Determinants of mortality for necrotizing soft-tissue infections

An elderly patient presenting with hip pain following a fall: an unusual presentation of necrotising fasciitis

Necrotising fasciitis (NF) is a rapidly progressive soft tissue infection involving necrosis of subcutaneous tissues. Early surgical intervention reduces mortality, but initial clinical findings are often non-specific and can delay the diagnosis. An 80-year-old patient, presented to our emergency department with pain in her left hip and mild bruising following a fall. An x-ray, requested to investigate a possible hip fracture, in fact demonstrated air in the subcutaneous tissues. She rapidly deteriorated and soon developed blood-filled blisters, crepitus and fixed staining of the skin. She underwent urgent debridement of involved tissues in theatre confirming the diagnosis of NF. The presence of subcutaneous emphysema on plain radiograph as in this case, is extremely specific to the diagnosis of NF. Although other imaging modalities can aid diagnosis these remain as an adjunct rather than a definitive diagnostic tool and should not delay surgical intervention based on clinical findings.

A 3-Year Experience with Necrotizing Fasciitis: Favorable Outcomes despite Operative Delays in a Busy Acute Care Hospital

Necrotizing fasciitis is a rare severe soft tissue infection that has historically been associated with high mortality. We sought to evaluate our experience with necrotizing fasciitis focusing on outcomes based on timing of operative intervention. Our study hypothesis was that delays in surgical management would negatively impact outcomes. Fifty-four patients were identified for a retrospective chart review from January 2008 to January 2011. Data analysis included demographics, admission laboratory values, imaging results, examination findings, timing and nature of operations, length of stay (LOS), and outcomes. Surgical intervention in 12 hours or more was considered a delay in care. Our study cohort was high risk based on a high prevalence of intravenous drug abuse, diabetes mellitus, hypertension, and end-stage liver disease. The average time to surgical intervention was 18 ± 25 hours and the overall mortality rate was 16 per cent. A delay to surgery did not impact mortality or the number of débridements and LOS. Mortality was high, 45 per cent, in patients requiring amputation. We observed a high-risk population managed with aggressive surgical care for necrotizing fasciitis. Our mortality was low compared with historical data and surgical delays did not impact outcomes. Those patients requiring amputation had worse outcomes.

Early diagnosis and treatment of necrotizing fasciitis can improve survival: an observational intensive care unit cohort study

BACKGROUND

The aim of this study was to describe the clinical characteristics, causative pathogens, clinical management and outcomes of patients presenting to a tertiary adult Australian intensive care unit (ICU) with a diagnosis of necrotizing fasciitis (NF).

METHODS

This retrospective observational study was conducted in a 19-bed, level III, adult ICU in a 450-bed tertiary, regional hospital. Clinical databases were accessed for patients diagnosed with NF and admitted to The Geelong Hospital ICU between 1 February 2000 and 1 June 2011. Information on severity of sepsis, surgical procedures and microbiological results were collected.

RESULTS

Twenty patients with NF were identified. The median age was 52.5 years and 38% were female. The overall mortality rate was 8.3%. Common co-morbidities were diabetes (21%) and heart failure (17%), although 50% of patients had no co-morbidities. Group A Streptococcus was the identified pathogen in 11 (46%) patients, and Streptococcus milleri group in 5 (21%) patients. Hyperbaric oxygen therapy was not used in the majority of patients. The initial antibiotics administered were active against subsequently cultured bacteria in 83% of patients. Median time to surgical debridement was 20 h. Diagnosis and management was delayed in the nosocomial group.

CONCLUSIONS

This study reports physiological data, aetiology and therapeutic interventions in NF for an adult tertiary hospital. We demonstrate one of the lowest reported mortality rates, with early surgical debridement being achieved in the majority of patients. The main delay was found to be in the diagnosis of NF.

Necrotising fasciitis of the thumb

Necrotising fasciitis is a rare condition that should be diagnosed early and managed aggressively in order to avoid death. We present a case of necrotising fasciitis of the thumb and discuss the assessment and management of this serious condition. A 44-year-old woman presented with a painful and erythematous right thumb and progressive swelling of her hand following a minor injury to the tip of her thumb 3 days previously. A diagnosis of necrotising fasciitis was made and the patient underwent urgent debridement of non-viable tissue. She required 1 week of supportive therapy in intensive treatment unit and was discharged from hospital after 3 weeks. Necrotising fasciitis is a rapidly progressing life-threatening infection, usually caused by streptococcal organisms. Immediate resuscitation, broad-spectrum intravenous antibiotics and early surgical debridement are necessary in order to avoid significant morbidity and mortality.

Characteristics and differences in necrotizing fasciitis and gas forming myonecrosis: a series of 36 patients

BACKGROUND AND AIMS

Necrotizing fasciitis (NF) and gas forming myonecrosis (GFM), both being subtypes of necrotizing soft tissue infection (NSTI), are life threatening conditions sharing certain similarities. Despite the necessity of early and radical surgical debridement in necrotizing infections, the distinction between these entities is of clinical relevance since gas forming myonecrosis in a number of cases results from an underlying abdominal cause and the focus of infection can be missed. This study was to evaluate the incidence and risk factors as well as the mortality rate in patients with NSTI and GFM.

