fasciitis (NF) is a rapidly progressive infectious disease that primarily involves the fascia and subcutaneous tissue. If not promptly treated, it can lead to morbidity as well as mortality. It can affect any part of the body, most commonly the extremities. Early and aggressive surgical treatment is the proper way of management. The purpose of this study was to identify the risk factors for mortality in late amputation among NF patients that may be used in routine clinical practice to prevent mortality. Methods A retrospective cohort study of hospitalized patients with NF was conducted in a tertiary teaching hospital in Taiwan between March 2015 and March 2018. All collected data were statistically analyzed. Results A total of 582 patients with NF were included; 35 of them had undergone amputation (7 primary and 28 late amputations), with a 6% amputation rate. Thirteen amputated patients still died eventually (all in the late amputation group). Significant risk factors for mortality identified in the late amputation group included hemorrhagic bullae (p = 0.001, OR 4.7, 95% confidence interval (CI) 2.68–8.69), peripheral vascular disease (p < 0.001, OR 3.2, 95% CI 1.12–10.58), bacteremia (p = 0.021, OR 2.87, 95% CI 2.07–5.96), and Laboratory Risk Indicator of Necrotizing Fasciitis (LRINEC) score > 8 (p < 0.001, OR 1.97, 95% CI 1.28–4.61). Vibrio vulnificus was the main causative organism based on our study, but the microbiology results showed no significant correlation. Conclusion NF patients with hemorrhagic bullae, comorbidity with peripheral vascular disease, presence of bacteremia, or LRINEC score > 8 should receive early and primary amputation in order to prevent mortality.
Collapse
|
170
|
Erichsen Andersson A, Egerod I, Knudsen VE, Fagerdahl AM. Signs, symptoms and diagnosis of necrotizing fasciitis experienced by survivors and family: a qualitative Nordic multi-center study. BMC Infect Dis 2018; 18:429. [PMID: 30153808 PMCID: PMC6114743 DOI: 10.1186/s12879-018-3355-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 08/22/2018] [Indexed: 01/11/2023] Open
Abstract
Background Necrotizing soft tissue infection is the most serious of all soft tissue infections. The patient’s life is dependent on prompt diagnosis and aggressive treatment. Diagnostic delays are related to increased morbidity and mortality, and the risk of under- or missed diagnosis is high due to the rarity of the condition. There is a paucity of knowledge regarding early indications of disease. The aim of the study has thus been to explore patients’ and families’ experiences of early signs and symptoms and to describe their initial contact with the healthcare system. Methods A qualitative explorative design was used to gain more knowledge about the experience of early signs and symptoms. Fifty-three participants from three study sites were interviewed. The framework method was used for data analysis. Results Most of the participants experienced treatment delay and contacted healthcare several times before receiving correct treatment. The experience of illness varied among the participants depending on the duration of antecedent signs and symptoms. Other important findings included the description of three stages of early disease progression with increase in symptom intensity. Pain experienced in necrotizing soft tissue infections is particularly excruciating and unresponsive to pain medication. Other common symptoms were dyspnea, shivering, muscle weakness, gastrointestinal problems, anxiety, and fear. Conclusion Our study adds to the understanding of the lived experience of NSTI by providing in-depth description of antecedent signs and symptoms precipitating NSTI-diagnosis. We have described diagnostic delay as patient-related, primary care related, or hospital related and recommend that patient and family narratives should be considered when diagnosing NSTI to decrease diagnostic delay.
Collapse
Affiliation(s)
- Annette Erichsen Andersson
- Institute of Health Care Sciences, Sahlgrenska Academy, University of Gothenburg, Box 457, 405 30, Göteborg, Sweden. .,Department of Orthopaedic Surgery, Sahlgrenska University Hospital/Mölndal, Gothenburg, Sweden.
| | - Ingrid Egerod
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Rigshospitalet, Copenhagen University Hospital, Intensive care unit 4131, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Vibeke E Knudsen
- Rigshospitalet, Copenhagen University Hospital, Intensive care unit 4131, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Ann-Mari Fagerdahl
- Wound Centre, Södersjukhuset, Department of Clinical Science and Education, 118 83 Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
171
|
Alkazemi MH, Brousell S, Fantony J, Tsivian M, Moul JW. A Case of Fatal Clostridial Necrotizing Fasciitis After Radical Prostatectomy. Urology 2018; 122:28-31. [PMID: 30009841 DOI: 10.1016/j.urology.2018.06.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 06/25/2018] [Accepted: 06/27/2018] [Indexed: 10/28/2022]
Affiliation(s)
| | - Steven Brousell
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC
| | - Joseph Fantony
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC
| | - Matvey Tsivian
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC
| | - Judd W Moul
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC.
| |
Collapse
|
172
|
Martinez M, Peponis T, Hage A, Yeh DD, Kaafarani HMA, Fagenholz PJ, King DR, de Moya MA, Velmahos GC. The Role of Computed Tomography in the Diagnosis of Necrotizing Soft Tissue Infections. World J Surg 2018; 42:82-87. [PMID: 28762168 DOI: 10.1007/s00268-017-4145-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The exact role of IV contrast-enhanced computed tomography (CT) in the diagnosis of necrotizing soft tissue infections (NSTIs) has not yet been established. We aimed to explore the role of CT in patients with clinical suspicion of NSTI and assess its sensitivity and specificity for NSTI. METHODS The medical records of patients admitted between 2009 and 2016, who received IV contrast-enhanced CT to rule out NSTI, were reviewed. CT was considered positive in case of: (a) gas in soft tissues, (b) multiple fluid collections, (c) absence or heterogeneity of tissue enhancement by the IV contrast, and (d) significant inflammatory changes under the fascia. NSTI was confirmed only by the presence of necrotic tissue during surgical exploration. NSTI was considered absent if surgical exploration failed to identify necrosis, or if the patient was successfully treated non-operatively. RESULTS Of the 184 patients, 17 had a positive CT and hence underwent surgical exploration with NSTI being confirmed in 13 of them (76%). Of the 167 patients that had a negative CT, 38 (23%) underwent surgical exploration due to the high clinical suspicion for NSTI and were all found to have non-necrotizing infections; the remaining 129 (77%) were managed non-operatively with successful resolution of symptoms. The sensitivity of CT in identifying NSTI was 100%, the specificity 98%, the positive predictive value 76%, and the negative predictive value 100%. CONCLUSIONS A negative IV contrast-enhanced CT scan can reliably rule out the need for surgical intervention in patients with initial suspicion of NSTI.
