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Lanckohr C, Horn D, Roßlenbroich S, Raschke MJ, Hirsch T, Stolberg-Stolberg J. [Necrotizing soft tissue infections]. DIE ANAESTHESIOLOGIE 2024; 73:608-616. [PMID: 39133289 DOI: 10.1007/s00101-024-01442-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/05/2024] [Indexed: 08/13/2024]
Abstract
Necrotizing soft tissue infections are a heterogeneous group of severe infections of the skin, connective tissue and muscles in which necrotic destruction of the tissue occurs at the site of infection. Various bacteria are known as "typical" triggering pathogens and the infection can occur on the entire surface of the body. Necrotizing soft tissue infections are always a time-sensitive emergency associated with high mortality. Many affected patients are critically ill and require treatment in an intensive care unit. The rapid and radical surgical treatment is an essential part of management and in addition an adequate and timely antimicrobial treatment is of great importance. The health consequences for surviving patients are often severe, as extensive soft tissue damage leads to functional impairments. In many cases extensive plastic surgery follow-up is necessary. Therefore, necrotizing soft tissue infections are "complicated" in every phase of the disease and require interprofessional treatment. This review article provides a current overview of various aspects of the diagnostics, treatment and aftercare of necrotizing soft tissue infections.
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Affiliation(s)
- Christian Lanckohr
- Antibiotic Stewardship (ABS)-Team, Institut für Hygiene, Universitätsklinikum Münster, Robert-Koch-Straße 41, 48149, Münster, Deutschland.
| | - Dagmar Horn
- Geschäftsbereich Apotheke, Universitätsklinikum Münster, Münster, Deutschland
| | - Steffen Roßlenbroich
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Münster, Deutschland
| | - Michael J Raschke
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Münster, Deutschland
| | - Tobias Hirsch
- Klinik für Plastische Chirurgie, Universitätsklinikum Münster, Münster, Deutschland
| | - Josef Stolberg-Stolberg
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Münster, Deutschland
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Jiang X, Chen G. Letter to the editor regarding the article "Can the systemic Immune‑Inflammation index (SII) and Charlson Comorbidity Index (CCI) be used to predict mortality in patients with necrotizing fasciitis?". INTERNATIONAL ORTHOPAEDICS 2024:10.1007/s00264-024-06260-y. [PMID: 39102030 DOI: 10.1007/s00264-024-06260-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2024] [Accepted: 07/16/2024] [Indexed: 08/06/2024]
Affiliation(s)
- Xiaohua Jiang
- Jining Medical University, No.45 Jianshe south Road, Jining City, Shandong Province, China
| | - Guowu Chen
- Department of Spine Surgery, Affiliated Hospital of Jining Medical University, No.89 Guhuai Road, Jining City, Shandong Province, China.
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Wei W, Bai YT, Chang E, Liu JF. Post-marketing safety surveillance of fostamatinib: an observational, pharmacovigilance study leveraging FAERS database. Expert Opin Drug Saf 2024:1-9. [PMID: 39078338 DOI: 10.1080/14740338.2024.2387315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 06/10/2024] [Accepted: 06/27/2024] [Indexed: 07/31/2024]
Abstract
OBJECTIVE Fostamatinib, an FDA-approved oral small-molecule spleen tyrosine kinase (SYK) inhibitor, is used to treat thrombocytopenia in adults with chronic immune thrombocytopenia (ITP) who have not responded to previous treatments. However, comprehensive safety data is lacking. This study uses the FDA Adverse Event Reporting System (FAERS) database to explore real-world adverse events (AEs) related to fostamatinib, aiming to inform its clinical use. METHODS The FAERS database was retrospectively queried to extract reports associated with fostamatinib from 2019 to 2023. To identify and evaluate potential AEs in patients receiving fostamatinib, various disproportionality analyses such as the reporting odds ratio (ROR), the proportional reporting ratio (PRR), the Bayesian confidence propagation neural network (BCPNN), and the multi-item gamma Poisson shrinker (MGPS) were employed. RESULTS A total of 23 AE signals were included in our analysis. Among them, hypertension, blood pressure increase, blood pressure abnormality, hepatic enzyme increase, and diarrhea were consistent with the common AEs described for fostamatinib in clinical trials. In addition, unexpected serious AEs were detected including cerebral thrombosis and necrotizing soft tissue infection. The median time to onset of fostamatinib-related AEs was 86 days. CONCLUSION Our investigation revealed several possibly emergent safety concerns associated with fostamatinib in real-world clinical practice, which might provide essential vigilance evidence for clinicians and pharmacists to manage the safety issues of fostamatinib.
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Affiliation(s)
- Wei Wei
- Department of Pharmacy, People's Hospital of Zhongjiang County, Deyang, Sichuan, China
| | - Ying-Tao Bai
- Department of Pharmacy, People's Hospital of Zhongjiang County, Deyang, Sichuan, China
| | - En Chang
- Department of Pharmacy, People's Hospital of Zhongjiang County, Deyang, Sichuan, China
| | - Jin-Feng Liu
- Department of Pharmacy, People's Hospital of Zhongjiang County, Deyang, Sichuan, China
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4
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Montravers P, Norrby-Teglund A, Munoz P. Treating necrotizing skin and soft-tissue infections. Intensive Care Med 2024; 50:1342-1345. [PMID: 38753269 DOI: 10.1007/s00134-024-07466-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 04/24/2024] [Indexed: 08/09/2024]
Affiliation(s)
- Philippe Montravers
- Department of Anaesthesiology and Surgical Intensive Care, DMU PARABOL, APHP, Hôpital Bichat, 75018, Paris, France.
- UFR Paris Nord, Université Paris Cité, 75006, Paris, France.
- Université Paris Cité, INSERM UMR 1152 PHERE, 75018, Paris, France.
| | - Anna Norrby-Teglund
- Karolinska Institutet, Center for Infectious Medicine, Karolinska University Hospital, 141 52, Huddinge, Sweden
| | - Patricia Munoz
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
- CIBER of Respiratory Diseases (CIBERES CB06/06/0058), Madrid, Spain
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Hainsworth L, Vaughan A, Picardo N, Gough AT. Necrotising fasciitis of the upper limb: a review of the literature. Musculoskelet Surg 2024:10.1007/s12306-024-00843-z. [PMID: 38954324 DOI: 10.1007/s12306-024-00843-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 06/21/2024] [Indexed: 07/04/2024]
Abstract
Necrotising fasciitis is an uncommon life-threatening surgical emergency. While most commonly seen in the lower limb it can also affect the upper limb. This article reviews and summarises the current literature on necrotising fasciitis in the upper limb, covering common predisposing factors, clinical presentations, scoring systems, common organism types and the timing of surgical treatment. The key to managing this condition continues to be early clinical diagnosis and aggressive surgical debridement to attempt to reduce the morbidity and mortality of this condition.
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Affiliation(s)
- L Hainsworth
- Musgrove Park Hospital, Somerset NHS Foundation Trust, Parkfield Drive, Taunton, TA1 5DA, UK.
| | | | | | - A T Gough
- Musgrove Park Hospital, Somerset NHS Foundation Trust, Parkfield Drive, Taunton, TA1 5DA, UK
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Salim OA, Hillier-Smith R, Ardolino A. Necrotising fasciitis, invasive Group A Streptococcus (iGAS) infection; a case series of 8 patients requiring surgical debridement in one trauma unit within 9 months. J Surg Case Rep 2024; 2024:rjad708. [PMID: 38966684 PMCID: PMC11222963 DOI: 10.1093/jscr/rjad708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 12/11/2023] [Indexed: 07/06/2024] Open
Abstract
Necrotising fasciitis (NF) is a rare but life-threatening skin and soft tissue infection. It requires urgent surgical debridement. The most common cause of monomicrobial NF is invasive Group A Streptococcus (IGAS). We present eight patients who were all treated in a single trauma unit within a 9-month period. All cases required surgical debridement and had positive microbiology testing for IGAS. The eight patients did not present typically for NF, nor did they all have typical risk factors for the development of NF. The in-hospital mortality rate was 37.5%. This series represents an epidemiological spike of IGAS infections causing NF. The findings from this series could inform future practice if similar spikes were to be encountered.
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Affiliation(s)
- Omar-Adam Salim
- Trauma and Orthopaedics, Basingstoke and North Hampshire NHS Foundation Trust, Hampshire RG24 9NA, United Kingdom
| | - Ryan Hillier-Smith
- Hampshire Hospitals NHS Foundation Trust, Hampshire RG24 9NA, United Kingdom
| | - Antonella Ardolino
- Hampshire Hospitals NHS Foundation Trust, Hampshire RG24 9NA, United Kingdom
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Schoettler JJ, Brohm K, Mindt S, Jäger E, Hahn B, Fuderer T, Lindner HA, Schneider-Lindner V, Krebs J, Neumaier M, Thiel M, Centner FS. Mortality Prediction by Kinetic Parameters of Lactate and S-Adenosylhomocysteine in a Cohort of Critically Ill Patients. Int J Mol Sci 2024; 25:6391. [PMID: 38928097 PMCID: PMC11204002 DOI: 10.3390/ijms25126391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 06/01/2024] [Accepted: 06/05/2024] [Indexed: 06/28/2024] Open
Abstract
Tissue hypoxia is associated with the development of organ dysfunction and death in critically ill patients commonly captured using blood lactate. The kinetic parameters of serial lactate evaluations are superior at predicting mortality compared with single values. S-adenosylhomocysteine (SAH), which is also associated with hypoxia, was recently established as a useful predictor of septic organ dysfunction and death. We evaluated the performance of kinetic SAH parameters for mortality prediction compared with lactate parameters in a cohort of critically ill patients. For lactate and SAH, maxima and means as well as the normalized area scores were calculated for two periods: the first 24 h and the total study period of up to five days following ICU admission. Their performance in predicting in-hospital mortality were compared in 99 patients. All evaluated parameters of lactate and SAH were significantly higher in non-survivors compared with survivors. In univariate analysis, the predictive power for mortality of SAH was higher compared with lactate in all forms of application. Multivariable models containing SAH parameters demonstrated higher predictive values for mortality than models based on lactate parameters. The optimal models for mortality prediction incorporated both lactate and SAH parameters. Compared with lactate, SAH displayed stronger predictive power for mortality in static and dynamic application in critically ill patients.
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Affiliation(s)
- Jochen J. Schoettler
- Department of Anesthesiology, Surgical Intensive Care Medicine and Pain Medicine, Medical Faculty Mannheim, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (J.J.S.); (F.-S.C.)
| | - Kathrin Brohm
- Department of Anesthesiology, Surgical Intensive Care Medicine and Pain Medicine, Medical Faculty Mannheim, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (J.J.S.); (F.-S.C.)
- Merck KGaA (SQ-Animal Affairs), Frankfurterstrasse 250, 64293 Darmstadt, Germany
| | - Sonani Mindt
- Institute for Clinical Chemistry, Medical Faculty Mannheim, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
- Institute for Laboratory and Transfusion Medicine, Hospital Passau, Innstrasse 76, 94032 Passau, Germany
| | - Evelyn Jäger
- Institute for Clinical Chemistry, Medical Faculty Mannheim, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Bianka Hahn
- Department of Anesthesiology, Surgical Intensive Care Medicine and Pain Medicine, Medical Faculty Mannheim, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (J.J.S.); (F.-S.C.)
| | - Tanja Fuderer
- Department of Anesthesiology, Surgical Intensive Care Medicine and Pain Medicine, Medical Faculty Mannheim, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (J.J.S.); (F.-S.C.)
| | - Holger A. Lindner
- Department of Anesthesiology, Surgical Intensive Care Medicine and Pain Medicine, Medical Faculty Mannheim, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (J.J.S.); (F.-S.C.)
| | - Verena Schneider-Lindner
- Department of Anesthesiology, Surgical Intensive Care Medicine and Pain Medicine, Medical Faculty Mannheim, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (J.J.S.); (F.-S.C.)
| | - Joerg Krebs
- Department of Anesthesiology, Surgical Intensive Care Medicine and Pain Medicine, Medical Faculty Mannheim, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (J.J.S.); (F.-S.C.)
| | - Michael Neumaier
- Institute for Clinical Chemistry, Medical Faculty Mannheim, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Manfred Thiel
- Department of Anesthesiology, Surgical Intensive Care Medicine and Pain Medicine, Medical Faculty Mannheim, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (J.J.S.); (F.-S.C.)
| | - Franz-Simon Centner
- Department of Anesthesiology, Surgical Intensive Care Medicine and Pain Medicine, Medical Faculty Mannheim, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (J.J.S.); (F.-S.C.)