MATERIAL AND METHODS

All patients with NSTI treated in the authors' hospital between January 2005 and Decem-ber 2009 were enrolled in the study. Medical records, histological slides, microbiological and laboratory parameters as well as Computerized Tomography (CT) and magnetic resonance imaging (MRI) scans were reviewed for all patients. Differences between NF and GFM regarding hospital stay, number of surgical interventions and pre-existing comorbidities as well as mortality rate were analyzed. The laboratory risk factor for necrotizing fasciitis (LRINEC) score was calculated in all patients on admission.

RESULTS AND CONCLUSIONS

Thirty patients (17 female, 13 male) with necrotizing fasciitis with a mean age of 55 years (SD 15.5) were included in the study. There was no statistically significant difference between survivors and deceased patients comparing the LRINEC score (n.s.). Patients with necrotizing fasciitis secondarily involving the trunk had a significantly higher mortality rate (OR 11.2; 95% CI=1.7-72.3). In the majority of cases (12 cases), minor skin lesions were identified as the site of origin. Amongst all necrotizing soft tissue infections six patients (female n=3; male n=3) with a mean age of 61.5 years (SD 12.2) with non-clostridial gas forming myonecrosis were identified. Three patients had a history of malignancy and in three patients the infection was secondary to major surgery. The mean LRINEC score was 8.5 (SD 1). Three patients (50%) died due to GFM. Early diagnosis and appropriate intervention is critical to provide accurate treatment decisions. Eradicating the differing primary sources of infection in GFM and NF will have a positive impact on outcome.

Serratia marcescens necrotizing fasciitis presenting as bilateral breast necrosis

Serratia marcescens is an extremely rare cause of necrotizing fasciitis. We report the first case of necrotizing fasciitis of the chest wall due to infection with S. marcescens that initially manifested as bilateral breast necrosis. The patient had a fulminant course leading to death within 72 h of presentation. Literature pertinent to S. marcescens-mediated necrotizing fasciitis is also reviewed.

Prognostic aspects, survival rate, and predisposing risk factors in patients with Fournier's gangrene and necrotizing soft tissue infections: evaluation of clinical outcome of 55 patients

OBJECTIVE

To determine predisposing or prognostic factors and mortality rates of patients with Fournier's gangrene compared to other necrotizing soft tissue infections (NSTI).

MATERIAL AND METHODS

Data of 55 intensive care patients (1981-2010) with NSTI were evaluated. Data were collected prospectively.

RESULTS

43.4% of the patients were in septic condition and 27.3% were hemodynamically unstable. Half of the patients showed predisposing factors (52.7%). The lower extremity (63.2%), abdomen (30.9%), and perineum (14.5%) were most affected. Polymicrobial infections were frequent (65.5%, mean 2.8, range: 1-4). The mortality rate was 16.4% (n = 9). An increase was shown for diabetes mellitus (20%), cardiac insufficiency (22.3%), septic condition at presentation (33.3%), abdominal affection (47.1%), and hemodynamic instability (46.7%). Comparing survivors and nonsurvivors, statistical significance was seen with age (p < 0.001), septic condition at admission (p < 0.001), hemodynamic instability (p < 0.001), low blood pressure (p < 0.001), and abdominal affection (p < 0.001). In laboratory findings, an increase of creatine kinase (p < 0.001) and lactate (p < 0.001) and a decrease of antithrombin III (p < 0.007) and the Quick value (p < 0.01) proved to be significant.

CONCLUSION

Patients with Fournier's gangrene do not differ in all aspects from those with other NSTI. Successful treatment consists of immediate surgical debridement, broad-spectrum antibiotic treatment, and critical care management. Supportive hyperbaric oxygen therapy should be considered.

Recent trend of necrotizing fasciitis in Taiwan: focus on monomicrobial Klebsiella pneumoniae necrotizing fasciitis

BACKGROUND

Necrotizing fasciitis (NF) is a rapidly progressive, life-threatening soft-tissue infection that is traditionally caused by group A Streptococcus (GAS) or mixed aerobic/anaerobic bacteria. Monomicrobial Klebsiella pneumoniae NF (KP-NF) has been reported since 1996 but has not yet been systematically studied.

METHODS

We retrospectively studied consecutive NF cases treated at a university hospital in Taiwan during 1997-2010 and investigated the clinical characteristics and outcomes associated with monomicrobial KP-NF, using monomicrobial GAS-NF as a reference. We also analyzed the virulence gene profiles of the isolated K. pneumoniae strains.

RESULTS

Of 134 NF cases, 88 were monomicrobial, of which the most common pathogens were GAS (n = 16) and K. pneumoniae (n = 15). Monomicrobial KP-NF entailed a moderate risk of limb loss (20% vs 25%; P = 1.000) and high mortality (47% vs 19%; P = .135), and it was more likely to involve bacteremia (80% vs 31%; P = .011), concomitant distant abscesses (27% vs 0%; P = .043), and underlying immunocompromising conditions (100% vs 63%; P = .018), compared with GAS-NF. The isolated K. pneumoniae strains (n = 10) were of capsular polysaccharides genotype K1 (n = 4), K54/K20/K5 (n = 4), K2 (n = 1), and K16 (n = 1). All strains carried rmpA, iucABCDiutA, and iroA. Genotype K1 strains had a significantly higher risk of concomitant distant abscesses, compared with non-K1 strains (75% vs 0%; P = .033).

CONCLUSIONS

K. pneumoniae has become a common pathogen of monomicrobial NF in Taiwan. Physicians treating patients with monomicrobial KP-NF should be aware of the risk of concomitant distant abscesses, particularly in cases caused by genotype K1.