Collapse
Affiliation(s)
- Myriam Martinez
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - Thomas Peponis
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - Aglaia Hage
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - Daniel D Yeh
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - Peter J Fagenholz
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - David R King
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - Marc A de Moya
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA.
| |
Collapse
|
173
|
Paulis J, Tay ET. Necrotizing fasciitis with pulmonary septic emboli following an infected insect bite. Am J Emerg Med 2018; 36:2134.e3-2134.e4. [PMID: 30126671 DOI: 10.1016/j.ajem.2018.08.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 08/11/2018] [Indexed: 12/01/2022] Open
Abstract
Although systemic infections originating from skin infections caused by insect bites are uncommon, it is imperative to maintain a broad differential diagnosis should patients develop systemic symptoms. Necrotizing fasciitis is a rare diagnosis, and progression to septic pulmonary emboli is even less common. Emergent identification and aggressive treatment of these two disease processes are imperative as both carry high rates of morbidity and mortality.
Collapse
Affiliation(s)
- Jacqueline Paulis
- New York University School of Medicine, Department of Emergency Medicine, 462 First Ave, Suite A345, New York, NY 10016, United States of America
| | - Ee Tein Tay
- New York University School of Medicine, Department of Emergency Medicine, 462 First Ave, Suite A345, New York, NY 10016, United States of America.
| |
Collapse
|
174
|
Yun SH, Park JC, Kim YJ. Necrotizing fasciitis likely mistaken for chronic low back pain - A case report -. Anesth Pain Med (Seoul) 2018. [DOI: 10.17085/apm.2018.13.3.298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- So Hui Yun
- Department of Anesthesiology and Pain Medicine, Jeju National University Hospital, Jeju, Korea
- Department of Anesthesiology and Pain Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - Jong Cook Park
- Department of Anesthesiology and Pain Medicine, Jeju National University Hospital, Jeju, Korea
- Department of Anesthesiology and Pain Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - You Jin Kim
- Department of Anesthesiology and Pain Medicine, Jeju National University Hospital, Jeju, Korea
| |
Collapse
|
175
|
Hyperbaric Oxygen Therapy and Utilization in Infectious Disease. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2018. [DOI: 10.1007/s40138-018-0166-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
176
|
González-Senac NM, García Pardo de Santayana MÁ, Pérez Aznar MC. [Necrotising fasciitis in an elderly oncologic patient]. Rev Esp Geriatr Gerontol 2018; 53:230-232. [PMID: 29162277 DOI: 10.1016/j.regg.2017.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 10/03/2017] [Indexed: 06/07/2023]
Affiliation(s)
| | | | - María Coro Pérez Aznar
- Unidad de Cuidados Paliativos, Hospital General Universitario Gregorio Marañón, Madrid, España
| |
Collapse
|
177
|
Haac B, Henry S, Diaz J, Scalea T, Stein D. Early Enteral Nutrition is Associated with Reduced Morbidity in Critically Ill Soft Tissue Patients. Am Surg 2018. [DOI: 10.1177/000313481808400656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Soft tissue diseases including necrotizing soft tissue infections are associated with high mortality and morbidity with hospital-acquired infection rates up to 76 per cent. Critically ill patients with soft tissue infections have increased metabolic requirements; however, the effect of early nutrition on inhospital morbidity including nosocomial infection rates remains unclear. We hypothesized that enteral nutrition within 48 hours of intensive care unit admission would be associated with fewer hospital-acquired infections. We conducted a retrospective review of patients with soft tissue infection requiring intensive care unit admission for >72 hours from January 2013 through December 2014 to a high-volume, dedicated soft tissue service. Variables were compared using chisquared, Student's t test, linear regression, and binary logistic regression analysis. Eighty-five patients met inclusion criteria; 80 per cent started enteral nutrition within 48 hours. Twenty-six per cent had a hospital-acquired infection postadmission requiring treatment. Patients started on enteral nutrition within 48 hours had fewer ventilator days (mean 5 vs 12) and shorter hospital length of stay (mean 18 vs 40 days) when adjusted for age, gender, and confounding variables present on admission. Patients receiving early nutrition also had fewer hospital-acquired infections (18 vs 59%) when adjusted for confounding factors (aOR 0.15, P = 0.045). No significant difference in mortality (13.2% early vs 5.9% late, P = 0.4) or for inhospital morbidity when evaluating percentage of goal calories or protein received or time to goal tube feed rate was found. Early enteral feeding is associated with reduced inhospital morbidity in critically ill soft tissue patients, including fewer hospital-acquired infections and ventilator days, and shorter total length of stay.
Collapse
Affiliation(s)
- Bryce Haac
- From the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - Sharon Henry
- From the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - Jose Diaz
- From the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - Thomas Scalea
- From the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - Deborah Stein
- From the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| |
Collapse
|
178
|
Yeika EV, Foryoung JB, Efie DT, Nkwetateba EA, Tolefac PN, Ngowe MN. Multidrug resistant Proteus mirabilis and Escherichia coli causing fulminant necrotising fasciitis: a case report. BMC Res Notes 2018; 11:322. [PMID: 29784062 PMCID: PMC5963038 DOI: 10.1186/s13104-018-3413-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 05/07/2018] [Indexed: 11/17/2022] Open
Abstract
Background Necrotizing fasciitis is a rare soft tissue infection characterized by rapid progressive necrosis with relative sparing of underlying muscles. This case is reported to highlight the emergence of multidrug resistant microbes in recent days which limits the use of empiric antibiotic therapy and necessitates early cultures and sensitivity enabling targeted antibiotic therapy. Factors that lead to antimicrobial resistance especially in sub-Saharan Africa have also been discussed. Case presentation We report the case of a 52-year-old black man who was referred to our centre for the management of cellulitis and suppurating ulcers of the right leg which had progressed to a wet gangrene. Following physical examination and work-up, a diagnosis of fulminant necrotizing fasciitis of the right leg caused by multidrug resistant Proteus mirabilis and Escherichia coli was made. Despite the broad-spectrum empiric antibiotic therapy and aggressive multiple surgical debridement, necrosis progressed leading to an above-knee amputation. Conclusion Necrotizing fasciitis is a surgical emergency that requires prompt diagnosis and aggressive surgical debridement in order to reduce morbidity and mortality. The emergence of multidrug resistant organisms in recent days have limited the use of empiric antibiotic therapy, necessitating early culture and sensitivity and the use of susceptibility-guided antibiotic therapy. Timely action to control the use of antibiotics in sub-Saharan Africa will reduce multidrug resistance and delay the arrival of post-antibiotics era.