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Allaw F, Wehbe S, Kanj SS. Necrotizing fasciitis: an update on epidemiology, diagnostic methods, and treatment. Curr Opin Infect Dis 2024; 37:105-111. [PMID: 38037890 DOI: 10.1097/qco.0000000000000988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
PURPOSE OF REVIEW The aim of this review is to discuss the latest evidence of epidemiology, diagnostic methods, and treatment of necrotizing soft tissue infections (NSTIs) with a particular focus on necrotizing fasciitis (NF). RECENT FINDINGS NSTIs have been historically referred to as NF but encompass a broader range of infections, with variable rates ranging from 0.86 to 32.64 per 100 000 person-years, influenced by factors such as climate and seasonal variations. They have diverse microbiological profiles categorized into different types based on the involved pathogens, including polymicrobial or monomicrobial infections caused by organisms such as group A streptococcus (GAS), Staphylococcus aureus , some Gram-negative pathogens, and filamentous fungi following trauma and natural disasters. Diagnosis relies on clinical symptoms and signs, laboratory markers, and imaging. However, the gold standard for diagnosis remains intraoperative tissue culture. Treatment involves repeated surgical debridement of necrotic tissues in addition to intravenous antibiotics. Adjuvant therapies with intravenous immunoglobulin (IVIG) and hyperbaric oxygen therapy (HBOT) might have a role. Soft tissue reconstruction may be necessary following surgery. SUMMARY Prompt diagnosis and proper medical and surgical management of NSTI will improve outcomes.
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Affiliation(s)
- Fatima Allaw
- Division of Infectious Diseases, Department of Internal Medicine, American University of Beirut Medical Center
| | - Saliba Wehbe
- Division of Infectious Diseases, Department of Internal Medicine, American University of Beirut Medical Center
| | - Souha S Kanj
- Division of Infectious Diseases, Department of Internal Medicine, American University of Beirut Medical Center
- Center for Infectious Disease Research, American University of Beirut, Beirut, Lebanon
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Burillo A, Pulido-Pérez A, Bouza E. Current challenges in acute bacterial skin infection management. Curr Opin Infect Dis 2024; 37:71-79. [PMID: 38179868 DOI: 10.1097/qco.0000000000000989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
PURPOSE OF REVIEW There are aspects of skin and soft tissue infections (SSTIs) that remain unresolved, such as current numbers, classification criteria, how best to define severity and predict the outcome, what diagnostic tests to perform, what new treatment options are available, or what the duration of antibiotic treatment should be. We have reviewed the literature over the last 18 months to clarify these issues and provide our opinion. RECENT FINDINGS SSTIs are common and among the top 10 most frequent infections worldwide. They represent a burden on the healthcare system and have a major impact on the quality of life of patients. Regarding classification, the Infectious Diseases Society of America (IDSA) provides a practical guide that distinguishes between uncomplicated and complicated infections, acute and chronic wound infections, and necrotising and nonnecrotizing infections based on skin extension and tissue necrosis. With new microbiological and imaging diagnostic techniques, SSTIs can now be better diagnosed. New PCR techniques are available, and mass spectrometry can be applied to samples collected in liquid transport media. Moreover, new treatment methods such as photodynamic therapy, reactive oxygen, and phages are emerging. SSTI patients can be treated with shorter antibiotic courses if they receive an active drug with good tissue penetration. Antibiotic treatment in necrotizing infections can be shortened to 48 h after the last debridement. SUMMARY SSTIs remain a challenge regarding rapid and accurate diagnosis and clinical management.
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Affiliation(s)
- Almudena Burillo
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón
- Medicine Department, School of Medicine, Universidad Complutense de Madrid
- Gregorio Marañón Health Research Institute, (IiSGM)
| | - Ana Pulido-Pérez
- Gregorio Marañón Health Research Institute, (IiSGM)
- Department of Dermatology, Hospital General Universitario Gregorio Marañón
| | - Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón
- Medicine Department, School of Medicine, Universidad Complutense de Madrid
- Gregorio Marañón Health Research Institute, (IiSGM)
- CIBER of Respiratory Diseases (CIBERES CB06/06/0058), Madrid, Spain
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Montravers P, Soussan R, Tanaka S. Identifying patients with difficult-to-treat acute bacterial skin infections. Curr Opin Infect Dis 2024; 37:87-94. [PMID: 38037891 DOI: 10.1097/qco.0000000000000991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
PURPOSE OF REVIEW The early recognition of acute bacterial skin infections (ABSIs) and their swift and adequate care are the major determinants of success. The features that can hamper or delay surgical and medical management can lead to 'difficult-to-treat' ABSIs. RECENT FINDINGS Delayed diagnosis and belated management are the key obstacles to be overcome. Clinicians should be careful about underestimating the severity of ABSIs and overlooking comorbidities, especially immunosuppression. Many conditions can lead to delayed source control, including a misdiagnosis, interhospital transfers, delayed re-exploration, or extensive injuries. Difficult therapeutic issues can occur, including rapidly destructive infections from highly pathogenic microorganisms (Group-A-streptococci, Vibrio spp., Clostridium spp. and Staphylococcus aureus ) or inadequate antibiotic therapy resulting from multidrug-resistant bacteria. Impaired pharmacokinetic capacities of antibiotic agents should also be considered as a source of clinical failure due to insufficient antimicrobial activity at the site of infection. SUMMARY Microbiological samples should be used for guiding antimicrobial therapy. Risk factors for multidrug-resistant bacteria should be considered, including local epidemiology and comorbidities. The optimization of antibiotic therapy should be achieved. Optimized care should be achieved through multidisciplinary management involving professionals with sufficient and appropriate training.
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Affiliation(s)
- Philippe Montravers
- Université Paris Cité
- AP-HP Nord, Anaesthesiology and Intensive Care Department, Bichat-Claude Bernard University Hospital
- PHERE, Physiopathology and Epidemiology of Respiratory Diseases, French Institute of Health and Medical Research (INSERM) U1152, Paris
| | - Romy Soussan
- Université Paris Cité
- AP-HP Nord, Anaesthesiology and Intensive Care Department, Bichat-Claude Bernard University Hospital
| | - Sébastien Tanaka
- AP-HP Nord, Anaesthesiology and Intensive Care Department, Bichat-Claude Bernard University Hospital
- DéTROI, Institute of Health and Medical Research (INSERM) U1188, Saint-Pierre, Reunion Island, France
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Nies I, Gourde E, Newman W, Schiele R. Impact of Iron Supplementation on Hospital Length of Stay for Pneumonia or Skin and Skin Structure Infections: A Retrospective Cohort Study. Hosp Pharm 2024; 59:152-158. [PMID: 38450363 PMCID: PMC10913890 DOI: 10.1177/00185787231196428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
Objectives: Pathogenic organisms utilize iron to survive and replicate and have evolved many processes to extract iron from human hosts. The goal of this study was to elucidate the impact of iron supplementation given in the setting of acute infection. Methods: This was a retrospective cohort study of Veterans Affairs patients who received intravenous antibiotics for pneumonia or skin and skin structure infections. Five-thousand subjects were included in each of the 2 cohorts: iron-receiving and non-iron-receiving. Data was analyzed using Fischer's Exact test if categorical and independent t-tests if continuous. Primary and secondary objectives analyzed with Cox proportional hazard regression and outcome rates estimated utilizing Kaplan-Meier method. Results: Five-thousand patients were included in each cohort. The iron cohort was significantly older (Mean-years: Iron = 71.6, No-iron = 68.9; mean-difference = 2.7, P < .0001) with reduced renal function (Mean-eGFR[mL/min/1.73 m²]: Iron = 67.2, No-iron = 77.4; mean-difference = 10.2, P < .0001). For the primary outcome, the iron cohort had a significantly longer mean length of hospital stay (10.4 days) compared to the no-iron cohort (8.7 days) (mean difference 1.7 days, P < .0001). Secondary outcome analysis showed the iron cohort received intravenous antibiotics for longer (Iron = 8.2 days, No-iron = 7.1 days; mean-difference = 1.1 days, P < .0001) with a higher proportion of 30-day readmissions (Iron = 15.6%, No-iron = 12.8%; proportion difference = 2.8%, P < .0001). No significant difference was found between cohort proportions for 30-day mortality (Iron = 12.7%, No-iron = 11.3%, proportion difference = 1.4%, P = .052). Conclusions: Baseline characteristic differences between cohorts is representative of patients who would be expected to require iron replacement therapy. Given the magnitude of primary and secondary-outcomes, further studies controlling for these factors would be warranted.
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Affiliation(s)
- Isaac Nies
- Fargo VA Healthcare System, Fargo, ND, USA
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Suijker J, Pijpe A, Hoogerbrug D, Heymans MW, van Zuijlen PPM, Halm JA, Meij-de Vries A. IDENTIFICATION OF POTENTIALLY MODIFIABLE FACTORS TO IMPROVE RECOGNITION AND OUTCOME OF NECROTIZING SOFT-TISSUE INFECTIONS. Shock 2024; 61:585-591. [PMID: 38315508 DOI: 10.1097/shk.0000000000002325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
ABSTRACT Background : Necrotizing soft-tissue infections (NSTIs) present a surgical emergency of increasing incidence, which is often misdiagnosed and associated with substantial mortality and morbidity. A retrospective multicenter (11 hospitals) cohort study was initiated to identify the early predictors of misdiagnosis, mortality, and morbidity (skin defect size and amputation). Methods : Patients of all ages who presented with symptoms and were admitted for acute treatment of NSTIs between January 2013 and December 2017 were included. Generalized estimating equation analysis was used to identify early predictors (available before or during the first debridement surgery), with a significance level of P < 0.05. Results : The median age of the cohort (N = 216) was 59.5 (interquartile range = 23.6) years, of which 138 patients (63.9%) were male. Necrotizing soft-tissue infections most frequently originated in the legs (31.0%) and anogenital area (30.5%). More than half of the patients (n = 114, 54.3%) were initially misdiagnosed. Thirty-day mortality was 22.9%. Amputation of an extremity was performed in 26 patients (12.5%). Misdiagnosis was more likely in patients with a higher Charlson Comorbidity Index (β = 0.20, P = 0.001), and less likely when symptoms started in the anogenital area (β = -1.20, P = 0.003). Besides the established risk factors for mortality (septic shock and age), misdiagnosis was identified as an independent predictor of 30-day mortality (β = 1.03, P = 0.01). The strongest predictors of the final skin defect size were septic shock (β = 2.88, P < 0.001) and a skin-sparing approach to debridement (β = -1.79, P = 0.002). Conclusion : Recognition of the disease is essential for the survival of patients affected by NSTI, as is adequate treatment of septic shock. The application of a skin-sparing approach to surgical debridement may decrease morbidity.
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Affiliation(s)
| | | | | | - Martijn W Heymans
- Amsterdam, Department of Epidemiology and Data Science, Amsterdam, The Netherlands
| | | | - Jens A Halm
- Trauma Unit, Amsterdam UMC location AMC, Amsterdam, The Netherlands
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Toppen W, Cho NY, Sareh S, Kjellberg A, Medak A, Benharash P, Lindholm P. Contemporary national outcomes of hyperbaric oxygen therapy in necrotizing soft tissue infections. PLoS One 2024; 19:e0300738. [PMID: 38512943 PMCID: PMC10956790 DOI: 10.1371/journal.pone.0300738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 03/04/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND The role of hyperbaric oxygen therapy (HBOT) in necrotizing soft tissue infections (NSTI) is mainly based on small retrospective studies. A previous study using the 1998-2009 National Inpatient Sample (NIS) found HBOT to be associated with decreased mortality in NSTI. Given the argument of advancements in critical care, we aimed to investigate the continued role of HBOT in NSTI. METHODS The 2012-2020 National Inpatient Sample (NIS) was queried for NSTI admissions who received surgery. 60,481 patients between 2012-2020 were included, 600 (<1%) underwent HBOT. Primary outcome was in-hospital mortality. Secondary outcomes included amputation, hospital length of stay, and costs. A multivariate model was constructed to account for baseline differences in groups. RESULTS Age, gender, and comorbidities were similar between the two groups. On bivariate comparison, the HBOT group had lower mortality rate (<2% vs 5.9%, p<0.001) and lower amputation rate (11.8% vs 18.3%, p<0.001) however, longer lengths of stay (16.9 days vs 14.6 days, p<0.001) and higher costs ($54,000 vs $46,000, p<0.001). After multivariate analysis, HBOT was associated with decreased mortality (Adjusted Odds Ratio (AOR) 0.22, 95% CI 0.09-0.53, P<0.001) and lower risk of amputation (AOR 0.73, 95% CI 0.55-0.96, P = 0.03). HBO was associated with longer stays by 1.6 days (95% CI 0.4-2.7 days) and increased costs by $7,800 (95% CI $2,200-$13,300), they also had significantly lower risks of non-home discharges (AOR 0.79, 95%CI 0.65-0.96). CONCLUSIONS After correction for differences, HBOT was associated with decreased mortality, amputations, and non-home discharges in NSTI with the tradeoff of increase to costs and length of stay.