Necrotising fasciitis in the central part of the body: diagnosis, management and review of the literature

Necrotising fasciitis (NF) is characterised by rapidly spreading necrosis of the soft tissue and fascia. It is rare but can be fatal when not managed properly. The aim of this study is to evaluate the diagnosis, treatment and results such as mortality, morbidity and reconstructive options of NF localised in the central part of the body. The main goal is to emphasise upon the clinical symptoms for early diagnosis which is the most important factor in saving the lives of these patients. Between January 2000 and December 2010, 30 patients with NF localised in central parts of the body were treated. Six of the patients were female (20%) and the others were male (80%). The mean age was 54·03 years (ranged between 26 and 83 years). The average time from the onset of symptoms to diagnosis was 6 days, ranging from 2 to 11 days. The localisation of NF was perineum in 24 patients (80%); inguinal and thigh region in 5 patients (16·7); and back in 1 patient (3·3%). The hospitalisation time was varying between 17 and 32 days (mean 23 days). Six patients (20%) died and 24 patients (80%) survived. All non-survivors had risk factors and secondary comorbidities such as immunosuppression, chronic cardiac failure, and diabetes with high glucose level. Survivors also underwent repeated debridement operation 2-4 times. Reconstructive procedures were split-thickness skin graft (STSG) in eight patients (33·3%), fasciocutaneous flaps in four patients (16·6%), fasciocutaneous flap + STSG in six patients (25%), scrotal flap + STSG in two patients (6·6%), scrotal flap in two patients (6·6%) and musculocutaneous flap + STSG in one patient (3·3%). There was no major complication such as flap and graft loss, after reconstructive procedures. Early diagnosis of NF may be the lifesaving factor. Amuputation can save the patient's life in the case of NF in the extremities; however, this is not an option for NF in central parts of the body. In these cases, when NF is suspected, early debridement of necrotic tissues should be performed. As soon as the infection and the spread of the necrosis are controlled, reconstruction should be considered.

Bacterial infections other than spontaneous bacterial peritonitis in cirrhosis

Cirrhotic patients are immunocompromised with a high risk of infection. Proinflammatory cytokines and hemodynamic circulation derangement further facilitate the development of serious consequences of infections. Other than spontaneous bacterial peritonitis, bacteremia and bacterial infections of other organ systems are frequently observed. Gram-negative enteric bacteria are the most common causative organism. Other bacterial infections, such as enterococci, Vibrio spp., Aeromonas spp., Clostridium spp., Listeria monocytogenes, Plesiomonas shigelloides and Mycobacterium tuberculosis are more prevalent and more virulent. Generally, intravenous third generation cephalosporins are recommended as empirical antibiotic therapy. Increased incidences of gram-positive and drug-resistant organisms have been reported, particularly in hospital-acquired infections and in patients receiving quinolones prophylaxis. This review focuses upon epidemiology, microbiology, clinical features and treatment of infections in cirrhosis other than spontaneous bacterial peritonitis, including pathogen-specific and liver disease-specific issues.

Necrotizing fasciitis caused by Staphylococcus aureus: the emergence of methicillin-resistant strains

Staphylococcus aureus is an uncommon causative agent of monomicrobial necrotizing fasciitis, but we have noted several cases over the years. The patients treated for necrotizing fasciitis between January 1998 and December 2008 in our institution were identified, and their medical records were reviewed. Of 105 necrotizing fasciitis cases during the study period, 18 were caused by monomicrobial S. aureus infection (17%). The median age was 62 years (range, 12-81 years). Among this cohort, 10 patients had coexisting medical conditions or risk factors, including diabetes and hypertension. Lower limbs and upper limbs are the most commonly involved sites. Among the bacterial isolates from these cases, 8 were methicillin-sensitive S. aureus (MSSA) and 10 were methicillin-resistant S. aureus (MRSA). One patient died in the MSSA group, and 5 patients died in the MRSA group. The mortality rate and other clinical characteristics were not significantly different between the 2 groups. However, all MRSA necrotizing fasciitis developed after the year 2000, and it was significantly different from MSSA necrotizing fasciitis that predominantly took place before the year 2000. In conclusion, S. aureus is an important pathogen of monomicrobial necrotizing fasciitis, and MRSA has emerged as the predominant causative agent in recent years. Therefore, MRSA-directed antibiotic therapy should be considered when treating patients suspected with necrotizing fasciitis in endemic areas.

Hepatitis C viral infection as an associated risk factor for necrotizing fasciitis

Necrotizing fasciitis is a rare soft tissue infection associated with a high mortality rate. Several risk factors for the development of necrotizing fasciitis have been studied, which has given surgeons insight into the types of patients who are more likely to present with this rapidly progressive infection. The concomitant diagnosis of hepatitis C viral infection has not been reported in the literature previously. In this retrospective study covering a 12-year period in 1 Level I trauma center, 10 (34%) of 29 patients presenting with necrotizing fasciitis had an underlying diagnosis of hepatitis C viral infection. The mortality rate in patients with hepatitis C viral infection was 30% compared with 21% for those without hepatitis C viral infection (P=.59). The proportion of patients presenting with the concomitant diagnosis of hepatitis C viral infection and necrotizing fasciitis was statistically greater than that expected from the prevalence of hepatitis C viral infection in the general population (1.8%; P<.001).Our study showed that hepatitis C viral infection is a risk factor for developing necrotizing fasciitis. Although our sample size was too small to show a statistical significance, we believe that a clinically significant increase in mortality of necrotizing fasciitis occurred in patients with concomitant hepatitis C viral infection. Therefore, the presence of hepatitis C viral infection in patients presenting with symptoms of necrotizing fasciitis should raise the clinical suspicion for this diagnosis, with the potential for a worse prognosis.