Collapse
Affiliation(s)
- Eugene Vernyuy Yeika
- Saint Elizabeth Catholic General Hospital and Cardiac Centre Shisong, PO Box 8, Kumbo, Cameroon. .,Clinical Research Education Networking and Consultancy, Douala, Cameroon. .,Health and Human Development Research Group, Douala, Cameroon.
| | - Joyce Bei Foryoung
- Saint Elizabeth Catholic General Hospital and Cardiac Centre Shisong, PO Box 8, Kumbo, Cameroon.,Health and Human Development Research Group, Douala, Cameroon
| | | | | | | | | |
Collapse
|
179
|
Cholesterol-dependent cytolysins impair pro-inflammatory macrophage responses. Sci Rep 2018; 8:6458. [PMID: 29691463 PMCID: PMC5915385 DOI: 10.1038/s41598-018-24955-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 04/11/2018] [Indexed: 12/20/2022] Open
Abstract
Necrotizing soft tissue infections are lethal polymicrobial infections. Two key microbes that cause necrotizing soft tissue infections are Streptococcus pyogenes and Clostridium perfringens. These pathogens evade innate immunity using multiple virulence factors, including cholesterol-dependent cytolysins (CDCs). CDCs are resisted by mammalian cells through the sequestration and shedding of pores during intrinsic membrane repair. One hypothesis is that vesicle shedding promotes immune evasion by concomitantly eliminating key signaling proteins present in cholesterol-rich microdomains. To test this hypothesis, murine macrophages were challenged with sublytic CDC doses. CDCs suppressed LPS or IFNγ-stimulated TNFα production and CD69 and CD86 surface expression. This suppression was cell intrinsic. Two membrane repair pathways, patch repair and intrinsic repair, might mediate TNFα suppression. However, patch repair did not correlate with TNFα suppression. Intrinsic repair partially contributed to macrophage dysfunction because TLR4 and the IFNγR were partially shed following CDC challenge. Intrinsic repair was not sufficient for suppression, because pore formation was also required. These findings suggest that even when CDCs fail to kill cells, they may impair innate immune signaling responses dependent on cholesterol-rich microdomains. This is one potential mechanism to explain the lethality of S. pyogenes and C. perfringens during necrotizing soft tissue infections.
Collapse
|
180
|
Solomon IH, Borscheid R, Laga AC, Askari R, Granter SR. Frozen sections are unreliable for the diagnosis of necrotizing soft tissue infections. Mod Pathol 2018; 31:546-552. [PMID: 29243739 DOI: 10.1038/modpathol.2017.173] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 10/14/2017] [Accepted: 10/15/2017] [Indexed: 11/09/2022]
Abstract
Necrotizing soft tissue infections are rare but are associated with high rates of morbidity and mortality. The use of bedside or intraoperative frozen sections has been reported to be associated with faster diagnosis and better outcomes; however, to date no large studies have been published to determine the sensitivity and specificity of frozen sections in this setting. Twenty years of cases suspicious for necrotizing soft tissue infection at a large academic referral center were reviewed, blinded to the final clinical diagnosis (gold standard). Cases were assessed for the number of neutrophils, extent of necrosis, presence of thrombi, bacteria, karyorrhexis, and fibrin, and concordance with permanent sections. A total of 166 cases suspicious for necrotizing soft tissue infection had frozen section slides available for review. Sixty-three cases were clinically determined to be positive and 103 negative. Neutrophils, necrosis, thrombi, bacteria, karyorrhexis, and fibrin were present in both positive and negative cases; however, no histological feature or combination of features was found to be both sensitive and specific for necrotizing soft tissue infection. The combined presence of necrosis and frequent neutrophils was 73% sensitive and 68% specific, with a 58% positive predictive value and 80% negative predictive value. The additional observation of bacteria decreased sensitivity to 32%, whereas raising specificity to 91%, with 69% positive predictive value and 68% negative predictive value. Thirty-two cases (19%) contained findings identified on permanent sections (eg, bacteria) not observed on frozen section slides, highlighting the risk of false negatives owing to technical limitations or sampling errors. Frozen sections in necrotizing soft tissue infections and negative cases may show similar histological findings. Combined with the risk of false negatives, these results suggest that frozen sections are likely to be of limited clinical utility due to lack of sensitivity and specificity, and risk for delayed diagnosis and treatment.
Collapse
Affiliation(s)
- Isaac H Solomon
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rene Borscheid
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alvaro C Laga
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Reza Askari
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Scott R Granter
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
181
|
Thompson KM, Sterkel AK, McBride JA, Corliss RF. The Shock of Strep: Rapid Deaths Due to Group a Streptococcus. Acad Forensic Pathol 2018; 8:136-149. [PMID: 31240031 DOI: 10.23907/2018.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/07/2017] [Accepted: 12/02/2017] [Indexed: 11/12/2022]
Abstract
Streptococcus pyogenes, also known as group A beta-hemolytic strep, is a Gram positive coccus responsible for several million infections every year. The types of infections vary widely from pharyngitis to myositis, but all can advance to severe life threatening invasive disease. Of those infected, approximately 1100 to 1600 people die each year due to invasive disease. Why certain individuals contract severe infections is not known, but many strains of Streptococcus pyogenes are known to produce toxins and superantigens. Invasive Streptococcus pyogenes infections have been shown to cause significant morbidity and rapid mortality. In many cases, patients expire before full antemortem testing can be performed, causing physicians and families to look to forensic pathologists for answers. Understanding the pathogenesis of invasive group A strep infections, relevant gross and microscopic findings, and proper culturing techniques is critical for forensic pathologists to diagnosis this condition and assist in the education and protection of the communities they serve.
Collapse
Affiliation(s)
- Katrina M Thompson
- University of Wisconsin Hospital and Clinics - Department of Pathology and Laboratory Medicine
| | - Alana K Sterkel
- Wisconsin State Laboratory of Hygiene - Department of Communicable Disease
| | - Joseph A McBride
- University of Wisconsin Hospital and Clinics, Department of Medicine and Pediatrics, Division of Infectious Diseases
| | - Robert F Corliss
- University of Wisconsin Hospital and Clinics - Department of Pathology and Laboratory Medicine
| |
Collapse
|
182
|
Ibelli T, Templeton S, Levi-Polyachenko N. Progress on utilizing hyperthermia for mitigating bacterial infections. Int J Hyperthermia 2018; 34:144-156. [DOI: 10.1080/02656736.2017.1369173] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Taylor Ibelli
- Zanvyl Kreiger School of Arts and Sciences, Johns Hopkins University, Baltimore, MD, USA
| | | | - Nicole Levi-Polyachenko
- Department of Plastic and Reconstructive Surgery, Wake Forest University Health Sciences, Winston-Salem, NC, USA
| |
Collapse
|
183
|
Necrotizing Soft Tissue Infections at a Tertiary Referral Hospital in Rwanda: Epidemiology and Risk Factors for Mortality. World J Surg 2018; 42:2314-2320. [DOI: 10.1007/s00268-018-4515-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|
184
|
Brengard-Bresler T, De Runz A, Bourhis F, Mezzine H, Khairallah G, Younes M, Brix M, Simon E. [Postoperative quality of life of patients with a bacterial necrotizing dermis-hypodermitis or necrotizing fasciitis, a ten-year study]. ANN CHIR PLAST ESTH 2018; 62:31-44. [PMID: 26946930 DOI: 10.1016/j.anplas.2016.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 02/02/2016] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Bacterial necrotizing dermis-hypodermitis and necrotizing fasciitis (BNDH-NF) are serious life-threatening soft-tissue infections. The object is to evaluate the quality of life (QOL) of patients who have been operated in our plastic surgery departement. PATIENTS AND METHODS This is a retrospective study of cases who have been treated at Nancy University Hospital between 2005 and 2014. We analyzed the perioperative data (demographic, clinical, bacteriological), the surgical data (excision, reconstruction) and the follow up data (consequences, mortality). The quality of life was assessed by the Short-Form 36 score, and the patients' satisfaction was assessed by a four-level scale. RESULTS We analyzed 23 patients with an average age of 60 years (28-84 years). The main comorbidities were diabetes (43 %) and obesity (39 %). The average number of surgical excision was about 1.9 (1-5) and the average excised body surface area was about 5 % (1-16 %). The short-term mortality was about 17 %. The mortality rate has been statistically correlated with the surgically excised body surface area (short-term 95 days: P=0.02; and long-term: P=0.003). The statistical analysis has shown a strong relative linear relationship between number of surgical excision and the physical score of QOL (P<0.001), between number of surgical excision and mental score of QOL (P=0.032), and between age and physical score of QOL (P≤0.021). The statistical analysis has also shown a strong relative linear relationship between E. coli infections and physical score of QOL (P=0.01). The percentage of patients' satisfaction in our study was evaluated at 86 %. CONCLUSION We have found that multiple surgical excisions, an advanced age of patients and E. coli infections have been associated with poor QOL. The mortality rate increased in relation with the importance of excised body surface. In spite of the gravity of these infections, our patients were satisfied of their treatment.