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Affiliation(s)
- William Toppen
- Division of Hyperbaric Medicine, Department of Emergency Medicine, University of California San Diego, San Diego, CA, United States of America
| | - Nam Yong Cho
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Sohail Sareh
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Anders Kjellberg
- Dept. Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
- Hyperbaric Medicine, Medical Unit Intensive Care and Thoracic Surgery, Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Anthony Medak
- Division of Hyperbaric Medicine, Department of Emergency Medicine, University of California San Diego, San Diego, CA, United States of America
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Peter Lindholm
- Division of Hyperbaric Medicine, Department of Emergency Medicine, University of California San Diego, San Diego, CA, United States of America
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14
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Tölken LA, Paulikat AD, Jachmann LH, Reder A, Salazar MG, Medina LMP, Michalik S, Völker U, Svensson M, Norrby-Teglund A, Hoff KJ, Lammers M, Siemens N. Reduced interleukin-18 secretion by human monocytic cells in response to infections with hyper-virulent Streptococcus pyogenes. J Biomed Sci 2024; 31:26. [PMID: 38408992 PMCID: PMC10898077 DOI: 10.1186/s12929-024-01014-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/20/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Streptococcus pyogenes (group A streptococcus, GAS) causes a variety of diseases ranging from mild superficial infections of the throat and skin to severe invasive infections, such as necrotizing soft tissue infections (NSTIs). Tissue passage of GAS often results in mutations within the genes encoding for control of virulence (Cov)R/S two component system leading to a hyper-virulent phenotype. Dendritic cells (DCs) are innate immune sentinels specialized in antigen uptake and subsequent T cell priming. This study aimed to analyze cytokine release by DCs and other cells of monocytic origin in response to wild-type and natural covR/S mutant infections. METHODS Human primary monocyte-derived (mo)DCs were used. DC maturation and release of pro-inflammatory cytokines in response to infections with wild-type and covR/S mutants were assessed via flow cytometry. Global proteome changes were assessed via mass spectrometry. As a proof-of-principle, cytokine release by human primary monocytes and macrophages was determined. RESULTS In vitro infections of moDCs and other monocytic cells with natural GAS covR/S mutants resulted in reduced secretion of IL-8 and IL-18 as compared to wild-type infections. In contrast, moDC maturation remained unaffected. Inhibition of caspase-8 restored secretion of both molecules. Knock-out of streptolysin O in GAS strain with unaffected CovR/S even further elevated the IL-18 secretion by moDCs. Of 67 fully sequenced NSTI GAS isolates, 28 harbored mutations resulting in dysfunctional CovR/S. However, analyses of plasma IL-8 and IL-18 levels did not correlate with presence or absence of such mutations. CONCLUSIONS Our data demonstrate that strains, which harbor covR/S mutations, interfere with IL-18 and IL-8 responses in monocytic cells by utilizing the caspase-8 axis. Future experiments aim to identify the underlying mechanism and consequences for NSTI patients.
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Affiliation(s)
- Lea A Tölken
- Department of Molecular Genetics and Infection Biology, University of Greifswald, Greifswald, Germany
| | - Antje D Paulikat
- Department of Molecular Genetics and Infection Biology, University of Greifswald, Greifswald, Germany
| | - Lana H Jachmann
- Department of Molecular Genetics and Infection Biology, University of Greifswald, Greifswald, Germany
| | - Alexander Reder
- Department of Functional Genomics, University Medicine Greifswald, Greifswald, Germany
| | | | - Laura M Palma Medina
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Sweden
| | - Stephan Michalik
- Department of Functional Genomics, University Medicine Greifswald, Greifswald, Germany
| | - Uwe Völker
- Department of Functional Genomics, University Medicine Greifswald, Greifswald, Germany
| | - Mattias Svensson
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Sweden
| | - Anna Norrby-Teglund
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Sweden
| | - Katharina J Hoff
- Institute of Mathematics and Computer Science, University of Greifswald, Greifswald, Germany
| | - Michael Lammers
- Department of Synthetic and Structural Biochemistry, Institute of Biochemistry, University of Greifswald, Greifswald, Germany
| | - Nikolai Siemens
- Department of Molecular Genetics and Infection Biology, University of Greifswald, Greifswald, Germany.
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15
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Gundersen IM, Bruun T, Almeland SK, Skutlaberg DH, Nedrebø T, Rath E, Oppegaard O, Guttormsen AB, Norrby-Teglund A, Mosevoll KA, Skrede S. Necrotising soft tissue infections. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2024; 144:23-0720. [PMID: 38415568 DOI: 10.4045/tidsskr.23.0720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024] Open
Abstract
Necrotising soft tissue infections can affect the skin, subcutaneous tissue, superficial fascia, deep fascia and musculature. The infections are severe, they spread quickly and can result in extensive tissue loss. Although rare, morbidity and mortality rates are high. Early clinical identification is crucial for the outcome, and rapid infection control through surgery and targeted antibiotic treatment is needed to save lives. Few prospective clinical trials have been conducted for the treatment of this type of infection. Specific challenges include rapid identification of the condition and the uncertain efficacy of the various treatment options. In this clinical review article, we describe clinical characteristics, diagnostics and treatment.
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Affiliation(s)
- Ingunn Margareetta Gundersen
- Seksjon for infeksjonssjukdommar, Medisinsk klinikk, Haukeland universitetssjukehus, og, Klinisk institutt 2, Det medisinske fakultet, Universitetet i Bergen
| | - Trond Bruun
- Seksjon for infeksjonssjukdommar, Medisinsk klinikk, Haukeland universitetssjukehus, og, Klinisk institutt 2, Det medisinske fakultet, Universitetet i Bergen
| | - Stian Kreken Almeland
- Avdeling for plastikk-, hand- og rekonstruktiv kirurgi, og, Brannskadeavdelinga, Haukeland universitetssjukehus, og, Klinisk institutt 1, Det medisinske fakultet, Universitetet i Bergen
| | | | - Torbjørn Nedrebø
- Seksjon for hyperbarmedisin, Yrkesmedisinsk avdeling, og, Kirurgisk serviceklinikk, Haukeland universitetssjukehus
| | - Eivind Rath
- Seksjon for infeksjonssjukdommar, Medisinsk klinikk, og, Mottaksklinikken, Haukeland universitetssjukehus
| | - Oddvar Oppegaard
- Seksjon for infeksjonssjukdommar, Medisinsk klinikk, Haukeland universitetssjukehus, og, Klinisk institutt 2, Det medisinske fakultet, Universitetet i Bergen
| | - Anne Berit Guttormsen
- Klinisk institutt 1, Det medisinske fakultet, Universitetet i Bergen, og, Kirurgisk serviceklinikk, Haukeland universitetssjukehus
| | - Anna Norrby-Teglund
- Center for infektionsmedicin, Karolinska Institutet, Karolinska Universitetssjukhuset
| | - Knut Anders Mosevoll
- Seksjon for infeksjonssjukdommar, Medisinsk klinikk, Haukeland universitetssjukehus, og, Klinisk institutt 2, Det medisinske fakultet, Universitetet i Bergen
| | - Steinar Skrede
- Seksjon for infeksjonssjukdommar, Medisinsk klinikk, Haukeland universitetssjukehus, og, Klinisk institutt 2, Det medisinske fakultet, Universitetet i Bergen
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16
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Rasooly R, Do P, He X, Hernlem B. Streptococcal pyrogenic exotoxin B is a superantigen that induces murine splenocyte proliferation and secretion of IL-2 and IFN-γ ex vivo. FEMS Microbiol Lett 2024; 371:fnae036. [PMID: 38806245 DOI: 10.1093/femsle/fnae036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 05/13/2024] [Accepted: 05/27/2024] [Indexed: 05/30/2024] Open
Abstract
Streptococcus pyogenes is a significant human pathogen, producing a range of virulence factors, including streptococcal pyrogenic exotoxin B (SpeB) that is associated with foodborne outbreaks. It was only known that this cysteine protease mediates cleavage of transmembrane proteins to permit bacterial penetration and is found in 25% of clinical isolates from streptococcal toxic shock syndrome patients with extreme inflammation. Its interaction with host and streptococcal proteins has been well characterized, but doubt remains about whether it constitutes a superantigen. In this study, for the first time it is shown that SpeB acts as a superantigen, similarly to other known superantigens such as staphylococcal enterotoxin A or streptococcal pyrogenic exotoxin type C, by inducing proliferation of murine splenocytes and cytokine secretion, primarily of interleukin-2 (IL-2), as shown by cytometric bead array analysis. IL-2 secretion was confirmed by enzyme-linked immunosorbent assay (ELISA) as well as secretion of interferon-γ. ELISA showed a dose-dependent relationship between SpeB concentration in splenocyte cells and IL-2 secretion levels, and it was shown that SpeB retains activity in milk pasteurized for 30 min at 63°C.
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Affiliation(s)
- Reuven Rasooly
- Foodborne Toxin Detection & Prevention Research Unit, Western Regional Research Center, Agricultural Research Service, United States Department of Agriculture, Albany, CA 94710, United States
| | - Paula Do
- Foodborne Toxin Detection & Prevention Research Unit, Western Regional Research Center, Agricultural Research Service, United States Department of Agriculture, Albany, CA 94710, United States
| | - Xiaohua He
- Foodborne Toxin Detection & Prevention Research Unit, Western Regional Research Center, Agricultural Research Service, United States Department of Agriculture, Albany, CA 94710, United States
| | - Bradley Hernlem
- Foodborne Toxin Detection & Prevention Research Unit, Western Regional Research Center, Agricultural Research Service, United States Department of Agriculture, Albany, CA 94710, United States
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17
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Hansen SUB, Jespersen FVB, Markvart M, Hyldegaard O, Plaschke CC, Bjarnsholt T, Nielsen CH, Jensen SS. Characterization of patients with odontogenic necrotizing soft tissue infections in the head and neck area. A retrospective analysis. Acta Odontol Scand 2024; 82:40-47. [PMID: 37688516 DOI: 10.1080/00016357.2023.2254389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 08/13/2023] [Accepted: 08/27/2023] [Indexed: 09/11/2023]
Abstract
OBJECTIVE Necrotizing soft-tissue infection (NSTI) in the head and neck area may develop from odontogenic infections. The aim of this study was to characterize patients with NSTI in the head and neck with odontogenic origin in a well-defined prospectively collected cohort. MATERIAL AND METHODS Patients with NSTI in the head and neck, hospitalized between 2013 and 2017 at Copenhagen University Hospital and registered in the Scandinavian INFECT database were included. Medical records of identified patients and from the INFECT database were screened for a defined set of data including the primary focus of infection, comorbidities, predisposing factors, clinical and radiographic diagnostics, course of treatment, and treatment outcome. RESULTS Thirty-five patients with NSTI in the head and neck area were included in the study. A total of 54% had odontogenic origin, primarily from mandibular molars, and 94% had radiographic signs of infectious oral conditions. Overall, comorbidities were reported in 51% with cardiovascular disease being the most prevalent. In 20%, no comorbidities or predisposing conditions could be identified. The overall 30-day mortality rate was 9%. CONCLUSIONS More than half of NSTI cases in the head and neck region had an odontogenic origin, and special attention should be paid to infections related to mandibular molars.
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Affiliation(s)
| | | | - Merete Markvart
- Department of Odontology, University of Copenhagen, Copenhagen, Denmark
| | - Ole Hyldegaard
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christina Caroline Plaschke
- Department of Otorhinolaryngology Head and Neck Surgery and Audiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Thomas Bjarnsholt
- Department of Clinical Microbiology, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Immunology and Microbiology, Costerton Biofilm Center, University of Copenhagen, Copenhagen, Denmark
| | - Claus Henrik Nielsen
- Department of Odontology, University of Copenhagen, Copenhagen, Denmark
- Institute for Inflammation Research, Copenhagen University Hospital, Copenhagen, Denmark
| | - Simon Storgård Jensen
- Department of Odontology, University of Copenhagen, Copenhagen, Denmark
- Deparment of Oral & Maxillofacial Surgery, Copenhagen University Hospital, Copenhagen, Denmark
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18
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Cen H, Jin R, Yin J, Wang X. Risk Factors for Predicting Mortality and Amputation of Patients with Necrotizing Soft-Tissue Infections: Retrospective Analysis of 111 Cases from a Single Medical Center. Emerg Med Int 2023; 2023:6316896. [PMID: 38029225 PMCID: PMC10657247 DOI: 10.1155/2023/6316896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 10/23/2023] [Accepted: 10/31/2023] [Indexed: 12/01/2023] Open
Abstract
Objective Necrotizing soft-tissue infections (NSTIs) are rare clinical infections with surgical emergencies having a high mortality rate. This study aimed to investigate risk factors for mortality and amputation of patients with NSTI. Methods We retrospectively analyzed critical factors for outcomes of 111 patients with NSTI hospitalized in our department from 1 January 1999 to 31 December 2018. NSTI diagnosis was based on the patient's clinical characteristics, laboratory risk indicator for necrotizing fasciitis (LRINEC) score, laboratory test data, and microbiological findings in blood and wound culture. The risk factors for mortality and amputation of NSTI were determined using univariate or multivariate logistic regression analysis, receiver operating characteristics (ROC), and the area under the ROC curve (AUC) at 90 days after admission. Results Diagnosis of 111 patients with NSTI was confirmed according to clinical features, LRINEC score, image data, laboratory findings, and microorganism culture in blood and wounds. The mortality rate was 9.91% (11/111) at day 90 follow-up. High white blood cell (WBC), low hematocrit (HCT), and multiple surgeries were identified to be critical risk factors for NSTI mortality in univariate and multivariate logistic analyses. AUCs, 95% confidence intervals (CI), and P values of risk factors were 0.699, 0.54-0.95, and P = 0.0117 for high WBC; 0.788, 0.63-0.97, and P = 0.0006 for low HCT; and 0.745, 0.59-0.90, and P = 0.0018 for multiple surgeries, respectively. These patients also had high LRINEC scores. Amputation occurred in 34.23% (38/111) of patients. Risk factors for amputation were higher age, low hemoglobin (Hb), and multiple wounds. AUCs, 95% confidence intervals (CI), and P values were 0.713, 0.11-0.32, and P < 0.0001 for higher age; 0.798, 0.08-0.29, and P=0.0007 for low Hb; and 0.757, 0.17-0.34, and P < 0.0001 for multiple lesion sites, respectively. Conclusions High LRINEC scores, high WBC, low HCT, and multiple surgeries were relevant to increased mortality. Higher age, low Hb, and multiple wounds were associated with amputation risk. These clinical features must be paid attention to when patients are diagnosed with NSTI.