Multifocal necrotising fasciitis: an overlooked entity?

OBJECTIVE

The aim of the study is to report a case of multi-focal necrotising fasciitis, review research on this subject to identify common aetiological factors and highlight suggestions to improve management.

CONTEXT

Necrotising fasciitis is a severe, life-threatening soft tissue infection that typically arises from a single area, usually secondary to a minor penetrating injury. Multi-focal necrotising fasciitis, where there is more than one non-contiguous area of necrosis, is much less commonly reported. There are no guidelines specific to the management of multi-focal necrotising fasciitis, and its under-reporting may lead to missed management opportunities.

DESIGN

A systematic literature review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol.

DATA SOURCES

A search of MEDLINE, OLD MEDLINE and the Cochrane Collaboration was performed from 1966 to March 2011 using 16 search terms.

DATA EXTRACTION

All articles were screened for genuine non-contiguous multi-focal necrotising fasciitis. Of the papers that met this criterion, data on patient demographics, likely inciting injury, presentation time-line, microbial agents, sites affected, objective assessment scores, treatment and outcome were extracted.

DATA SYNTHESIS

A total of 31 studies met our inclusion criteria and 33 individual cases of multi-focal necrotising fasciitis were included in the quantitative analysis. About half (52%) of cases were type II necrotising fasciitis; 42% of cases had identifiable inciting injuries; 21% of cases developed multi-focal lesions non-synchronously, of which 86% were type II. Nearly all (94%) of cases had incomplete objective assessment scores. One case identified inflammatory imaging findings prior to clinical necrosis.

CONCLUSIONS

Multifocality in necrotising fasciitis is likely to be associated with type II disease. We postulate that validated objective tools will aid necrotising fasciitis management pathways that will identify high-risk groups for multifocality and advise early pre-emptive imaging. We recommend the adoption of regional multi-focal necrotising fasciitis registers.

Primary necrotizing fasciitis of the breast: a case report and review of the literature

Primary necrotizing fasciitis of the breast is extremely rare. We describe a case of a 51-year-old diabetic smoker who presented with primary necrotizing fasciitis of the breast, with signs of severe systemic sepsis. She required intravenous antibiotics, radical emergency surgery, intensive care treatment and inotropic support. After daily wound inspections and changes of dressings, the wound was amenable to delayed primary closure on day 6. We describe this case in detail and review the literature on this extremely rare, but potentially fatal, infection.

Diagnosis and management of skin and soft-tissue infections (SSTI): a literature review and consensus statement on behalf of the Italian Society of Infectious Diseases and International Society of Chemotherapy

Skin and soft-tissue infections (SSTIs) are among the most common bacterial infections, posing considerable diagnostic and therapeutic challenges and resulting in significant morbidity and mortality among patients as well as increased healthcare costs. eight members of the SSTI working group of the Italian Society of infectious Diseases prepared a draft of the statements, grading the quality of each piece of evidence after a careful review of the current literature using MEDLINE database and their own clinical experience. Statements were graded for their strength and quality using a system based on the one adopted by the Infectious Diseases Society of America (IDSA). The manuscript was successively reviewed by seven members of the SSTI working group of the international Society of Chemotherapy, and ultimately re-formulated by all e xperts. the microbiological and clinical aspects together with diagnostic features were considered for uncomplicated and complicated SSTIs. Antimicrobial therapy was considered as well -both empirical and targeted to methicillin-resistant Staphylococcus aureus (MRSA) and/or other main pathogens.

Autologous creatinine clearance in a case of necrotizing fasciitis and anuria

Necrotizing fasciitis can present with concomitant acute kidney injury. The etiology of acute kidney injury is often multifactorial; potential sources include volume depletion, abdominal compartment syndrome, rhabdomyolysis, and acute tubular necrosis (which may be related to hemodynamic instability, medications, or sepsis/infection). Kidney injury, defined via changes in serum creatinine, portends increased morbidity and mortality. Thus, it is crucial to accurately diagnose and assess the severity of kidney injury. We present the case of a patient with necrotizing fasciitis who endured 31 consecutive days of complete anuria. His serum creatinine decreased over this interval without the use of extracorporeal hemofiltration or dialysis. The explanation for this novel phenomenon lies in massive daily sero-sanguineous discharge and insensible losses with subsequent volume resuscitation. The patient's own convective clearance was substantial enough to maintain a modest creatinine clearance of 15 ml/min during sustained anuria. Our case emphasizes the importance of employing the creatinine, estimated glomerular filtration rate, and urine output portions of the Acute Kidney Injury Network (AKIN) or Risk Injury Failure Loss End stage (RIFLE) criteria in assessing the severity of kidney injury. It further reinforces the imperfection in using serum creatinine as a primary measure of glomerular filtration rate.