Collapse
Affiliation(s)
- T Brengard-Bresler
- Service de chirurgie maxillofaciale, plastique, reconstructrice et esthétique, CHU de Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54000 Nancy, France; Faculté de médecine, université de Lorraine, 54000 Nancy, France.
| | - A De Runz
- Service de chirurgie maxillofaciale, plastique, reconstructrice et esthétique, CHU de Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54000 Nancy, France; Faculté de médecine, université de Lorraine, 54000 Nancy, France
| | - F Bourhis
- Mapi Group, Health Economics and Outcomes Research, 41, rue des Trois-Fontanot, 92000 Nanterre, France
| | - H Mezzine
- Service de chirurgie maxillofaciale, plastique, reconstructrice et esthétique, CHU de Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54000 Nancy, France; Faculté de médecine, université de Lorraine, 54000 Nancy, France
| | - G Khairallah
- Service de chirurgie maxillofaciale, plastique, reconstructrice et esthétique, CHR de Metz-Thionville, 1, allée du Château, 57085 Metz, France
| | - M Younes
- Service de chirurgie maxillofaciale, plastique, reconstructrice et esthétique, CHU de Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54000 Nancy, France; Faculté de médecine, université de Lorraine, 54000 Nancy, France
| | - M Brix
- Service de chirurgie maxillofaciale, plastique, reconstructrice et esthétique, CHU de Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54000 Nancy, France; Faculté de médecine, université de Lorraine, 54000 Nancy, France
| | - E Simon
- Service de chirurgie maxillofaciale, plastique, reconstructrice et esthétique, CHU de Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54000 Nancy, France; Faculté de médecine, université de Lorraine, 54000 Nancy, France
| |
Collapse
|
185
|
Moskowitz E, Schroeppel T. Necrotizing fasciitis following abdominal gunshot wound. Trauma Surg Acute Care Open 2018; 3:e000163. [PMID: 29766139 PMCID: PMC5887769 DOI: 10.1136/tsaco-2018-000163] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 01/07/2018] [Accepted: 01/09/2018] [Indexed: 11/04/2022] Open
Affiliation(s)
- Eliza Moskowitz
- Department of Surgery, Memorial Hospital, Colorado Springs, Colorado, USA.,Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Thomas Schroeppel
- Department of Surgery, Memorial Hospital, Colorado Springs, Colorado, USA
| |
Collapse
|
186
|
Hyperbaric Oxygen Therapy in Necrotizing Soft Tissue Infections: A Retrospective Study. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1072:263-267. [DOI: 10.1007/978-3-319-91287-5_42] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
|
187
|
Sartelli M, Guirao X, Hardcastle TC, Kluger Y, Boermeester MA, Raşa K, Ansaloni L, Coccolini F, Montravers P, Abu-Zidan FM, Bartoletti M, Bassetti M, Ben-Ishay O, Biffl WL, Chiara O, Chiarugi M, Coimbra R, De Rosa FG, De Simone B, Di Saverio S, Giannella M, Gkiokas G, Khokha V, Labricciosa FM, Leppäniemi A, Litvin A, Moore EE, Negoi I, Pagani L, Peghin M, Picetti E, Pintar T, Pupelis G, Rubio-Perez I, Sakakushev B, Segovia-Lohse H, Sganga G, Shelat V, Sugrue M, Tarasconi A, Tranà C, Ulrych J, Viale P, Catena F. 2018 WSES/SIS-E consensus conference: recommendations for the management of skin and soft-tissue infections. World J Emerg Surg 2018; 13:58. [PMID: 30564282 PMCID: PMC6295010 DOI: 10.1186/s13017-018-0219-9] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 11/22/2018] [Indexed: 02/08/2023] Open
Abstract
Skin and soft-tissue infections (SSTIs) encompass a variety of pathological conditions that involve the skin and underlying subcutaneous tissue, fascia, or muscle, ranging from simple superficial infections to severe necrotizing infections. SSTIs are a frequent clinical problem in surgical departments. In order to clarify key issues in the management of SSTIs, a task force of experts met in Bertinoro, Italy, on June 28, 2018, for a specialist multidisciplinary consensus conference under the auspices of the World Society of Emergency Surgery (WSES) and the Surgical Infection Society Europe (SIS-E). The multifaceted nature of these infections has led to a collaboration among general and emergency surgeons, intensivists, and infectious disease specialists, who have shared these clinical practice recommendations.