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Affiliation(s)
- Hanghui Cen
- Department of Burns and Wound Repair Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, China
| | - Ronghua Jin
- Department of Burns and Wound Repair Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, China
| | - Jun Yin
- Department of Burns and Wound Repair Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, China
| | - Xingang Wang
- Department of Burns and Wound Repair Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, China
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19
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Vinkel J, Rib L, Buil A, Hedetoft M, Hyldegaard O. Key pathways and genes that are altered during treatment with hyperbaric oxygen in patients with sepsis due to necrotizing soft tissue infection (HBOmic study). Eur J Med Res 2023; 28:507. [PMID: 37946314 PMCID: PMC10636866 DOI: 10.1186/s40001-023-01466-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/21/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND For decades, the basic treatment strategies of necrotizing soft tissue infections (NSTI) have remained unchanged, primarily relying on aggressive surgical removal of infected tissue, broad-spectrum antibiotics, and supportive intensive care. One treatment strategy that has been proposed as an adjunctive measure to improve patient outcomes is hyperbaric oxygen (HBO2) treatment. HBO2 treatment has been linked to several immune modulatory effects; however, investigating these effects is complicated due to the disease's acute life-threatening nature, metabolic and cell homeostasis dependent variability in treatment effects, and heterogeneity with respect to both patient characteristics and involved pathogens. To embrace this complexity, we aimed to explore the underlying biological mechanisms of HBO2 treatment in patients with NSTI on the gene expression level. METHODS We conducted an observational cohort study on prospective collected data, including 85 patients admitted to the intensive care unit (ICU) for NSTI. All patients were treated with one or two HBO2 treatments and had one blood sample taken before and after the intervention. Total RNAs from blood samples were extracted and mRNA purified with rRNA depletion, followed by whole-transcriptome RNA sequencing with a targeted sequencing depth of 20 million reads. A model for differentially expressed genes (DEGs) was fitted, and the functional aspects of the obtained set of genes was predicted with GO (Gene Ontology) and KEGG (Kyoto Encyclopedia of genes and Genomes) enrichment analyses. All analyses were corrected for multiple testing with FDR. RESULTS After sequential steps of quality control, a final of 160 biological replicates were included in the present study. We found 394 protein coding genes that were significantly DEGs between the two conditions with FDR < 0.01, of which 205 were upregulated and 189 were downregulated. The enrichment analysis of these DEGs revealed 20 GO terms in biological processes and 12 KEGG pathways that were significantly overrepresented in the upregulated DEGs, of which the term; "adaptive immune response" (GO:0002250) (FDR = 9.88E-13) and "T cell receptor signaling pathway" (hsa04660) (FDR = 1.20E-07) were the most significant. Among the downregulated DEGs two biological processes were significantly enriched, of which the GO term "apoptotic process" (GO:0006915) was the most significant (FDR = 0.001), followed by "Positive regulation of T helper 1 cell cytokine production" (GO:2000556), and "NF-kappa B signaling pathway" (hsa04064) was the only KEGG pathway that was significantly overrepresented (FDR = 0.001). CONCLUSIONS When one or two sessions of HBO2 treatment were administered to patients with a dysregulated immune response and systemic inflammation due to NSTI, the important genes that were regulated during the intervention were involved in activation of T helper cells and downregulation of the disease-induced highly inflammatory pathway NF-κB, which was associated with a decrease in the mRNA level of pro-inflammatory factors. TRIAL REGISTRATION Biological material was collected during the INFECT study, registered at ClinicalTrials.gov (NCT01790698).
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Affiliation(s)
- Julie Vinkel
- Department of Anesthesiology, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Leonor Rib
- Biotech Research and Innovation Centre, University of Copenhagen, Copenhagen, Denmark
| | - Alfonso Buil
- Institute for Biological Psychiatry, Mental Health Centre Sct. Hans, Roskilde, Denmark
| | - Morten Hedetoft
- Department of Anesthesiology, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark
- Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
| | - Ole Hyldegaard
- Department of Anesthesiology, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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20
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Suijker J, Wurfbain L, Emmen AMLH, Pijpe A, Kwa KAA, van der Vlies CH, Nieuwenhuis MK, van Zuijlen PPM, Meij-de Vries A. The Role of Burn Centers in the Treatment of Necrotizing Soft-Tissue Infections: A Nationwide Dutch Study. J Burn Care Res 2023; 44:1405-1412. [PMID: 37227902 PMCID: PMC10628513 DOI: 10.1093/jbcr/irad073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Indexed: 05/27/2023]
Abstract
Patients with extensive and complex wounds due to Necrotizing Soft-Tissue Infections (NSTI) may be referred to a burn center. This study describes the characteristics, outcomes, as well as diagnostic challenges of these patients. Patients admitted to three hospitals with a burn center for the treatment of NSTI in a 5-year period were included. Eighty patients (median age 54 years, 60% male) were identified, of whom 30 (38%) were referred by other centers, usually after survival of the initial septic phase. Those referred from other centers, compared to those primarily admitted to the study hospitals, were more likely to have group A streptococcal involvement (62% vs 35%, p = .02), larger wounds (median 7% vs 2% total body surface area, p < .001), and a longer length of stay (median 49 vs 22 days, p < .001). Despite a high incidence of septic shock (50%), the mortality rate was low (12%) for those primarily admitted. Approximately half (53%) of the patients were initially misdiagnosed upon presentation, which was associated with delay to first surgery (16 hours vs 4 hours, p < .001). Those initially misdiagnosed had more (severe) comorbidities, and less frequently reported pain or blue livid discoloration of the skin. This study underlines the burn centers' function as referral centers for extensively affected patients with NSTI. Besides the unique wound and reconstructive expertise, the low mortality rate indicates these centers provide adequate acute care as well. A major remaining challenge remains recognition of the disease upon presentation. Future studies in which factors associated with misdiagnosis are explored are needed.
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Affiliation(s)
- Jaco Suijker
- Burn Centre, Red Cross Hospital, Beverwijk, The Netherlands
- Association of Dutch Burn Centres, Beverwijk, The Netherlands
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Plastic, Reconstructive and Hand Surgery, De Boelelaan 1117, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Tissue Function and Regeneration, Amsterdam, The Netherlands
| | - Lisca Wurfbain
- Burn Centre, Red Cross Hospital, Beverwijk, The Netherlands
| | - Anouk M L H Emmen
- Department of Surgery, Rode Kruis Ziekenhuis, Beverwijk, The Netherlands
| | - Anouk Pijpe
- Burn Centre, Red Cross Hospital, Beverwijk, The Netherlands
- Association of Dutch Burn Centres, Beverwijk, The Netherlands
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Plastic, Reconstructive and Hand Surgery, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Kelly A A Kwa
- Burn Centre, Red Cross Hospital, Beverwijk, The Netherlands
| | - Cornelis H van der Vlies
- Burn Centre, Maasstad Ziekenhuis, Rotterdam, The Netherlands
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Marianne K Nieuwenhuis
- Association of Dutch Burn Centers, Burn Centre, Martini Hospital, Groningen, The Netherlands
- Centre for Human Movement Sciences, University Medical Centre Groningen, Groningen, The Netherlands
- Research group Healthy Ageing, Allied Health Care and Nursing, Hanze University of Applied Sciences Groningen, Groningen, Nederland
| | - Paul P M van Zuijlen
- Burn Centre, Red Cross Hospital, Beverwijk, The Netherlands
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Plastic, Reconstructive and Hand Surgery, De Boelelaan 1117, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Tissue Function and Regeneration, Amsterdam, The Netherlands
- Amsterdam UMC location University of Amsterdam, Pediatric Surgical Centre, Emma Children's Hospital, Meibergdreef 9, Amsterdam, Netherlands
| | - Annebeth Meij-de Vries
- Burn Centre, Red Cross Hospital, Beverwijk, The Netherlands
- Department of Surgery, Rode Kruis Ziekenhuis, Beverwijk, The Netherlands
- Amsterdam UMC location University of Amsterdam, Pediatric Surgical Centre, Emma Children's Hospital, Meibergdreef 9, Amsterdam, Netherlands
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21
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Windsor C, Urbina T, de Prost N. Severe skin infections. Curr Opin Crit Care 2023; 29:407-414. [PMID: 37641501 DOI: 10.1097/mcc.0000000000001069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
PURPOSE OF REVIEW The incidence of necrotizing soft-tissue infections (NSTI) has increased during recent decades. These infections are still associated with high morbidity and mortality, underlining a need for continued education of the medical community. This review will focus on practical approaches to management of NSTI focusing on antibiotic therapies and optimizing the management of group A streptococcus (GAS)-associated NSTIs. RECENT FINDINGS Antibiotic therapy for NSTI patients faces several challenges as the rapid progression of NSTIs mandates broad-spectrum agents with bactericidal action. Current recommendations support using clindamycin in combination with penicillin in case of GAS-documented NSTIs. Linezolide could be an alternative in case of clindamycin resistance. SUMMARY Reducing the time to diagnosis and first surgical debridement, initiating early broad-spectrum antibiotics and early referral to specialized centres are the key modifiable factors that may impact the prognosis of NSTIs. Causative organisms vary widely according to the topography of the infection, underlying conditions, and geographic location. Approximately one third of NSTIs are monomicrobial, involving mainly GAS or Staphylococcus aureus . Data for antibiotic treatment specifically for necrotizing soft-tissue infections are scarce, with guidelines mainly based on expert consensus.
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Affiliation(s)
- Camille Windsor
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor- Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP)
- Groupe de Recherche Clinique CARMAS, Université Paris Est-Créteil, Créteil
| | - Tomas Urbina
- Service de Médecine Intensive Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris
| | - Nicolas de Prost
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor- Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP)
- Groupe de Recherche Clinique CARMAS, Université Paris Est-Créteil, Créteil
- Université Paris-Est Créteil Val de Marne (UPEC), Créteil, France
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22
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Vinkel J, Arenkiel B, Hyldegaard O. The Mechanisms of Action of Hyperbaric Oxygen in Restoring Host Homeostasis during Sepsis. Biomolecules 2023; 13:1228. [PMID: 37627293 PMCID: PMC10452474 DOI: 10.3390/biom13081228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/02/2023] [Accepted: 08/05/2023] [Indexed: 08/27/2023] Open
Abstract
The perception of sepsis has shifted over time; however, it remains a leading cause of death worldwide. Sepsis is now recognized as an imbalance in host cellular functions triggered by the invading pathogens, both related to immune cells, endothelial function, glucose and oxygen metabolism, tissue repair and restoration. Many of these key mechanisms in sepsis are also targets of hyperbaric oxygen (HBO2) treatment. HBO2 treatment has been shown to improve survival in clinical studies on patients with necrotizing soft tissue infections as well as experimental sepsis models. High tissue oxygen tension during HBO2 treatment may affect oxidative phosphorylation in mitochondria. Oxygen is converted to energy, and, as a natural byproduct, reactive oxygen species are produced. Reactive oxygen species can act as mediators, and both these and the HBO2-mediated increase in oxygen supply have the potential to influence the cellular processes involved in sepsis. The pathophysiology of sepsis can be explained comprehensively through resistance and tolerance to infection. We argue that HBO2 treatment may protect the host from collateral tissue damage during resistance by reducing neutrophil extracellular traps, inhibiting neutrophil adhesion to vascular endothelium, reducing proinflammatory cytokines, and halting the Warburg effect, while also assisting the host in tolerance to infection by reducing iron-mediated injury and upregulating anti-inflammatory measures. Finally, we show how inflammation and oxygen-sensing pathways are connected on the cellular level in a self-reinforcing and detrimental manner in inflammatory conditions, and with support from a substantial body of studies from the literature, we conclude by demonstrating that HBO2 treatment can intervene to maintain homeostasis.