Necrotizing fasciitis caused by a primary appendicocutaneous fistula

We report a case of necrotizing fasciitis in the loin of a 76-year old man with several coexisting or past health issues, including diabetes mellitus, hypertension, alcohol-related liver cirrhosis, gastrectomy for gastric cancer, subarachnoid hemorrhage, normal pressure hydrocephalus, and cerebral infarction. Incision of the necrotizing fasciitis was successful, but it revealed an appendicocutaneous fistula; thus, we performed appendectomy and fistulectomy. We think that the necrotizing fasciitis was caused by appendicitis perforation involving the retroperitoneum, inducing the formation of an appendicocutaneous fistula. Necrotizing fasciitis and appendicocutaneous fistulae are rare complications of appendicitis. Moreover, to our knowledge, this is the first report of fluoroscopic examination demonstrating that a primary appendicocutaneous fistula had caused necrotizing fasciitis. Our search of the literature found 12 cases of necrotizing fasciitis caused by preoperative appendicitis. We discuss the characteristics and findings of these cases.

Life-threatening necrotizing fasciitis due to 'bath salts' injection

Necrotizing fasciitis is an orthopedic emergency. The ability to quickly and accurately diagnose this rapidly spreading disease can save a patient's life and limb. However, the diagnosis is complex because necrotizing fasciitis usually manifests as a less severe cellulitis or abscess while the majority of the damages rage beneath the surface of the skin. Although the diagnosis is not new, the potential causes and vectors continually change. This article reports a new source of necrotizing fasciitis in an intramuscular injection of "bath salts," a rapidly emerging street drug that is legal in some states and evades authorities with its innocuous name. The patient presented 2 days after injection of bath salts with extensive cellulitis extending to the mid portion of her upper arm. The cellulitis initially responded to broad-spectrum intravenous antibiotics, but rapidly deteriorated 48 hours later, leading to a forequarter amputation with radical mastectomy and chest wall debridement to obtain healthy tissue margins and control the disease. The patient made a full recovery after further minor debridements, negative pressure dressings, directed antibiotic therapy, and skin grafting. The recent emerging popularity of this highly obtainable, injectable substance may lead to an increase in cases of necrotizing fasciitis. Orthopedic surgeons should be vigilant in diagnosing this process early and should perform an extensive debridement.

Fulminant necrotizing fasciitis caused by Aeromonas sobria in neutropenic patients

Infection with Aeromonas species has been reported to occur in neutropenic patients. Necrotizing fasciitis caused by Aeromonas species is uncommon but potentially life-threatening. We herein describe three cases of fulminant necrotizing fasciitis caused by Aeromonas sobria in neutropenic patients. These cases shared many clinical characteristics, including shock, coagulopathy, multiple organ failure and rapidly deteriorating and eventually fatal clinical courses. In all cases, Aeromonas sobria was resistant to most antibiotics, except quinolones. Our experience suggests that necrotizing fasciitis caused by Aeromonas sobria is a distinctive and fatal entity. As the use of quinolones is not usually considered in cases of febrile neutropenia, it is important to adjust the antibiotics in time when culture results become available. In some cases, early treatment with quinolones and surgical intervention should be considered, especially when this complication occurs in patients with profound neutropenia.

Necrotizing fasciitis in a pediatric patient caused by lancefield group g streptococcus: case report and brief review of the literature

We report a case of necrotizing fasciitis with an accompanying toxic shock syndrome caused by Group G Streptococcus in a pediatric patient with a lymphatic malformation. Pediatricians need to be aware of the possibility of such infections, especially in those with vascular/lymphatic malformations, as early treatment is critical for survival.

Necrotizing fasciitis of the knee following primary total knee arthroplasty

Necrotizing fasciitis is a rare, life-threatening and rapidly spreading soft-tissue infection that results in necrosis of the muscle, fascia and surrounding tissue. It can be result of a polymicrobial synergistic infection or a streptococcal infection. The authors report a case of necrotizing fasciitis occurring in the knee of a 65-year-old woman following an uneventful primary total knee arthroplasty and resulting in above-the-knee amputation. Having in mind severe infections like necrotising fasciitis, one should be aware of the possibility of such postoperative complications especially in patients with risk factors even in routine procedures like a total knee arthroplasty.

Necrotizing soft-tissue infections

OBJECTIVE

To provide a contemporary review of the diagnosis and management of necrotizing soft-tissue infections.

DATA SOURCES

Scientific literature and internet sources.

STUDY SELECTION

Major articles of importance in this area.

CONCLUSIONS

The mortality for necrotizing soft-tissue infections appears to be decreasing, possibly due to improved recognition and earlier delivery of more effective therapy. Establishing a diagnosis and initiating treatment as soon as possible provides the best opportunity for a good outcome.

Defunctioning loop ileostomy: not always a safe option

A 74-year-old woman underwent a low anterior resection and defunctioning loop ileostomy for a T1 N1 M0 rectal adenocarcinoma. Three months following surgery she attended complaining of pain inferior to the loop ileostomy. A clinical examination demonstrated an extensive area of spreading cellulitis on the lower abdominal wall inferior to the loop ileostomy with associated crepitus and skin necrosis. The clinical diagnosis of necrotising fasciitis was confirmed radiologically on emergency computed tomography. The patient underwent an emergency debridement of the anterior abdominal wall.