Collapse
Affiliation(s)
| | - Xavier Guirao
- 0000 0000 9238 6887grid.428313.fUnit of Endocrine, Head, and Neck Surgery and Unit of Surgical Infections Support, Department of General Surgery, Parc Taulí Hospital Universitari, Sabadell, Spain
| | - Timothy C. Hardcastle
- Trauma Service, Inkosi Albert Luthuli Central Hospital and Department of Surgery, Nelson R Mandela School of Clinical Medicine, Durban, South Africa
| | - Yoram Kluger
- 0000 0000 9950 8111grid.413731.3Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Marja. A. Boermeester
- 0000000404654431grid.5650.6Department of Surgery, Academic Medical Centre, Amsterdam, Netherlands
| | - Kemal Raşa
- Department of Surgery, Anadolu Medical Center, Kocaali, Turkey
| | - Luca Ansaloni
- 0000 0004 1758 8744grid.414682.dGeneral Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Federico Coccolini
- 0000 0004 1758 8744grid.414682.dGeneral Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Philippe Montravers
- 0000 0000 8588 831Xgrid.411119.dAnesthesiology and Critical Care Medicine, Paris Diderot Sorbonne Cite University, Bichat-Claude Bernard University Hospital, HUPNSV, Paris, France
| | - Fikri M. Abu-Zidan
- 0000 0001 2193 6666grid.43519.3aDepartment of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Michele Bartoletti
- 0000 0004 1757 1758grid.6292.fInfectious Diseases Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Matteo Bassetti
- 0000 0001 2113 062Xgrid.5390.fInfectious Diseases Division, Department of Medicine University of Udine and Azienda Sanitaria Universitaria Intergrata di Udine, Udine, Italy
| | - Offir Ben-Ishay
- 0000 0000 9950 8111grid.413731.3Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Walter L. Biffl
- Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, CA USA
| | - Osvaldo Chiara
- General Surgery-Trauma Team, State University of Milano, Niguarda Hospital Milano, Milan, Italy
| | - Massimo Chiarugi
- grid.414498.4Emergency Surgery Unit, State University of Pisa, Cisanello Hospital, Pisa, Italy
| | - Raul Coimbra
- 0000 0000 9852 649Xgrid.43582.38Riverside University Health System Medical Center and Loma Linda University School of Medicine, Moreno Valley, CA USA
| | - Francesco Giuseppe De Rosa
- 0000 0001 2336 6580grid.7605.4Department of Medical Sciences, Infectious Diseases, University of Turin, Turin, Italy
| | - Belinda De Simone
- Unit of General, Emergency and Trauma Surgery, Regional Hospital of Perpignan, Perpignan, France
| | - Salomone Di Saverio
- 0000 0004 0383 8386grid.24029.3dDepartment of Surgery, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Maddalena Giannella
- 0000 0004 1757 1758grid.6292.fInfectious Diseases Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - George Gkiokas
- 0000 0001 2155 0800grid.5216.0Second Department of Surgery, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Vladimir Khokha
- Department of Emergency Surgery, City Hospital, Mozyr, Belarus
| | | | - Ari Leppäniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Andrey Litvin
- 0000 0001 1018 9204grid.410686.dDepartment of Surgical Disciplines, Immanuel Kant Baltic Federal University, Regional Clinical Hospital, Kaliningrad, Russian Federation
| | - Ernest E. Moore
- Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, CO USA
| | - Ionut Negoi
- Department of Surgery, Emergency Hospital of Bucharest, Bucharest, Romania
| | - Leonardo Pagani
- Infectious Diseases Unit, Bolzano Central Hospital, Bolzano, Italy
| | - Maddalena Peghin
- 0000 0001 2113 062Xgrid.5390.fInfectious Diseases Division, Department of Medicine University of Udine and Azienda Sanitaria Universitaria Intergrata di Udine, Udine, Italy
| | - Edoardo Picetti
- grid.411482.aDepartment of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
| | - Tadeja Pintar
- 0000 0004 0571 7705grid.29524.38Department of Surgery, UMC Ljubljana, Ljubljana, Slovenia
| | - Guntars Pupelis
- 0000 0004 0375 2558grid.488518.8Department of General and Emergency Surgery, Riga East University Hospital ‘Gailezers’, Riga, Latvia
| | - Ines Rubio-Perez
- 0000 0000 8970 9163grid.81821.32General Surgery Department, Colorectal Surgery Unit, La Paz University Hospital, Madrid, Spain
| | - Boris Sakakushev
- 0000 0001 0726 0380grid.35371.33General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Helmut Segovia-Lohse
- 0000 0001 2289 5077grid.412213.7Second Department of Surgery, Hospital de Clínicas, Universidad Nacional de Asuncion, San Lorenzo, Paraguay
| | - Gabriele Sganga
- 0000 0001 0941 3192grid.8142.fEmergency Surgery (or Division of Emergency Surgery), Fondazione Policlinico Universitario A. Gemelli IRCCS – Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vishal Shelat
- grid.240988.fGeneral Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Michael Sugrue
- 0000 0004 0617 6488grid.415900.9Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, Ireland
| | - Antonio Tarasconi
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
| | - Cristian Tranà
- Department of Surgery, Macerata Hospital, Macerata, Italy
| | - Jan Ulrych
- 0000 0000 9100 9940grid.411798.2First Department of Surgery, Department of Abdominal, Thoracic Surgery and Traumatology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Pierluigi Viale
- 0000 0004 1757 1758grid.6292.fInfectious Diseases Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Fausto Catena
- 0000 0001 0941 3192grid.8142.fEmergency Surgery (or Division of Emergency Surgery), Fondazione Policlinico Universitario A. Gemelli IRCCS – Università Cattolica del Sacro Cuore, Rome, Italy
| |
Collapse
|
188
|
Kadri SS, Swihart BJ, Bonne SL, Hohmann SF, Hennessy LV, Louras P, Evans HL, Rhee C, Suffredini AF, Hooper DC, Follmann DA, Bulger EM, Danner RL. Impact of Intravenous Immunoglobulin on Survival in Necrotizing Fasciitis With Vasopressor-Dependent Shock: A Propensity Score-Matched Analysis From 130 US Hospitals. Clin Infect Dis 2017; 64:877-885. [PMID: 28034881 DOI: 10.1093/cid/ciw871] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 12/22/2016] [Indexed: 01/12/2023] Open
Abstract
Background Shock frequently complicates necrotizing fasciitis (NF) caused by group A Streptococcus (GAS) or Staphylococcus aureus. Intravenous immunoglobulin (IVIG) is sometimes administered for presumptive toxic shock syndrome (TSS), but its frequency of use and efficacy are unclear. Methods Adult patients with NF and vasopressor-dependent shock undergoing surgical debridement from 2010 to 2014 were identified at 130 US hospitals. IVIG cases were propensity-matched and risk-adjusted. The primary outcome was in-hospital mortality and the secondary outcome was median length of stay (LOS). Results Of 4127 cases of debrided NF with shock at 121 centers, only 164 patients (4%) at 61 centers received IVIG. IVIG subjects were younger with lower comorbidity indices, but higher illness severity. Clindamycin and vasopressor intensity were higher among IVIG cases, as was coding for TSS and GAS. In-hospital mortality did not differ between matched IVIG and non-IVIG groups (crude mortality, 27.3% vs 23.6%; adjusted odds ratio, 1.00 [95% confidence interval, .55-1.83]; P = .99). Early IVIG (≤2 days) did not alter this effect (P = .99). Among patients coded for TSS, GAS, and/or S. aureus, IVIG use was still unusual (59/868 [6.8%]) and lacked benefit (P = .63). Median LOS was similar between IVIG and non-IVIG groups (26 [13-49] vs 26 [11-43]; P = .84). Positive predictive values for identifying true NF and debridement among IVIG cases using our algorithms were 97% and 89%, respectively, based on records review at 4 hospitals. Conclusions Adjunctive IVIG was administered infrequently in NF with shock and had no apparent impact on mortality or hospital LOS beyond that achieved with debridement and antibiotics.