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Affiliation(s)
- Julie Vinkel
- Department of Anesthesiology, Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Bjoern Arenkiel
- Department of Anesthesiology, Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark
| | - Ole Hyldegaard
- Department of Anesthesiology, Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, 2200 Copenhagen, Denmark
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23
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Shumba P, Sura T, Moll K, Chakrakodi B, Tölken LA, Hoßmann J, Hoff KJ, Hyldegaard O, Nekludov M, Svensson M, Arnell P, Skrede S, Norrby-Teglund A, Siemens N. Neutrophil-derived reactive agents induce a transient SpeB negative phenotype in Streptococcus pyogenes. J Biomed Sci 2023; 30:52. [PMID: 37430325 DOI: 10.1186/s12929-023-00947-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 07/03/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Streptococcus pyogenes (group A streptococci; GAS) is the main causative pathogen of monomicrobial necrotizing soft tissue infections (NSTIs). To resist immuno-clearance, GAS adapt their genetic information and/or phenotype to the surrounding environment. Hyper-virulent streptococcal pyrogenic exotoxin B (SpeB) negative variants caused by covRS mutations are enriched during infection. A key driving force for this process is the bacterial Sda1 DNase. METHODS Bacterial infiltration, immune cell influx, tissue necrosis and inflammation in patient´s biopsies were determined using immunohistochemistry. SpeB secretion and activity by GAS post infections or challenges with reactive agents were determined via Western blot or casein agar and proteolytic activity assays, respectively. Proteome of GAS single colonies and neutrophil secretome were profiled, using mass spectrometry. RESULTS Here, we identify another strategy resulting in SpeB-negative variants, namely reversible abrogation of SpeB secretion triggered by neutrophil effector molecules. Analysis of NSTI patient tissue biopsies revealed that tissue inflammation, neutrophil influx, and degranulation positively correlate with increasing frequency of SpeB-negative GAS clones. Using single colony proteomics, we show that GAS isolated directly from tissue express but do not secrete SpeB. Once the tissue pressure is lifted, GAS regain SpeB secreting function. Neutrophils were identified as the main immune cells responsible for the observed phenotype. Subsequent analyses identified hydrogen peroxide and hypochlorous acid as reactive agents driving this phenotypic GAS adaptation to the tissue environment. SpeB-negative GAS show improved survival within neutrophils and induce increased degranulation. CONCLUSIONS Our findings provide new information about GAS fitness and heterogeneity in the soft tissue milieu and provide new potential targets for therapeutic intervention in NSTIs.
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Affiliation(s)
- Patience Shumba
- Department of Molecular Genetics and Infection Biology, University of Greifswald, Greifswald, Germany
| | - Thomas Sura
- Department of Microbial Proteomics, Institute of Microbiology, University of Greifswald, Greifswald, Germany
| | - Kirsten Moll
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Bhavya Chakrakodi
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Lea A Tölken
- Department of Molecular Genetics and Infection Biology, University of Greifswald, Greifswald, Germany
| | - Jörn Hoßmann
- Helmholtz Center for Infection Research, Brunswick, Germany
| | - Katharina J Hoff
- Institute of Mathematics and Computer Science, University of Greifswald, Greifswald, Germany
| | - Ole Hyldegaard
- Department of Anaesthesia, Head and Orthopedic Center, University Hospital Copenhagen, Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Michael Nekludov
- Department of Anaesthesia, Surgical Services and Intensive Care, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Mattias Svensson
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Per Arnell
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Anna Norrby-Teglund
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Nikolai Siemens
- Department of Molecular Genetics and Infection Biology, University of Greifswald, Greifswald, Germany.
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24
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Movert E, Bolarin JS, Valfridsson C, Velarde J, Skrede S, Nekludov M, Hyldegaard O, Arnell P, Svensson M, Norrby-Teglund A, Cho KH, Elhaik E, Wessels MR, Råberg L, Carlsson F. Interplay between human STING genotype and bacterial NADase activity regulates inter-individual disease variability. Nat Commun 2023; 14:4008. [PMID: 37414832 PMCID: PMC10326033 DOI: 10.1038/s41467-023-39771-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 06/28/2023] [Indexed: 07/08/2023] Open
Abstract
Variability in disease severity caused by a microbial pathogen is impacted by each infection representing a unique combination of host and pathogen genomes. Here, we show that the outcome of invasive Streptococcus pyogenes infection is regulated by an interplay between human STING genotype and bacterial NADase activity. S. pyogenes-derived c-di-AMP diffuses via streptolysin O pores into macrophages where it activates STING and the ensuing type I IFN response. However, the enzymatic activity of the NADase variants expressed by invasive strains suppresses STING-mediated type I IFN production. Analysis of patients with necrotizing S. pyogenes soft tissue infection indicates that a STING genotype associated with reduced c-di-AMP-binding capacity combined with high bacterial NADase activity promotes a 'perfect storm' manifested in poor outcome, whereas proficient and uninhibited STING-mediated type I IFN production correlates with protection against host-detrimental inflammation. These results reveal an immune-regulating function for bacterial NADase and provide insight regarding the host-pathogen genotype interplay underlying invasive infection and interindividual disease variability.
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Affiliation(s)
- Elin Movert
- Department of Biology, Lund University, Sölvegatan 35, 223 62, Lund, Sweden
| | | | | | - Jorge Velarde
- Division of Infectious Diseases, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, USA
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Michael Nekludov
- Department of Anaesthesia, Surgical Services and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Ole Hyldegaard
- Department of Anaesthesia, Head and Orthopedic Center, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Per Arnell
- Department of Anaesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mattias Svensson
- Centre for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Norrby-Teglund
- Centre for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Kyu Hong Cho
- Department of Biology, Indiana State University, Terre Haute, USA
| | - Eran Elhaik
- Department of Biology, Lund University, Sölvegatan 35, 223 62, Lund, Sweden
| | - Michael R Wessels
- Division of Infectious Diseases, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, USA
| | - Lars Råberg
- Department of Biology, Lund University, Sölvegatan 35, 223 62, Lund, Sweden
| | - Fredric Carlsson
- Department of Biology, Lund University, Sölvegatan 35, 223 62, Lund, Sweden.
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25
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Barbier F, Woerther PL, Timsit JF. Rapid diagnostics for skin and soft tissue infections: the current landscape and future potential. Curr Opin Infect Dis 2023; 36:57-66. [PMID: 36718917 DOI: 10.1097/qco.0000000000000901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE OF REVIEW Managing antimicrobial therapy in patients with complicated skin and soft tissue infections (SSTI) constitutes a growing challenge due to the wide spectrum of potential pathogens and resistance phenotypes. Today, microbiological documentation relies on cultural methods. This review summarizes the available evidence regarding the clinical input of rapid microbiological diagnostic tools (RMDT) and their impact on the management of antimicrobial therapy in SSTI. RECENT FINDINGS Accurate tools are already available for the early detection of methicillin-resistant Staphylococcus aureus (MRSA) in SSTI samples and may help avoiding or shortening empirical anti-MRSA coverage. Further research is necessary to develop and evaluate RMDT detecting group A streptococci (e.g., antigenic test) and Gram-negative pathogens (e.g., multiplex PCR assays), including through point-of-care utilization. Next-generation sequencing (NGS) methods could provide pivotal information for the stewardship of antimicrobial therapy, especially in case of polymicrobial or fungal SSTI and in the immunocompromised host; however, a shortening in the turnaround time and prospective data regarding their therapeutic input are needed to better appraise the clinical positioning of these promising approaches. SUMMARY The clinical input of RMDT in SSTI is currently limited due to the scarcity of available dedicated assays and the polymicrobial feature of certain cases. NGS appears as a relevant tool but requires further developments before its implementation in routine clinical practice.
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Affiliation(s)
- François Barbier
- Médecine Intensive - Réanimation, Centre Hospitalier Régional d'Orléans, Orléans
- CEPR/INSERM U1100, Université de Tours, Tours
| | - Paul-Louis Woerther
- Département de Microbiologie, Centre Hospitalier Universitaire Henri Mondor, Assistance Publique - Hôpitaux de Paris
- DYNAMYC/EA7380, Université Paris Est - Créteil, Créteil
| | - Jean-François Timsit
- Réanimation Médicale et des Maladies Infectieuses, Centre Hospitalier Universitaire Bichat - Claude Bernard, Assistance Publique - Hôpitaux de Paris
- DeSCID/IAME/INSERM U1137, Université Paris Cité, Paris, France
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26
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Rath E, Palma Medina LM, Jahagirdar S, Mosevoll KA, Damås JK, Madsen MB, Svensson M, Hyldegaard O, Martins Dos Santos VAP, Saccenti E, Norrby-Teglund A, Skrede S, Bruun T. Systemic immune activation profiles in streptococcal necrotizing soft tissue infections: A prospective multicenter study. Clin Immunol 2023; 249:109276. [PMID: 36871764 DOI: 10.1016/j.clim.2023.109276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/05/2023] [Accepted: 02/28/2023] [Indexed: 03/07/2023]
Abstract
OBJECTIVE Early stages with streptococcal necrotizing soft tissue infections (NSTIs) are often difficult to discern from cellulitis. Increased insight into inflammatory responses in streptococcal disease may guide correct interventions and discovery of novel diagnostic targets. METHODS Plasma levels of 37 mediators, leucocytes and CRP from 102 patients with β-hemolytic streptococcal NSTI derived from a prospective Scandinavian multicentre study were compared to those of 23 cases of streptococcal cellulitis. Hierarchical cluster analyses were also performed. RESULTS Differences in mediator levels between NSTI and cellulitis cases were revealed, in particular for IL-1β, TNFα and CXCL8 (AUC >0.90). Across streptococcal NSTI etiologies, eight biomarkers separated cases with septic shock from those without, and four mediators predicted a severe outcome. CONCLUSION Several inflammatory mediators and wider profiles were identified as potential biomarkers of NSTI. Associations of biomarker levels to type of infection and outcomes may be utilized to improve patient care and outcomes.
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Affiliation(s)
- Eivind Rath
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.
| | - Laura M Palma Medina
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Huddinge, Sweden
| | - Sanjeevan Jahagirdar
- Laboratory of Systems and Synthetic Biology, Wageningen University & Research, Wageningen, the Netherlands
| | - Knut A Mosevoll
- Department of Medicine, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, University of Bergen, Norway
| | - Jan K Damås
- Department of Infectious Diseases, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway; Centre of Molecular Inflammation Research, Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Martin B Madsen
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Mattias Svensson
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Huddinge, Sweden
| | - Ole Hyldegaard
- Department of Anaesthesia- and Surgery, Head and Orthopaedic centre, Hyperbaric Unit, Copenhagen University Hospital, Rigshospitalet, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Vitor A P Martins Dos Santos
- Laboratory of Systems and Synthetic Biology, Wageningen University & Research, Wageningen, the Netherlands; LifeGlimmer GmbH, Berlin, Germany
| | - Edoardo Saccenti
- Laboratory of Systems and Synthetic Biology, Wageningen University & Research, Wageningen, the Netherlands
| | - Anna Norrby-Teglund
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Huddinge, Sweden
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, University of Bergen, Norway
| | - Trond Bruun
- Department of Medicine, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, University of Bergen, Norway
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27
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Hua C, Urbina T, Bosc R, Parks T, Sriskandan S, de Prost N, Chosidow O. Necrotising soft-tissue infections. THE LANCET. INFECTIOUS DISEASES 2023; 23:e81-e94. [PMID: 36252579 DOI: 10.1016/s1473-3099(22)00583-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/05/2022] [Accepted: 08/22/2022] [Indexed: 11/07/2022]
Abstract
The incidence of necrotising soft-tissue infections has increased during recent decades such that most physicians might see at least one case of these potentially life-threatening infections in their career. Despite advances in care, necrotising soft-tissue infections are still associated with high morbidity and mortality, underlining a need for continued education of the medical community. In particular, failure to suspect necrotising soft-tissue infections, fuelled by poor awareness of the disease, promotes delays to first surgical debridement, amplifying disease severity and adverse outcomes. This Review will focus on practical approaches to management of necrotising soft-tissue infections including prompt recognition, initiation of specific management, exploratory surgery, and aftercare. Increased alertness and awareness for these infections should improve time to diagnosis and early referral to specialised centres, with improvement in the prognosis of necrotising soft-tissue infections.
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Affiliation(s)
- Camille Hua
- Service de Dermatologie, Assistance Publique-Hôpitaux de Paris, Créteil, France; Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France; Epidemiology in Dermatology and Evaluation of Therapeutics, Université Paris Est Créteil, Créteil, France; Groupe Infectiologie Dermatologique-Infections Sexuellement Transmissibles, Société Française de Dermatologie, Paris, France
| | - Tomas Urbina
- Service de Médecine Intensive Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Romain Bosc
- Service de Chirurgie Plastique, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Tom Parks
- Department of Infectious Diseases, Imperial College London, London, UK
| | - Shiranee Sriskandan
- Department of Infectious Diseases, Imperial College London, London, UK; MRC Centre for Molecular Bacteriology and Infection, Imperial College London, London, UK
| | - Nicolas de Prost
- Service de Médecine Intensive Réanimation, Assistance Publique-Hôpitaux de Paris, Créteil, France; CARMAS Research Group, UPEC-Université Paris-Est Créteil Val de Marne, Faculté de médecine de Créteil, Créteil, France
| | - Olivier Chosidow
- Service de Dermatologie, Assistance Publique-Hôpitaux de Paris, Créteil, France; Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France; Groupe Infectiologie Dermatologique-Infections Sexuellement Transmissibles, Société Française de Dermatologie, Paris, France; Research group Dynamyc, Faculté de Santé de Créteil, Ecole Nationale Vétérinaire d'Alfort, USC ANSES, Université Paris-Est Créteil, Créteil, France.