Necrotizing fasciitis of the extremities: a prospective study

Necrotizing fasciitis is a rapidly progressive infection and is a necrosis of the fascia and surrounding tissues. Despite recent advances in its management, outcomes have not improved and mortality rate is still high. Between September 2007 and August 2009, we prospectively studied twenty-four histopathologically proven necrotizing fasciitis patients to assess the prognostic factors that indicate the outcome. Mortality rate was 20.8%. Twelve patients (50%) improved, while seven patients (29.2%) were complicated by limb loss. Mortality rates related to upper and lower limb involvement were similar (20% vs. 22.2%). The rates of gangrene and amputation in patients with diabetes mellitus were significantly higher than other comorbidities. Patients with gram-positive infections had significantly lower rates of amputation (15.4% vs. 54.5%, P = 0.04). Mean band cell count and serum potassium level were significantly higher in the nonsurvivors same as leukocyte count in the patients with gangrene, while serum sodium level was significantly lower in nonsurvivors. We conclude that hyponatremia, hyperkalemia, and increased band cells in the peripheral blood of patients may be useful parameters in distinguishing life-threatening necrotizing fasciitis; hence, we recommended lower threshold to amputation during surgery for this group of patients.

[Necrotizing fasciitis. 2011 update]

Necrotizing fasciitis belongs to a group of complicated soft tissue infections that can be even life threatening. Despite growing knowledge about its etiology, predictors, and the clinical progression, the mortality remains at a high level with 20%. A relevant reduction can be achieved only by an early diagnosis followed by consistent therapy. The clinical findings in about 75% of the cases are pain out of proportion, edema and tenderness, blisters, and erythema. It is elementary to differentiate a necrotizing or a non-necrotizing soft tissue infection early. In uncertain cases it can be necessary to perform a surgical exploration to confirm the diagnosis. The histopathologic characteristics are the fascial necrosis, vasculitis, thrombosis of perforating veins, the presence of the disease-causing bacteria as well as inflammatory cells like macrophages and polymorphonuclear granulocytes. Secondly, both the cutis and the muscle can be affected. In many cases there is a disproportion of the degree of local and systemic symptoms. Depending on the infectious agents there are two main types: type I is a polymicrobial infection and type II is a more invasive, serious, and fulminant monomicrobial infection mostly caused by group A Streptococcus pyogenes.Invasive, severe forms of streptococcal infections seem to occur more often in recent years. Multimodal and interdisciplinary therapy should be based on radical surgical débridement, systemic antibiotic therapy as well as enhanced intensive care therapy, which is sometimes combined with immunoglobulins (in streptococcal or staphylococcal infections) or hyperbaric oxygen therapy (HBOT, in clostridial infections). For wound care of extensive soft tissue defects vacuum-assisted closure has shown its benefit.

Local variations in the epidemiology, microbiology, and outcome of necrotizing soft-tissue infections: a multicenter study

BACKGROUND

Necrotizing soft-tissue infections (NSTIs) are rare and highly lethal.

METHODS

A retrospective chart review of patients with NSTIs treated at 6 academic hospitals in Texas between January 1, 2004 and December 31, 2007. Patient demographics, presentation, microbiology, treatment, and outcome were recorded. Analysis of variance, chi-square test, and logistic regression analysis were performed.

RESULTS

Mortality rates varied between hospitals from 9% to 25% (n = 296). There was significant interhospital variation in patient characteristics, microbiology, and etiology of NSTIs. Despite hospital differences in treatment, primarily in critical care interventions, patient age and severity of disease (reflected by shock requiring vasopressors and renal failure postoperatively) were the main predictors of mortality.

CONCLUSIONS

Significant center differences occur in patient populations, etiology, and microbiology of NSTIs, even within a concentrated region. Management should be based on these characteristics given that adjunctive treatments are unproven and variations in outcome are likely because of patient disease at presentation.

Pressure sores significantly increase the risk of developing a Fournier's gangrene in patients with spinal cord injury

STUDY DESIGN

Retrospective chart review.

OBJECTIVES

The aim of our study was to evaluate the mortality rate and further specific risk factors for Fournier's gangrene in patients with spinal cord injury (SCI).

SETTING

Division of Spinal Cord Injury, BG-University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Germany.

METHODS

All patients with a SCI and a Fournier's gangrene treated in our hospital were enrolled in this study. Following parameters were taken form patients medical records: age, type of SCI, cause of Fournier's gangrene, number of surgical debridements, length of hospital and intensive care unit stay, co morbidity factors and mortality rate. In addition, laboratory parameter including the laboratory risk indicator for necrotizing fasciitis (LRINEC) score and microbiological findings were analyzed. Clinical diagnosis was made via histological examination.

RESULTS

A total of 16 male patients (15 paraplegic and one tetraplegic) were included in the study. In 81% of all cases, the origin of Fournier's gangrene was a pressure sore. The median LRINEC score on admission was 6.5. In the vast majority of cases, a polybacterial infection was found. No patient died during the hospital stay. The mean number of surgical debridements before soft tissue closure was 1.9 and after a mean time interval of 39.1 days wound closure was performed in all patients.

CONCLUSIONS

Pressure sores significantly increase the risk of developing Fournier's gangrene in patients with SCI. We reported the results of our patients to increase awareness among physicians and training staff working with patients with a SCI in order to expedite the diagnosis.

Transfer status: a risk factor for mortality in patients with necrotizing fasciitis

BACKGROUND

Necrotizing fasciitis (NF) is a rapidly progressive disease that requires urgent surgical debridement for survival. Interhospital transfer (IT) may be associated with delay to operation, which could increase mortality. We hypothesized that mortality would be higher in patients undergoing surgical debridement for necrotizing fasciitis after IT compared to Emergency Department (ED) admission.