Collapse
Affiliation(s)
- Sameer S Kadri
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland.,Division of Infectious Diseases, Massachusetts General Hospital, Boston
| | - Bruce J Swihart
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Stephanie L Bonne
- Department of General Surgery, Barnes Jewish Hospital, St Louis, Missouri
| | - Samuel F Hohmann
- Vizient, and.,Department of Health Systems Management, Rush University, Chicago, Illinois
| | - Laura V Hennessy
- Department of Surgery, Harborview Medical Center, Seattle, Washington; and
| | - Peter Louras
- Department of Surgery, Harborview Medical Center, Seattle, Washington; and
| | - Heather L Evans
- Department of Surgery, Harborview Medical Center, Seattle, Washington; and
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Anthony F Suffredini
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - David C Hooper
- Division of Infectious Diseases, Massachusetts General Hospital, Boston
| | - Dean A Follmann
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Eileen M Bulger
- Department of Surgery, Harborview Medical Center, Seattle, Washington; and
| | - Robert L Danner
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland
| |
Collapse
|
189
|
Yang D, Davies A, Burge B, Watkins P, Dissanaike S. Open-to-Air Is a Viable Option for Initial Wound Care in Necrotizing Soft Tissue Infection that Allows Early Detection of Recurrence without Need for Painful Dressing Changes or Return to Operating Room. Surg Infect (Larchmt) 2017; 19:65-70. [PMID: 29211657 DOI: 10.1089/sur.2017.080] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The standard treatment of necrotizing soft tissue infection (NSTI) includes extensive surgical debridement. Care of these debridements is challenging because of the size of the wound and associated pain. A potential solution is to leave the wounds open-to-air in the period after the initial debridement, allowing for regular inspection at bedside while reducing pain associated with frequent dressing changes. We evaluated the feasibility of this approach from a pain control standpoint. PATIENTS AND METHODS An audit of wound care modalities used on adult patients with NSTI admitted to a regional burn center between January 2009 and May 2014 was performed. Patients with at least one operation were included. Those opting for palliative care were excluded. Wound care was divided into four categories: open-to-air (OTA), negative-pressure wound therapy (NPWT), packing, and ointment. Wound care, pain score, pain medication use, and number of operations were collected for the first seven days after initial debridement. Pain management was assessed by pain scores. Analgesic use was measured and compared using conversion to morphine milligram equivalents (MME). RESULTS Ninety-six patients were included; 67% were men with average age of 50 years, resulting in a total of 672 days of wound care evaluated: 69 days of OTA, 127 days of NPWT, 200 days of packing, and 126 days of ointment (150 days were undocumented). Average daily pain score from all wound care modalities was 2.00. Negative pressure wound therapy had the highest reported daily pain score (2.18, p = 0.034), whereas OTA had the lowest pain score (1.63, p < 0.05). Mortality was lower in the OTA cohort but was not statistically significant; there were no other differences in long-term outcome. CONCLUSION Leaving wounds OTA is a safe and viable option in the immediate post-debridement period of NSTI to reduce pain, while permitting frequent re-evaluation for quick recognition of disease progression and repeat operative debridement if necessary.
Collapse
Affiliation(s)
- Derek Yang
- 1 Department of Surgery, Texas Tech University Health Sciences Center , School of Medicine, Lubbock, Texas
| | | | | | - Phillip Watkins
- 3 The Clinical Research Institute, Texas Tech University Health Sciences Center , Lubbock, Texas
| | - Sharmila Dissanaike
- 1 Department of Surgery, Texas Tech University Health Sciences Center , School of Medicine, Lubbock, Texas
| |
Collapse
|
190
|
Affiliation(s)
- Dennis L Stevens
- From the Veterans Affairs Medical Center, Boise, ID; and the University of Washington School of Medicine, Seattle
| | - Amy E Bryant
- From the Veterans Affairs Medical Center, Boise, ID; and the University of Washington School of Medicine, Seattle
| |
Collapse
|
191
|
Ingraham AM, Jung HS, Liepert AE, Warner-Hillard C, Greenberg CC, Scarborough JE. Effect of transfer status on outcomes for necrotizing soft tissue infections. J Surg Res 2017; 220:372-378. [DOI: 10.1016/j.jss.2017.06.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 05/12/2017] [Accepted: 06/06/2017] [Indexed: 12/21/2022]
|
192
|
Voelzke BB, Hagedorn JC. Presentation and Diagnosis of Fournier Gangrene. Urology 2017; 114:8-13. [PMID: 29146218 DOI: 10.1016/j.urology.2017.10.031] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 10/21/2017] [Accepted: 10/28/2017] [Indexed: 12/14/2022]
Abstract
Necrotizing fasciitis is a severe type of necrotizing soft tissue infection involving the superficial fascia and subcutaneous tissues. Fournier gangrene, a type of necrotizing fasciitis, affects the genitalia or perineum. Although a rare health condition, Fournier gangrene can result in significant morbidity and unnecessary mortality following delay in diagnosis and management. We provide a review of relevant presenting features to aid diagnosis and allow timely surgical management of this serious infectious condition.
Collapse
Affiliation(s)
- Bryan B Voelzke
- Department of Urology, University of Washington School of Medicine, Seattle, WA.
| | - Judith C Hagedorn
- Department of Urology, University of Washington School of Medicine, Seattle, WA
| |
Collapse
|
193
|
A Case of Rituximab-Induced Necrotizing Fasciitis and a Review of the Literature. Case Rep Hematol 2017; 2017:6971027. [PMID: 29082050 PMCID: PMC5634570 DOI: 10.1155/2017/6971027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 08/22/2017] [Indexed: 11/25/2022] Open
Abstract
Necrotizing fasciitis is a fulminant soft tissue infection characterized by rapid progression and high mortality. Rituximab is a generally well-tolerated immunosuppresive medication used for B-cell malignancies and some rheumatological disorders. We report a case of a 69-year-old male with chronic lymphocytic leukemia who suffered necrotizing fasciitis of his left lower extremity secondary to Clostridium septicum 7 weeks after treatment with rituximab. Despite immediate intravenous antimicrobial therapy and emergent fasciotomy with extensive debridement, his hospital course was complicated by septic shock and he required an above-the-knee amputation. Physicians need to be aware of the possibility of necrotizing fasciitis in patients presenting with skin infections after rituximab therapy.