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28
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The impact of necrotizing soft tissue infections on the lives of survivors: a qualitative study. Qual Life Res 2023:10.1007/s11136-023-03371-8. [PMID: 36840905 DOI: 10.1007/s11136-023-03371-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2023] [Indexed: 02/26/2023]
Abstract
PURPOSE Necrotizing soft tissue infections (NSTI) are potentially lethal infections marked by local tissue destruction and systemic sepsis, which require aggressive treatment. Survivors often face a long recovery trajectory. This study was initiated to increase understanding of the long-term impact of NSTI on health related quality of life (HRQoL), and how care may be improved. METHODS Thematic analysis was applied to qualitative data from 25 NSTI-survivors obtained through two focus groups (n = 14) and semi-structured interviews (n = 11). RESULTS The median age of the participants was 49 years, 14 were female. The median time since diagnosis was 5 years. Initial misdiagnosis was common, causing delay to treatment. Survivors experienced long-term physical consequences (scarring, cognitive impairment, fatigue, sleeping problems, recurrent infections), psychological consequences (traumatic stress symptoms, fear of relapse, adjusting to an altered appearance, sexual issues) and social and relational consequences (changes in social contacts, a lack of understanding). The disease also had a major psychological impact on family members, as well as major financial impact in some. There was a strong desire to reflect on 'mistakes' in case of initial misdiagnosis. To improve care, patient and family centered care, smooth transitions after discharge, and the availability of understandable information were deemed important. CONCLUSION This study reveals that NSTI have a large impact on physical and psychosocial wellbeing of survivors and their relatives. Except for a few differences (misdiagnosis, fear for re-infection and actual re-infection), the patient experience of patients with NSTI is largely similar to those of burn survivors. Thus, questionnaires to assess HRQoL in burn survivors may be used in future NSTI studies.
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29
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Hedetoft M, Madsen MB, Hyldegaard O. Hyperbaric oxygen treatment in the management of necrotising soft-tissue infections: results from a Danish nationwide registry study. BMJ Open 2023; 13:e066117. [PMID: 36813488 PMCID: PMC9950903 DOI: 10.1136/bmjopen-2022-066117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
OBJECTIVES Application of hyperbaric oxygen (HBO2) treatment in the multidisciplinary setting of necrotising soft-tissue infection (NSTI) is debated as a considerable number of studies are of low quality with marked prognostication bias due to inadequately addressing disease severity. The objective of this study was to associate HBO2 treatment with mortality in patients with NSTI including disease severity as a prognostic variable. DESIGN Nationwide population-based register study. SETTING Denmark. PARTICIPANTS Danish residents with NSTI patients between January 2011 and June 2016. PRIMARY AND SECONDARY OUTCOME MEASURES Thirty-day mortality was compared between patients receiving and patients not receiving HBO2 treatment using inverse probability of treatment weighting and propensity-score matching with predetermined variables (age, sex and weighted Charlson comorbidity score, presence of septic shock and Simplified Acute Physiology Score II (SAPS II)). RESULTS A total of 671 NSTI patients were included with a median age of 63 (52-71), 61% male sex, 30% had septic shock and a median SAPS II of 46 (34-58). Patients who received HBO2 treatment (n=266) were younger and had lower SAPS II, but a larger fraction had septic shock compared with patients not receiving HBO2 treatment. Overall, all-cause 30-day mortality was 19% (95% CI 17% to 23%). The statistical models were in general acceptably balanced with covariates reaching <0.1 absolute standardised mean differences and patients receiving HBO2 treatment were associated with lower 30-day mortality (OR 0.40, 95% CI 0.30 to 0.53, p<0.001). CONCLUSIONS In analyses using inverse probability of treatment weighting and propensity score analysis, patients treated with HBO2 treatment were associated with improved 30-day survival.
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Affiliation(s)
- Morten Hedetoft
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Martin Bruun Madsen
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ole Hyldegaard
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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30
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Hu X, Li H, Guo W, Xiang H, Hao L, Ai F, Sahu S, Li C. Vacuum sealing drainage system combined with an antibacterial jackfruit aerogel wound dressing and 3D printed fixation device for infections of skin soft tissue injuries. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2022; 34:1. [PMID: 36586047 PMCID: PMC9805414 DOI: 10.1007/s10856-022-06709-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 12/12/2022] [Indexed: 05/21/2023]
Abstract
Injuries and infections of skin and soft tissue are commonly encountered in primary health care and are challenging to manage. Vacuum sealing drainage (VSD) is generally used in clinical treatment, but current commercial methods of VSD have some disadvantages, such as easy blockage, nonantibacterial effects, and inconvenient curved surfaces. Herein, we report a functional zinc oxide/jackfruit aerogel (ZnO/JFA) composite material that is ultralight, superabsorbent and antibacterial as a new antibacterial VSD wound dressing. The JFA is carbonized from fresh jackfruit, and the JFA exhibits superhydrophilicity and superabsorbability. The water absorption rate of JFA was up to 1209.39%, and the SBF absorption rate was up to 1384.22%. The water absorption rate of ZnO/JFA was up to 494.47%, and the SBF absorption rate was up to 473.71%. The JFA and ZnO/JFA possess a pipeline structure, which is beneficial for absorbing wound exudates. In addition, surface modification of nanosized ZnO and its effects on antibacterial properties and biocompatibility were performed. When the concentration of ZnO/JFA was 3.125 mg/mL, the survival rate of human fibroblast cells was close to 80%, while the antibacterial rates against Staphylococcus aureus, Pseudomonas aeruginosa and Escherichia coli were up to 99.06%, 75.28% and 93.58%, respectively. Moreover, a 3D printed assisted device was introduced to make the ZnO/JFA wound dressing more attached to the bottom of the wound on a curved surface. An integrated device was formed under the printing mold, and then animal experiments were conducted in vivo. The results showed that a healing rate of almost 100% for infected skin wounds was obtained with this novel VSD device after 14 days, compared to only 79.65% without the VSD device. This novel VSD with a negative pressure suction dressing is beneficial for healing infectious wounds.
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Affiliation(s)
- Xin Hu
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Huijian Li
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Wenting Guo
- The Second Clinical Medical School, Nanchang University, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Huiqin Xiang
- The Second Clinical Medical School, Nanchang University, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Liang Hao
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Fanrong Ai
- School of Mechanical & Electronic Engineering, Nanchang University, Nanchang, Jiangxi, 330031, People's Republic of China
| | - Souradeep Sahu
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Chen Li
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, 330006, People's Republic of China.
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31
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Windsor C, Hua C, De Roux Q, Harrois A, Anguel N, Montravers P, Vieillard-Baron A, Mira JP, Urbina T, Gaudry S, Turpin M, Damoisel C, Annane D, Ricard JD, Hersant B, Dessap AM, Chosidow O, Layese R, de Prost N. Healthcare trajectory of critically ill patients with necrotizing soft tissue infections: a multicenter retrospective cohort study using the clinical data warehouse of Greater Paris University Hospitals. Ann Intensive Care 2022; 12:115. [PMID: 36538244 PMCID: PMC9768077 DOI: 10.1186/s13613-022-01087-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 11/26/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Necrotizing skin and soft tissue infections (NSTIs) are rare but serious and rapidly progressive infections characterized by necrosis of subcutaneous tissue, fascia and even muscle. The care pathway of patients with NSTIs is poorly understood. A better characterization of the care trajectory of these patients and a better identification of patients at risk of a complicated evolution, requiring prolonged hospitalization, multiple surgical re-interventions, or readmission to the intensive care unit (ICU), is an essential prerequisite to improve their care. The main objective of this study is to obtain large-scale data on the care pathway of these patients. We performed a retrospective multicenter observational cohort study in 13 Great Paris area hospitals, including patients hospitalized between January 1, 2015 and December 31, 2019 in the ICU for surgically confirmed NSTIs. RESULTS 170 patients were included. The median duration of stay in ICU and hospital was 8 (3-17) and 37 (14-71) days, respectively. The median time from admission to first surgical debridement was 1 (0-2) day but 69.9% of patients were re-operated with a median of 1 (0-3) additional debridement. Inter-hospital transfer was necessary in 52.4% of patients. 80.2% of patients developed organ failures during the course of ICU stay with 51.8% of patients requiring invasive mechanical ventilation, 77.2% needing vasopressor support and 27.7% renal replacement therapy. In-ICU and in-hospital mortality rates were 21.8% and 28.8%, respectively. There was no significant difference between patients with abdomino-perineal NSTIs (n = 33) and others (n = 137) in terms of in-hospital or ICU mortality. Yet, immunocompromised patients (n = 43) showed significantly higher ICU and in-hospital mortality rates than non-immunocompromised patients (n = 127) (37.2% vs. 16.5%, p = 0.009, and 53.5% vs. 20.5%, p < 0.001). Factors associated with a complicated course were the presence of a polymicrobial infection (adjusted odds ratio [aOR = 3.18 (1.37-7.35); p = 0.007], of a bacteremia [aOR = 3.29 (1.14-9.52); p = 0.028] and a higher SAPS II score [aOR = 1.05 (1.02-1.07); p < 0.0001]. 62.3% of patients were re-hospitalized within 6 months. CONCLUSION In this retrospective multicenter study, we showed that patients with NSTI required complex management and are major consumers of care. Two-thirds of them underwent a complicated hospital course, associated with a higher SAPS II score, a polymicrobial NSTI and a bacteremia.