METHODS

We performed a retrospective cohort analysis from 2000-2006 using the Nationwide Inpatient Sample. Inclusion criteria were age >18 years, primary diagnosis of NF, and surgical therapy within 72 hours of admission. Logistic regression was used to assess the relationship between admission source, patient and hospital variables, and mortality.

RESULTS

We identified 9,958 cases over the study period. Patients in the ED group were more likely to be nonwhite and of lower income when compared with patients in the IT group. Unadjusted mortality was higher in the IT group than ED group (15.5% vs 8.7%, P < .001). After adjusting for potential confounders, odds of mortality were still greater in the IT (OR 2.04, CI 95% 1.60-2.59, P < .001).

CONCLUSION

Interhospital transfer is associated with increased risk of in-hospital mortality after surgical therapy for NF, a finding which persists after controlling for patient and hospital level variables.

The microbiological profile and presence of bloodstream infection influence mortality rates in necrotizing fasciitis

Introduction

Necrotizing fasciitis (NF) is a life threatening infectious disease with a high mortality rate. We carried out a microbiological characterization of the causative pathogens. We investigated the correlation of mortality in NF with bloodstream infection and with the presence of co-morbidities.

Methods

In this retrospective study, we analyzed 323 patients who presented with necrotizing fasciitis at two different institutions. Bloodstream infection (BSI) was defined as a positive blood culture result. The patients were categorized as survivors and non-survivors. Eleven clinically important variables which were statistically significant by univariate analysis were selected for multivariate regression analysis and a stepwise logistic regression model was developed to determine the association between BSI and mortality.

Results

Univariate logistic regression analysis showed that patients with hypotension, heart disease, liver disease, presence of Vibrio spp. in wound cultures, presence of fungus in wound cultures, and presence of Streptococcus group A, Aeromonas spp. or Vibrio spp. in blood cultures, had a significantly higher risk of in-hospital mortality. Our multivariate logistic regression analysis showed a higher risk of mortality in patients with pre-existing conditions like hypotension, heart disease, and liver disease. Multivariate logistic regression analysis also showed that presence of Vibrio spp in wound cultures, and presence of Streptococcus Group A in blood cultures were associated with a high risk of mortality while debridement > = 3 was associated with improved survival.

Conclusions

Mortality in patients with necrotizing fasciitis was significantly associated with the presence of Vibrio in wound cultures and Streptococcus group A in blood cultures.

Unique infective complication after routine vasectomy: a case report

INTRODUCTION

We present a case of a 51-year-old gentleman who, after undergoing routine vasectomy, presented with an infected wound 7 days after the procedure--one day after receiving oral sex from his wife.

AIM

We hope to present a unique case of an infected wound after oral sex. Group A Streptococcus (GAS) was cultured from the patient's wound and the asymptomatic wife's pharyngeal mucosa.

MAIN OUTCOME MEASURES

To educate and expose a rare but potentially devastating postvasectomy complication that, without prompt and aggressive treatment, can lead to significant morbidity.

METHODS

The patient was promptly treated and after hydration, broad spectrum antibiotics, and supportive care, patient showed excellent recovery. The wife was also treated with oral antibiotics.

RESULTS

Infective complicated are relatively uncommon after routine vasectomy. When present, the vast majority of the infections are treated with a simple course of oral antibiotics. There is strong evidence that establishes oral contact as a vector for transmission of virulent pathogens. Some have linked orogenital transmission of GAS since the 1970s.

CONCLUSION

To our knowledge, this is the first reported case of oropharyngeal transmission of GAS that led to rapidly progressive infection of the scrotum following vasectomy. Care should be taken to minimize exposure during postoperative healing.

Detection of subcutaneous and intramuscular air with sonography: a sensitive and specific modality

OBJECTIVES

Soft tissue air may raise suspicion for several life-threatening illnesses. Physical examination has limited sensitivity in detecting air, and computed tomography and magnetic resonance imaging are time-consuming and expensive. Sonography can show soft tissue air, but the sensitivity and specificity in this setting are currently unknown. Therefore, the purpose of this study was to assess the performance characteristics of sonography in depicting the presence, amount, and affected tissue plane in a cadaver model of soft tissue air.

METHODS

We conducted a single-blinded observational cadaver study. Cutaneous sites were selected and marked (≈4 or 5 sites on each of 6 cadavers). An examiner injected air at some sites, recording both the depth (plane) and volume. A second examiner, who was blinded to the injection procedure, examined each site with sonography and recorded the presence or absence of air and the plane (subcutaneous or intramuscular). The results were compared, and statistical analysis was performed.

RESULTS

Twenty-eight sites on 6 cadavers were used. Sites were not used if they were damaged or were within 10 cm of previous dissection. Air was injected in 20 of 28 sites; the remaining 8 were sham injections. Sonography showed air in all of the 20 sites with air injected. No air was detected in 7 of the 8 remaining sham sites, yielding 1 false-positive case. The plane was accurately assessed in all cases. Sensitivity for detection was 100%, and specificity was 87.5%.

CONCLUSIONS

Sonography accurately showed the presence, amount, and anatomic plane of soft tissue air in cadavers with sensitivity of 100%. It warrants investigation as a screening test in patients at high risk for subcutaneous air from conditions such as necrotizing fasciitis and gas gangrene.

Necrotizing fasciitis: early sonographic diagnosis

Necrotizing fasciitis is a rare, but potentially fatal bacterial infection of the soft tissues. Establishing the diagnosis at the early stages of the disease remains the greatest challenge. We report a case of necrotizing fasciitis involving the upper extremity. Sonography revealed subcutaneous emphysema spreading along the deep fascia, swelling, and increased echogenicity of the overlying fatty tissue with interlacing fluid collections. The patient responded well to early surgical debridement and parenteral antibiotics.