Collapse
|
194
|
Learning from Clinical Experience with Necrotizing Fasciitis: Treatment and Management. Adv Skin Wound Care 2017; 30:486-493. [PMID: 29049256 DOI: 10.1097/01.asw.0000525791.33664.e0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
GENERAL PURPOSE To provide information about necrotizing fasciitis (NF), how to recognize it, and evidence-based treatment. TARGET AUDIENCE This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES After completing this continuing education activity, you should be able to: ABSTRACT: Necrotizing fasciitis is a threatening, rapidly progressive, infectious disease of the soft tissue. In this article, based on 3 cases, the authors aim to summarize the clinical experience of patients with necrotizing fasciitis and the current concepts of the treatment and management of this disease.
Collapse
|
195
|
Virulence Characteristics of Carbapenem-Resistant Klebsiella pneumoniae Strains from Patients with Necrotizing Skin and Soft Tissue Infections. Sci Rep 2017; 7:13533. [PMID: 29051525 PMCID: PMC5648777 DOI: 10.1038/s41598-017-13524-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 09/22/2017] [Indexed: 12/18/2022] Open
Abstract
Two types of Klebsiella pneumoniae (KP) strains are currently emerging: hypervirulent (hvKP) strains and carbapenem-resistant (CR-KP) strains. To date, these two strain types rarely overlap. Recent reports, however, suggest that CR-KP strains are increasing in virulence. hvKP strains frequently present as highly invasive infections, such as necrotizing skin and soft tissue infections (NSSTI). To examine whether CR-KP strains with features of hvKP were present in our U.S. hospital, we retrospectively identified four cases of CR-KP NSSTI diagnosed between January 2012 and January 2016. Whole-genome sequencing was used to perform multilocus sequence typing, capsular typing, and identification of virulence and antimicrobial resistance genes. Additionally, the virulence of each isolate was determined in vitro and using murine pneumonia and subcutaneous infection models. We identified one CR-KP isolate that possessed features of hypervirulent KP, including a hypermucoviscous phenotype, K2 capsule, and resistance to phagocytosis. Of the four CR-KP isolates, two had no evidence of enhanced pathogenicity in either mouse model, demonstrating that low-virulence strains can cause NSSTI in immunosuppressed patients. The remaining two isolates exhibited low virulence in the pneumonia model but high virulence in the subcutaneous infection model, suggesting that the virulence attributes of these isolates are adapted to causing NSSTI.
Collapse
|
196
|
Polzik P, Johansson PI, Hyldegaard O. How biomarkers reflect the prognosis and treatment of necrotising soft tissue infections and the effects of hyperbaric oxygen therapy: the protocol of the prospective cohort PROTREAT study conducted at a tertiary hospital in Copenhagen, Denmark. BMJ Open 2017; 7:e017805. [PMID: 28982834 PMCID: PMC5640072 DOI: 10.1136/bmjopen-2017-017805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Not enough is known regarding the prognosis and treatment of necrotising soft tissue infections (NSTIs). Mortality has been shown to be 25%-35%, with survivors coping with amputations and prolonged rehabilitation. This study will evaluate soluble urokinase-type plasminogen activator receptor (suPAR) as a possible prognostic marker of NSTI severity and mortality, as well as whether hyperbaric oxygen therapy (HBOT) can modulate markers of endothelial damage during NSTI. We hypothesise that in patients with NSTI, suPAR can provide prognostic risk assessment on hospital admission and that HBOT can reduce the endothelial damage that these patients are exposed to. METHODS AND ANALYSIS This is a prospective observational study. Biomarkers will be measured in 150 patients who have been diagnosed with NSTI. On admission, baseline blood samples will be obtained. Following surgery and HBOT, daily blood samples will be obtained in order to measure endothelial and prognostic biomarkers (soluble thrombomodulin, syndecan-1, sE-selectin, vascular endothelial (VE)-cadherin, protein C and suPAR levels). Clinical data will be acquired during the first 7 days of stay in the intensive care unit. The primary outcomes in studies I and II will be endothelial biomarker levels after HBOT, and in study III suPAR levels as a marker of disease prognosis and severity. ETHICS AND DISSEMINATION The study has been approved by the Regional Scientific Ethical Committee of Copenhagen (H-16021845) and the Danish Data Protection Agency (RH-2016-199). Results will be presented at national and international conferences and published in peer-reviewed scientific journals. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Identifier NCT03147352. (Pre-results).
Collapse
Affiliation(s)
- Peter Polzik
- Department of Anesthesiology, Center of Head and Orthopedics, Copenhagen University Hospital (Rigshospitalet), Copenhagen Ø, Denmark
| | - Pär I Johansson
- Department of Clinical Immunology, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
| | - Ole Hyldegaard
- Department of Anesthesiology, Center of Head and Orthopedics, Copenhagen University Hospital (Rigshospitalet), Copenhagen Ø, Denmark
| |
Collapse
|
197
|
Spence LH, Yan H, Moazzez A, Schwed A, Keeley J, Karimzada M, Allison M, Neville A, Plurad D, Putnam B, De Virgilio C, Kim D. Mandatory Operative Re-Exploration after Initial Debridement of Necrotizing Soft Tissue Infections: Is it Mandatory? Am Surg 2017. [DOI: 10.1177/000313481708301021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Necrotizing soft tissue infections (NSTIs) are aggressive infections requiring prompt diagnosis and extensive surgical debridement. Traditionally, patients undergo mandatory re-exploration to ensure adequacy of source control. The purpose of this study is to determine if re-exploration in the operating room is mandatory for all patients with NSTIs. An eight-year retrospective analysis of adult patients with NSTIs was performed comparing two groups: mandatory operative re-exploration versus operative re-exploration based on clinical examination findings. Outcomes measured included mortality, number of debridements, and length of stay (LOS). Twenty-two per cent of patients underwent a mandatory re-exploration. These patients were older, had a higher incidence of diabetes, and a longer duration of symptoms. There were no significant differences between groups with regard to the physical examination, severity of sepsis, time to repeat debridements, or in-hospital mortality, whereas LOS and the total number of debridements were increased in mandatory re-exploration. Bacteremia and septic shock were predictive of the need for further debridement in patients in the operative re-exploration based on clinical examination findings group. Mandatory re-exploration after initial debridement may not be necessary in all patients with NSTIs. Instead, bedside wound checks may be a safe strategy to determine the need for further operative debridement.