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Affiliation(s)
- Camille Windsor
- grid.50550.350000 0001 2175 4109Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor–Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil, France
| | - Camille Hua
- grid.50550.350000 0001 2175 4109Service de Dermatologie, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique–Hôpitaux de Paris (AP-HP), Créteil, France ,grid.410511.00000 0001 2149 7878Université Paris-Est Créteil Val de Marne (UPEC), Créteil, France
| | - Quentin De Roux
- grid.412116.10000 0004 1799 3934Département d’anesthésie-Réanimation, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil, France
| | - Anatole Harrois
- grid.413784.d0000 0001 2181 7253Département d’anesthésie-Réanimation, Université Paris Saclay, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
| | - Nadia Anguel
- grid.413784.d0000 0001 2181 7253Service de Médecine Intensive Réanimation, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
| | - Philippe Montravers
- Department of Anesthesiology and Critical Care Medicine, Université Paris Cité, AP-HP, Hôpital Bichat-Claude Bernard; DMU PARABOL, Paris, France ,grid.7429.80000000121866389PHERE, Physiopathology and Epidemiology of Respiratory Diseases, French Institute of Health and Medical Research (INSERM) U1152, Paris, France
| | - Antoine Vieillard-Baron
- grid.413756.20000 0000 9982 5352Service de Médecine Intensive Réanimation, Hôpital Ambroise Paré, Assistance Publique-Hôpitaux de Paris (AP-HP), Boulogne-Billancourt, France ,grid.460789.40000 0004 4910 6535CESP, UMR 1018, Université Paris-Saclay, Gif-sur-Yvette, France
| | - Jean-Paul Mira
- grid.411784.f0000 0001 0274 3893Service de Médecine Intensive Réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Tomas Urbina
- grid.412370.30000 0004 1937 1100Service de Médecine Intensive Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Stéphane Gaudry
- grid.413780.90000 0000 8715 2621Service de Médecine Intensive Réanimation, Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris (AP-HP), Avicenne, Bobigny, France
| | - Matthieu Turpin
- grid.462844.80000 0001 2308 1657Service de Médecine Intensive Réanimation, Sorbonne Université, AP-HP. Hôpital Tenon, DMU APPROCHES, Paris, France
| | - Charles Damoisel
- Service de Médecine Intensive Réanimation, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Djillali Annane
- grid.413738.a0000 0000 9454 4367Service de Réanimation Polyvalente, Hôpital Antoine Béclère, Assistance Publique-Hôpitaux de Paris (AP-HP), Clamart, France
| | - Jean-Damien Ricard
- grid.414205.60000 0001 0273 556XService de Médecine Intensive Réanimation, Université Paris Cité, AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Colombes, France
| | - Barbara Hersant
- grid.50550.350000 0001 2175 4109Service de Chirurgie Plastique Esthétique et Reconstructrice, Hôpitaux Universitaires Henri Mondor–Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil, France
| | - Armand Mekontso Dessap
- grid.50550.350000 0001 2175 4109Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor–Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil, France ,grid.410511.00000 0001 2149 7878Groupe de Recherche Clinique CARMAS, Université Paris Est-Créteil, Créteil, France ,grid.410511.00000 0001 2149 7878Université Paris-Est Créteil Val de Marne (UPEC), Créteil, France
| | - Olivier Chosidow
- grid.50550.350000 0001 2175 4109Service de Dermatologie, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique–Hôpitaux de Paris (AP-HP), Créteil, France ,grid.410511.00000 0001 2149 7878Université Paris-Est Créteil Val de Marne (UPEC), Créteil, France
| | - Richard Layese
- grid.50550.350000 0001 2175 4109Unité de Recherche Clinique, Hôpitaux Universitaires Henri Mondor–Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil, France ,grid.462410.50000 0004 0386 3258Equipe CEpiA (Clinical Epidemiology and Ageing), Université Paris-Est Créteil, INSERM, IMRB, Créteil, France
| | - Nicolas de Prost
- grid.50550.350000 0001 2175 4109Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor–Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil, France ,grid.410511.00000 0001 2149 7878Groupe de Recherche Clinique CARMAS, Université Paris Est-Créteil, Créteil, France ,grid.410511.00000 0001 2149 7878Université Paris-Est Créteil Val de Marne (UPEC), Créteil, France
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Vinkel J, Rib L, Buil A, Hedetoft M, Hyldegaard O. Investigating the Effects of Hyperbaric Oxygen Treatment in Necrotizing Soft Tissue Infection With Transcriptomics and Machine Learning (the HBOmic Study): Protocol for a Prospective Cohort Study With Data Validation. JMIR Res Protoc 2022; 11:e39252. [PMID: 36427229 PMCID: PMC9736759 DOI: 10.2196/39252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 10/20/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Necrotizing soft tissue infections (NSTIs) are complex multifactorial diseases characterized by rapid bacterial proliferation and progressive tissue death. Treatment is multidisciplinary, including surgery, broad-spectrum antibiotics, and intensive care; adjunctive treatment with hyperbaric oxygen (HBO2) may also be applied. Recent advances in molecular technology and biological computation have given rise to new approaches to infectious diseases based on identifying target groups defined by activated pathophysiological mechanisms. OBJECTIVE We aim to capture NSTI disease signatures and mechanisms and responses to treatment in patients that receive the highest standard of care; therefore, we set out to investigate genome-wide transcriptional responses to HBO2 treatment during NSTI in the host and bacteria. METHODS The Effects of Hyperbaric Oxygen Treatment Studied with Omics (HBOmic) study is a prospective cohort study including 95 patients admitted for NSTI at the intensive care unit of Copenhagen University Hospital (Rigshospitalet), Denmark, between January 2013 and June 2017. All participants were treated according to a local protocol for management of NSTI, and biological samples were obtained and stored according to a standard operational procedure. In the proposed study, we will generate genome-wide expression profiles of whole-blood samples and samples of infected tissue taken before and after HBO2 treatment administered during the initial acute phase of infection, and we will analyze the profiles with unsupervised hierarchical clustering and machine learning. Differential gene expression will be compared in samples taken before and after HBO2 treatment (N=85), and integration of profiles from blood and tissue samples will be performed. Furthermore, findings will be compared to NSTI patients who did not receive HBO2 treatment (N=10). Transcriptomic data will be integrated with clinical data to investigate associations and predictors. RESULTS The first participant was enrolled on July 27, 2021, and data analysis is expected to begin during autumn 2022, with publication of results immediately thereafter. CONCLUSIONS The HBOmic study will provide new insights into personalized patient management in NSTIs. TRIAL REGISTRATION ClinicalTrials.gov NCT01790698; https://clinicaltrials.gov/ct2/show/NCT01790698. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/39252.
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Affiliation(s)
- Julie Vinkel
- Department of Anaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Leonor Rib
- Biotech Research and Innovation Centre, University of Copenhagen, Copenhagen, Denmark
| | - Alfonso Buil
- Institute for Biological Psychiatry, Center of Psychiatry Sankt Hans, Roskilde, Denmark
| | - Morten Hedetoft
- Department of Anaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Ole Hyldegaard
- Department of Anaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Decision support system and outcome prediction in a cohort of patients with necrotizing soft-tissue infections. Int J Med Inform 2022; 167:104878. [DOI: 10.1016/j.ijmedinf.2022.104878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 09/06/2022] [Accepted: 09/19/2022] [Indexed: 11/18/2022]
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Mladenov A, Diehl K, Müller O, von Heymann C, Kopp S, Peitsch WK. Outcome of necrotizing fasciitis and Fournier's gangrene with and without hyperbaric oxygen therapy: a retrospective analysis over 10 years. World J Emerg Surg 2022; 17:43. [PMID: 35932075 PMCID: PMC9356491 DOI: 10.1186/s13017-022-00448-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/24/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Necrotizing soft tissue infections (NSTI) require immediate radical debridement, broad-spectrum antibiotics and intensive care. Hyperbaric oxygen therapy (HBOT) may be performed adjunctively, but unequivocal evidence for its benefits is still lacking. METHODS We performed a retrospective single-center study including 192 patients with necrotizing fasciitis or Fournier's gangrene to assess in-hospital mortality and outcome dependent on patient, disease and treatment characteristics with or without HBOT. RESULTS The in-hospital mortality rate was 27.6%. Factors associated with increased mortality according to multivariate analysis were higher age, affection of multiple or problem localizations (odds ratio (OR) = 2.88, P = 0.003), ineligibility for HBOT despite clinical indication (OR = 8.59, P = 0.005), pathogens in blood cultures (OR = 3.36, P = 0.002), complications (OR = 10.35, P < 0.001) and sepsis/organ dysfunction (OR = 19.58, P < 0.001). Factors associated with better survival included vacuum-assisted wound closure (OR = 0.17, P < 0.001), larger number of debridements (OR = 0.83, P < 0.001) and defect closure with mesh graft (OR = 0.06, P < 0.001) or flap (OR = 0.09, P = 0.024). When participants were stratified into subgroups without requirement of HBOT (n = 98), treated with HBOT (n = 83) and ineligible for HBOT due to contraindications (n = 11), the first two groups had similar survival rates (75.5% vs. 73.5%) and comparable outcome, although patients with HBOT suffered from more severe NSTI, reflected by more frequent affection of multiple localizations (P < 0.001), sepsis at admission (P < 0.001) and intensive care treatment (P < 0.001), more debridements (P < 0.001) and a larger number of antibiotics (P = 0.001). In the subgroup ineligible for HBOT, survival was significantly worse (36.4%, P = 0.022). CONCLUSION These results point to a benefit from HBOT for treatment of NSTI in critically ill patients.
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Affiliation(s)
- Assen Mladenov
- Department of Plastic, Reconstructive and Aesthetic Surgery - Center of Wound Medicine, Vivantes Klinikum im Friedrichshain, Berlin, Germany.,Faculty of Medicine, Charité - University Medicine, Berlin, Germany
| | - Katharina Diehl
- Mannheim Institute of Public Health, Social and Preventive Medicine, Heidelberg University, Mannheim, Germany.,Department of Medical Informatics, Biometry and Epidemiology, Professorship of Epidemiology and Public Health, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Oliver Müller
- Center of Hyperbaric Oxygen Therapy and Diving Medicine, Vivantes Klinikum im Friedrichshain, Berlin, Germany.,Department of Anaesthesiology, Intensive Care Medicine, Emergency Care Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Christian von Heymann
- Center of Hyperbaric Oxygen Therapy and Diving Medicine, Vivantes Klinikum im Friedrichshain, Berlin, Germany.,Department of Anaesthesiology, Intensive Care Medicine, Emergency Care Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Susanne Kopp
- Department of Plastic, Reconstructive and Aesthetic Surgery - Center of Wound Medicine, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Wiebke K Peitsch
- Department of Dermatology and Phlebology, Vivantes Klinikum im Friedrichshain, Berlin, Germany.
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35
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Erickson BA, Flynn KJ. Management of Necrotizing Soft Tissue Infections (Fournier’s Gangrene) and Surgical Reconstruction of Debridement Wound Defects. Urol Clin North Am 2022; 49:467-478. [DOI: 10.1016/j.ucl.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Tanaka S, Thy M, Rozencwajg S, Tran-Dinh A, Montravers P. In severe necrotising soft-tissue infections, do skin defect surfaces matter? Anaesth Crit Care Pain Med 2022; 41:101071. [PMID: 35470050 DOI: 10.1016/j.accpm.2022.101071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 02/07/2022] [Accepted: 02/07/2022] [Indexed: 11/01/2022]
Affiliation(s)
- Sébastien Tanaka
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anesthesiology and Critical Care Medicine, Bichat-Claude Bernard Hospital, Paris, France; Réunion Island University, French Institute of Health and Medical Research (INSERM), U1188 Diabetes Atherothrombosis Réunion Indian Ocean (DéTROI), CYROI Plateform, Saint-Denis de La Réunion, France.
| | - Michael Thy
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anesthesiology and Critical Care Medicine, Bichat-Claude Bernard Hospital, Paris, France; University of Paris, UFR Denis Diderot, Paris, France
| | - Sacha Rozencwajg
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anesthesiology and Critical Care Medicine, Bichat-Claude Bernard Hospital, Paris, France; University of Paris, UFR Denis Diderot, Paris, France
| | - Alexy Tran-Dinh
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anesthesiology and Critical Care Medicine, Bichat-Claude Bernard Hospital, Paris, France; University of Paris, UFR Denis Diderot, Paris, France; French Institute of Health and Medical Research (INSERM) U1148, Laboratory for Vascular Translational Science, Paris, France
| | - Philippe Montravers
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anesthesiology and Critical Care Medicine, Bichat-Claude Bernard Hospital, Paris, France; University of Paris, UFR Denis Diderot, Paris, France; INSERM UMR 1152 - PHERE, Paris, France, Physiopathology and Epidemiology of Respiratory Diseases, Paris, France
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Jahagirdar S, Morris L, Benis N, Oppegaard O, Svenson M, Hyldegaard O, Skrede S, Norrby-Teglund A, Martins Dos Santos VAP, Saccenti E. Analysis of host-pathogen gene association networks reveals patient-specific response to streptococcal and polymicrobial necrotising soft tissue infections. BMC Med 2022; 20:173. [PMID: 35505341 PMCID: PMC9066942 DOI: 10.1186/s12916-022-02355-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 03/28/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Necrotising soft tissue infections (NSTIs) are rapidly progressing bacterial infections usually caused by either several pathogens in unison (polymicrobial infections) or Streptococcus pyogenes (mono-microbial infection). These infections are rare and are associated with high mortality rates. However, the underlying pathogenic mechanisms in this heterogeneous group remain elusive. METHODS In this study, we built interactomes at both the population and individual levels consisting of host-pathogen interactions inferred from dual RNA-Seq gene transcriptomic profiles of the biopsies from NSTI patients. RESULTS NSTI type-specific responses in the host were uncovered. The S. pyogenes mono-microbial subnetwork was enriched with host genes annotated with involved in cytokine production and regulation of response to stress. The polymicrobial network consisted of several significant associations between different species (S. pyogenes, Porphyromonas asaccharolytica and Escherichia coli) and host genes. The host genes associated with S. pyogenes in this subnetwork were characterised by cellular response to cytokines. We further found several virulence factors including hyaluronan synthase, Sic1, Isp, SagF, SagG, ScfAB-operon, Fba and genes upstream and downstream of EndoS along with bacterial housekeeping genes interacting with the human stress and immune response in various subnetworks between host and pathogen. CONCLUSIONS At the population level, we found aetiology-dependent responses showing the potential modes of entry and immune evasion strategies employed by S. pyogenes, congruent with general cellular processes such as differentiation and proliferation. After stratifying the patients based on the subject-specific networks to study the patient-specific response, we observed different patient groups with different collagens, cytoskeleton and actin monomers in association with virulence factors, immunogenic proteins and housekeeping genes which we utilised to postulate differing modes of entry and immune evasion for different bacteria in relationship to the patients' phenotype.
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Affiliation(s)
- Sanjeevan Jahagirdar
- Laboratory of Systems and Synthetic Biology, Wageningen University & Research, Stippeneng 4, 6708, WE, Wageningen, the Netherlands
| | - Lorna Morris
- Lifeglimmer GmbH, Markelstraße 38, 12163, Berlin, Germany
| | - Nirupama Benis
- Laboratory of Systems and Synthetic Biology, Wageningen University & Research, Stippeneng 4, 6708, WE, Wageningen, the Netherlands.,Present affiliation: Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
| | - Oddvar Oppegaard
- Department of Medicine, Division for infectious diseases, Haukeland University Hospital, Bergen, Norway
| | - Mattias Svenson
- Center for Infectious Medicine, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Sweden
| | - Ole Hyldegaard
- Department of Anesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Steinar Skrede
- Department of Medicine, Division for infectious diseases, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Anna Norrby-Teglund
- Center for Infectious Medicine, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Sweden
| | | | - Vitor A P Martins Dos Santos
- Laboratory of Systems and Synthetic Biology, Wageningen University & Research, Stippeneng 4, 6708, WE, Wageningen, the Netherlands.,Lifeglimmer GmbH, Markelstraße 38, 12163, Berlin, Germany
| | - Edoardo Saccenti
- Laboratory of Systems and Synthetic Biology, Wageningen University & Research, Stippeneng 4, 6708, WE, Wageningen, the Netherlands.