MR imaging of skeletal soft tissue infection: utility of diffusion-weighted imaging in detecting abscess formation

PURPOSE

Our objectives were to assess if diffusion-weighted imaging (DWI) can help identify abscess formation in the setting of soft tissue infection and to assess whether abscess formation can be diagnosed confidently with a combination of DWI and other unenhanced sequences.

METHODS

Eight cases of soft tissue infection imaged with MRI including DWI were retrospectively reviewed.

RESULTS

Two male and six female patients were studied (age range 23-50 years). Unenhanced MRI including DWI was performed in all patients. Post-contrast images were obtained in seven patients. All patients had clinically or surgically confirmed abscesses. Abscesses demonstrated restricted diffusion. DWI in conjunction with other unenhanced imaging showed similar confidence levels as post-contrast images in diagnosing abscess formation in four cases. In two cases, although the combined use of DWI and other unenhanced imaging yielded the same confidence levels as post-contrast imaging, DWI was more definitive for demonstrating abscess formation. In one case, post-contrast images had a better confidence for suggesting abscess. In one case, DWI helped detected the abscess, where gadolinium could not be administered because of a contraindication.

CONCLUSION

This preliminary study suggests that DWI is a useful adjunct in the diagnosis of skeletal soft tissue abscesses.

The use of extracorporeal membrane oxygenation in severe necrotizing soft tissue infections complicated by septic shock

Necrotizing soft tissue infections remain a challenging clinical problem. Delays in diagnosis, incomplete débridement of necrotic tissues, and the hemodynamic instability and end-organ failure associated with overwhelming sepsis all contribute to significant mortality. Extracorporeal support is a well-established tool to support profound cardiopulmonary failure. To broaden the indications for use, we present two cases of young adults with necrotizing soft tissue infections who sustained sepsis-induced hemodynamic collapse and required extracorporeal support to facilitate adequate tissue débridement as a bridge to recovery.

A fatal case of necrotizing Aeromonas schubertii fasciitis after penetrating injury

Necrotizing fasciitis is an uncommon but life-threatening condition with a high associated mortality and morbidity. Most infections are polymicrobial, another distinct form of necrotizing fasciitis that occurred by penetrating freshwater trauma, such as fishing or wading in wet fields. Aeromonas species are responsible. The rapidity of the infectious process is similar to that of clostridial infection, but gas production is not a consistent feature. We report a patient who presented with fever, chills, and bullae on left forearm, despite antibiotics and wound debridement; the infection extend to mid humerus with a rapid onset of skin necrosis and progressive sepsis. Aeromonas schubertii fasciitis is particularly virulent. An apparent superficial cellulitis that fails to respond to standard therapy must raise suspicion of a more extensive underlying subcutaneous infection. Aggressive surgical debridement and antibiotic coverage for gram-negative rods are the essential features of treatment. Delay caused by a mistaken diagnosis of cellulitis and subsequent inadequate debridement would likely prove fatal.

Prognostic factors and monomicrobial necrotizing fasciitis: gram-positive versus gram-negative pathogens

BACKGROUND

Monomicrobial necrotizing fasciitis is rapidly progressive and life-threatening. This study was undertaken to ascertain whether the clinical presentation and outcome for patients with this disease differ for those infected with a gram-positive as compared to gram-negative pathogen.

METHODS

Forty-six patients with monomicrobial necrotizing fasciitis were examined retrospectively from November 2002 to January 2008. All patients received adequate broad-spectrum antibiotic therapy, aggressive resuscitation, prompt radical debridement and adjuvant hyperbaric oxygen therapy. Eleven patients were infected with a gram-positive pathogen (Group 1) and 35 patients with a gram-negative pathogen (Group 2).

RESULTS

Group 2 was characterized by a higher incidence of hemorrhagic bullae and septic shock, higher APACHE II scores at 24 h post-admission, a higher rate of thrombocytopenia, and a higher prevalence of chronic liver dysfunction. Gouty arthritis was more prevalent in Group 1. For non-survivors, the incidences of chronic liver dysfunction, chronic renal failure and thrombocytopenia were higher in comparison with those for survivors. Lower level of serum albumin was also demonstrated in the non-survivors as compared to those in survivors.

CONCLUSIONS

Pre-existing chronic liver dysfunction, chronic renal failure, thrombocytopenia and hypoalbuminemia, and post-operative dependence on mechanical ventilation represent poor prognostic factors in monomicrobial necrotizing fasciitis. Patients with gram-negative monobacterial necrotizing fasciitis present with more fulminant sepsis.

Fournier's gangrene in a patient receiving treatment for idiopathic thrombocytopenic purpura

We report the case of a 68-year-old man who was diagnosed with Fournier's gangrene (FG), which developed during immunosuppresive treatment for idiopathic thrombocytopenic purpura (ITP). The patient was administered steroids for ITP but on the 36th day, he developed FG and septic shock. We initiated antibiotic treatment and drained a periproctal abscess immediately. On day 53, extensive drainage to progressive FG and a splenectomy was performed, following which both FG and thrombocytopenia improved. This is the first case of FG has developing in a ITP patient. It appears that high-dose immunoglobulin therapy and splenectomy should be considered earlier especially for a patient complicated with FG.