Collapse
Affiliation(s)
| | - Huan Yan
- Harbor UCLA Medical Center, Torrance, California
| | | | | | | | | | - Mari Allison
- Harbor UCLA Medical Center, Torrance, California
| | | | - David Plurad
- Harbor UCLA Medical Center, Torrance, California
| | - Brant Putnam
- Harbor UCLA Medical Center, Torrance, California
| | | | - Dennis Kim
- Harbor UCLA Medical Center, Torrance, California
| |
Collapse
|
198
|
Harada S, Kato T, Okada S, Nakatani K, Matsumoto R, Nishida K, Komuro H, Yokoyama A, Takase C, Suganuma T. Necrotizing soft tissue infection of the thigh associated with retroperitoneal abscess in a patient with locally advanced ascending colon cancer: A case report. IDCases 2017; 10:112-114. [PMID: 29124012 PMCID: PMC5671397 DOI: 10.1016/j.idcr.2017.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Revised: 09/05/2017] [Accepted: 09/05/2017] [Indexed: 12/04/2022] Open
Abstract
Necrotizing soft tissue infection (NSTI) is a rare but rapidly progressing soft-tissue infection. Few reports of NSTI caused by colon cancer have been published. We present a rare case of NSTI of the thigh associated the retroperitoneal spread of ascending colon cancer. A 64-year-old man had noticed right hip pain since 3 months before admission, he felt pain in the right thigh which was reddening, and he had difficulty in walking. He was referred to Yokosuka general hospital Uwamachi. Anterolateral aspect of his right thigh was reddening and swelling. The patient was diagnosed with a psoas abscess and a NSTI of the right thigh caused by penetration of ascending colon tumor. The patient underwent debridement of severely necrotized tissue in the right thigh, diverting ileostomy and subsequently a right hemicolectomy with reversal of the ileostomy were performed. He was discharged 70 days after the first surgery. Colon cancer can be a cause of retroperitoneal abscess accompanied by NSTI of the thigh. Two-stage surgery was an efficient option in this patient with NSTI of the thigh associated with locally advanced ascending colon cancer.
Collapse
Affiliation(s)
- Shotaro Harada
- Department of Surgery, Yokosuka General Hospital Uwamachi, 2-36 Uwamachi Yokosuka City, Kanagawa, 238-8567, Japan
| | - Takaharu Kato
- Department of Surgery, Yokosuka General Hospital Uwamachi, 2-36 Uwamachi Yokosuka City, Kanagawa, 238-8567, Japan.,Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama 330-8503, Japan
| | - Shinichiro Okada
- Department of Surgery, Yokosuka General Hospital Uwamachi, 2-36 Uwamachi Yokosuka City, Kanagawa, 238-8567, Japan
| | - Kensuke Nakatani
- Department of Surgery, Yokosuka General Hospital Uwamachi, 2-36 Uwamachi Yokosuka City, Kanagawa, 238-8567, Japan
| | - Risa Matsumoto
- Department of Surgery, Yokosuka General Hospital Uwamachi, 2-36 Uwamachi Yokosuka City, Kanagawa, 238-8567, Japan
| | - Kazuhiro Nishida
- Department of Surgery, Yokosuka General Hospital Uwamachi, 2-36 Uwamachi Yokosuka City, Kanagawa, 238-8567, Japan
| | - Hiroyasu Komuro
- Department of Surgery, Yokosuka General Hospital Uwamachi, 2-36 Uwamachi Yokosuka City, Kanagawa, 238-8567, Japan
| | - Ai Yokoyama
- Department of Plastic and Reconstructive Surgery, Yokosuka General Hospital Uwamachi, 2-36 Uwamachi, Yokosuka, Kanagawa 238-8567, Japan
| | - Chikara Takase
- Department of Plastic and Reconstructive Surgery, Yokosuka General Hospital Uwamachi, 2-36 Uwamachi, Yokosuka, Kanagawa 238-8567, Japan
| | - Toshiyuki Suganuma
- Department of Surgery, Yokosuka General Hospital Uwamachi, 2-36 Uwamachi Yokosuka City, Kanagawa, 238-8567, Japan
| |
Collapse
|
199
|
Zarb Adami R, Odeyinde S, Hazari A. Isolated digital necrotizing fasciitis: an unusual presentation. J Hand Surg Eur Vol 2017; 42:747-748. [PMID: 27881796 DOI: 10.1177/1753193416676423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
| | - S Odeyinde
- Queen Victoria Hospital, East Grinstead, UK
| | - A Hazari
- Queen Victoria Hospital, East Grinstead, UK
| |
Collapse
|
200
|
Horn CB, Wesp BM, Fiore NB, Rasane RK, Torres M, Turnbull IR, Ilahi ON, Punch LJ, Bochicchio GV. Fungal Infections Increase the Mortality Rate Three-Fold in Necrotizing Soft-Tissue Infections. Surg Infect (Larchmt) 2017; 18:793-798. [PMID: 28850295 DOI: 10.1089/sur.2017.164] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Necrotizing soft-tissue infections (NSTIs) result in significant morbidity and mortality rates, with as many as 76% of patients dying during their index admission. Published data suggest NSTIs rarely involve fungal infections in immunocompetent patients. However, because of the recent recognition of fungal infections in our population, we hypothesized that such infections frequently complicate NSTIs and are associated with higher morbidity and mortality rates. METHODS A prospectively maintained Acute and Critical Care Surgery (ACCS) database spanning 2008-2015 and including more than 7,000 patients was queried for patients with NSTIs. Microbiologic data, demographics, and clinical outcomes were abstracted. Risk factors and outcomes associated with NSTI with positive intra-operative fungal cultures were determined. Frequencies were compared by χ2 and continuous variables by the Student t-test using SPSS. Because the study included only archived data, no patient permission was needed. RESULTS A total of 230 patients were found to have NSTIs; 197 had intra-operative cultures, and 21 (10.7%) of these were positive for fungi. Fungal infection was more common in women, patients with higher body mass index (BMI), and patients who had had prior abdominal procedures. There were no significant differences in demographics, co-morbidities, or site of infection. The majority of patients (85.7%) had mixed bacterial and fungal infections; in the remaining patients, fungi were the only species isolated. Most fungal cultures were collected within 48 h of hospital admission, suggesting that the infections were not hospital acquired. Patients with positive fungal cultures required two more surgical interventions and had a three-fold greater mortality rate than patients without fungal infections. CONCLUSIONS This is the largest series to date describing the impact of fungal infection in NSTIs. Our data demonstrate a three-fold increase in the mortality rate and the need for two additional operations. Consideration should be given to starting patients on empiric anti-fungal therapy in certain circumstances.
Collapse
Affiliation(s)
| | - Brendan M Wesp
- Department of Surgery, Washington University , St Louis, Missouri
| | - Nicholas B Fiore
- Department of Surgery, Washington University , St Louis, Missouri
| | - Rohit K Rasane
- Department of Surgery, Washington University , St Louis, Missouri
| | - Marlon Torres
- Department of Surgery, Washington University , St Louis, Missouri
| | | | - Obeid N Ilahi
- Department of Surgery, Washington University , St Louis, Missouri
| | - Laurie J Punch
- Department of Surgery, Washington University , St Louis, Missouri
| | | |
Collapse
|