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Chen H, Gong SR, Yu RG. Increased normalized lactate load is associated with higher mortality in both sepsis and non-sepsis patients: an analysis of the MIMIC-IV database. BMC Anesthesiol 2022; 22:79. [PMID: 35337269 PMCID: PMC8951714 DOI: 10.1186/s12871-022-01617-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 03/16/2022] [Indexed: 11/19/2022] Open
Abstract
Background The present study aimed to evaluate the association between normalized lactate load, an index that incorporates the magnitude of change and the time interval of such evolution of lactate, and 28-day mortality in sepsis and non-sepsis patients. We also compared the accuracy of normalized lactate load in predicting mortality between these two populations. Methods Data were extracted from the Medical Information Mart for Intensive Care (MIMIC)-IV database. We defined lactate load as the sum of the area under the lactate concentration curve; we also defined normalized lactate load as the lactate load divided by time. The performance of maximum lactate, mean lactate and normalized lactate load in predicting 28-day mortality in sepsis and non-sepsis patients were compared by receiver-operating characteristic curves analysis. Results A total of 21,333 patients were included (4219 sepsis and 17,114 non-sepsis patients). Non-survivors had significantly higher normalized lactate load than survivors in sepsis and non-sepsis patients. The maximum lactate, mean lactate, and normalized lactate load AUCs were significantly greater in sepsis patients than in non-sepsis patients. Normalized lactate load had the greatest AUCs in predicting 28-day mortality in both sepsis and non-sepsis patients. Sensitivity analysis showed that the AUC of normalized lactate load increased in non-sepsis patients when more lactate measurement was obtained, but it was not improved in sepsis patients. Conclusions Normalized lactate load has the strongest predictive power compared with maximum or mean lactate in both sepsis and non-sepsis patients. The accuracy of normalized lactate load in predicting mortality is better in sepsis patients than in non-sepsis patients.
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Affiliation(s)
- Han Chen
- Department of Critical Care Medicine, Fujian Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, No 134, Dongjie Street, Gulou District, Fuzhou, 350001, Fujian, China
| | - Shu-Rong Gong
- Department of Critical Care Medicine, Fujian Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, No 134, Dongjie Street, Gulou District, Fuzhou, 350001, Fujian, China
| | - Rong-Guo Yu
- Department of Critical Care Medicine, Fujian Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, No 134, Dongjie Street, Gulou District, Fuzhou, 350001, Fujian, China.
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Shim H, Varakin N, Meyr AJ. Anatomic and Treatment Descriptive Features of Foot Infections Presenting With Radiographic Soft Tissue Emphysema. J Foot Ankle Surg 2022; 61:323-326. [PMID: 34607779 DOI: 10.1053/j.jfas.2021.08.012] [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: 06/22/2021] [Revised: 08/25/2021] [Accepted: 08/31/2021] [Indexed: 02/03/2023]
Abstract
Foot infections associated with soft tissue emphysema, or the radiographic appearance of gas, are widely considered to necessitate urgent decompression with excisional debridement of the necrotic and infectious tissue burden. The objective of this investigation was to describe anatomic features and clinical outcomes associated with the presence of soft tissue emphysema in foot infections. A retrospective chart review was performed of 62 subjects meeting selection criteria. These were primarily male (74.2%), with a history of diabetes mellitus (85.5%), and without a history of previous lower extremity revascularization (98.4%). The primary radiographic location of the soft tissue emphysema was most frequently in the forefoot (61.3%), followed by the midfoot (21.0%), and rearfoot (16.1%). The soft tissue emphysema was most frequently observed primarily in the dorsal foot tissue (49.2%), followed by both dorsal and plantar foot tissue (27.4%), and the plantar foot tissue (24.2%). The soft tissue emphysema was confined to the primary anatomic location in 74.2% of subjects, while 25.8% of cases demonstrated extension into a more proximal anatomic area. Eighty-two percent of subjects underwent a bedside incision and drainage procedure on presentation in the emergency department, and 95.2% underwent a formal incision and drainage procedure in the operating room at 1.05 ± 0.79 (0-5) postadmission days. Twenty-seven percent of subjects had an unplanned 30-day readmission and 17.7% underwent an unplanned reoperation within 30 days following the index discharge. Fifty-two percent of subjects underwent a minor or major amputation during the index admission, while 33.9% eventually resulted in major limb amputation within 12 months. We hope that this investigation adds to the body of knowledge and provides expectations with respect to the evaluation and treatment of foot soft tissue infections complicated by the presence of radiographic soft tissue emphysema.
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Affiliation(s)
- Hyun Shim
- Temple University Hospital Podiatric Surgical Residency Program, Philadelphia, PA
| | - Nicholas Varakin
- Temple University Hospital Podiatric Surgical Residency Program, Philadelphia, PA
| | - Andrew J Meyr
- Department of Podiatric Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA.
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Collins CM, McCarty A, Jalilvand A, Strassels S, Schubauer K, Gonzalez-Gallo K, Young A, Wisler J. Outcomes of Patients with Necrotizing Soft Tissue Infections: A Propensity-Matched Analysis Using the National Inpatient Sample. Surg Infect (Larchmt) 2022; 23:304-312. [PMID: 35196155 DOI: 10.1089/sur.2021.317] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: Necrotizing soft tissue infections (NSTIs) are severe, rapidly spreading infections with high morbidity and mortality. Attempts to identify risk factors for mortality and morbidity have produced variable results. We hope to determine which factors across the NSTI population impact mortality, morbidities, and discharge disposition. Patients and Methods: Retrospective data from the National Inpatient Sample from 2012-2018 of patients with primary diagnosis of NSTI (gas gangrene, necrotizing faciitis, cutaneous gangrene, or Fournier gangrene) were identified for analysis. A 1:4 greedy match was performed and risk factors for in-hospital mortality and discharge disposition were examined. Continuous variables were assessed using t-tests and Wilcoxon rank sum tests. Categorical variables were assessed using χ2 and Fisher exact tests. Statistical significance was defined as p < 0.05. Results: A total of 6,608 patients were identified. Weighted, this represents 33,040 patients; 32,390 are in the no-mortality cohort and 650 in the mortality cohort. Advanced age group was a risk factor for both in-hospital mortality and morbidity, but not for discharge to a skilled nursing or rehabilitation facility. Having two or more comorbidities was a risk factor for mortality, morbidity, and discharge to skilled nursing or rehabilitation facility. Cancer, liver disease, and kidney disease were predictors of in-hospital mortality. Diabetes mellitus and kidney disease were predictors of experiencing an in-hospital complication. Diabetes mellitus, heart disease, and kidney disease were predictors for discharge to skilled nursing or rehabilitation facility. Conclusions: Necrotizing soft tissue infections are associated with substantial morbidity and mortality. Identifying patients at higher risk for mortality, morbidity, and higher level of care at discharge can help providers properly allocate resources to improve patient outcomes and reduce the financial burden on patients and healthcare facilities. Special attention should be paid to those with existing or acute kidney dysfunction because this was the only comorbidity associated with increased risk mortality, morbidity, and discharge to higher level of care.
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Affiliation(s)
- Courtney M Collins
- Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Adara McCarty
- Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Anahita Jalilvand
- Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | | | | | | | - Andrew Young
- Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jonathan Wisler
- Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Kundu R, Srinivasan S. Necrotizing Soft Tissue Infections: More than What Meets the Eye. Indian J Crit Care Med 2022; 26:411-413. [PMID: 35656064 PMCID: PMC9067492 DOI: 10.5005/jp-journals-10071-24196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
How to cite this article: Kundu R, Srinivasan S. Necrotizing Soft Tissue Infections: More than What Meets the Eye. Indian J Crit Care Med 2022;26(4):411-413.
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Affiliation(s)
- Riddhi Kundu
- Department of Critical Care Medicine, Manipal Hospitals, New Delhi, India
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Kurian GP, Korula PJ, Jacob JM, Desha AMK, Karuppusami R, Kandasamy S. Patient Characteristics and Outcomes in Necrotizing Soft-tissue Infections: Results from a Prospective Cohort Study in a Tertiary Care Center Intensive Care Unit in South India. Indian J Crit Care Med 2022; 26:452-456. [PMID: 35656036 PMCID: PMC9067491 DOI: 10.5005/jp-journals-10071-24153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Necrotizing soft tissue infections (NSTIs) are life-threatening infections characterized by progressive destruction of muscle, fascia, and overlying subcutaneous tissue. Prospective studies in the field are few, and data from the Indian subcontinent are bleak. Prompt diagnosis and timely treatment are critical for optimal outcomes. The aims of this study are to provide detailed information on the clinical profile of patients with NSTIs and to identify predictors of mortality in order to pick up reversible factors that may improve outcomes. Materials and methods This study was a prospective cohort study of adult patients with NSTIs in a tertiary center in South India. All patients who were admitted to the surgical intensive care unit (ICU) of the institute with a diagnosis of NSTI were screened and enrolled. All patients were managed according to the local protocol for treatment of NSTIs and intensive care support. Results In our cohort of patients, simple and multiple logistic regression analysis showed that four factors, namely, AKIN stage 3, shock, need for mechanical ventilation for more than 3 days, and low serum albumin values were found to be significantly associated with higher mortality. Conclusion The successful management of these patients calls for early diagnosis, resuscitation, surgical debridement, appropriate and timely antibiotics, and early ventilatory weaning before multi-organ failure associated with shock and AKI occurs. How to cite this article Kurian GP, Korula PJ, Jacob JM, Desha AMK, Karuppusami R, Kandasamy S. Patient Characteristics and Outcomes in Necrotizing Soft-tissue Infections: Results from a Prospective Cohort Study in a Tertiary Care Center Intensive Care Unit in South India. Indian J Crit Care Med 2022;26(4):452-456.
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Affiliation(s)
- George Prashanth Kurian
- Division of Critical Care and Surgical ICU, Christian Medical College, Vellore, Tamil Nadu, India
| | - Pritish John Korula
- Division of Critical Care and Surgical ICU, Christian Medical College, Vellore, Tamil Nadu, India
| | - Jubin Merin Jacob
- Department of Anesthesiology, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Reka Karuppusami
- Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India
| | - Subramani Kandasamy
- Division of Critical Care and Surgical ICU, Christian Medical College, Vellore, Tamil Nadu, India
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Nazir H, Ying Chieng C, Rogers SN, Nekrasisus R, Dodd M, Shah N. Outcomes of necrotizing fasciitis in the head and neck region in the United Kingdom-a case series and literature review. ADVANCES IN ORAL AND MAXILLOFACIAL SURGERY 2022. [DOI: 10.1016/j.adoms.2022.100254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Association between adjunct clindamycin and in-hospital mortality in patients with necrotizing soft tissue infection due to group A Streptococcus: a nationwide cohort study. Eur J Clin Microbiol Infect Dis 2021; 41:263-270. [PMID: 34755257 DOI: 10.1007/s10096-021-04376-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/03/2021] [Indexed: 10/19/2022]
Abstract
Necrotizing soft tissue infection (NSTI) due to group A Streptococcus (GAS) is a severe life-threatening microbial infection. The administration of adjunct clindamycin has been recommended in the treatment of NSTIs due to GAS. However, robust evidence regarding the clinical benefits of adjunct clindamycin in NSTI patients remains controversial. We aimed to investigate the association between early administration of adjunct clindamycin and in-hospital mortality in patients with NSTI attributed to GAS. The present study was a nationwide retrospective cohort study, using the Japanese Diagnosis Procedure Combination inpatient database focusing on the period between 2010 and 2018. Data was extracted on patients diagnosed with NSTI due to GAS. We compared patients who were administered clindamycin on the day of admission (clindamycin group) with those who were not (control group). A propensity score overlap weighting method was adopted to adjust the unbalanced backgrounds. The primary endpoint was in-hospital mortality and survival at 90 days after admission. We identified 404 eligible patients during the study period. After adjustment, patients in the clindamycin group were not significantly associated with reduced in-hospital mortality (19.2% vs. 17.5%; odds ratio, 1.11; 95% confidence interval, 0.59-2.09; p = 0.74) or improved survival at 90 days after admission (hazard ratio, 0.92; 95% confidence interval, 0.51-1.68; p = 0.80). In this retrospective study, early adjunct clindamycin does not appear to improve survival. Therefore, the present study questions the benefits of clindamycin as an adjunct to broad spectrum antibiotics in patients with NSTI due to GAS.
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Adjunctive Rifampicin Increases Antibiotic Efficacy in Group A Streptococcal Tissue Infection Models. Antimicrob Agents Chemother 2021; 65:e0065821. [PMID: 34491807 DOI: 10.1128/aac.00658-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Biofilm has recently been highlighted as a complicating feature of necrotizing soft tissue infections (NSTI) caused by Streptococcus pyogenes (i.e., group A Streptococcus [GAS]) contributing to a persistence of bacteria in tissue despite prolonged antibiotic therapy. Here, we assessed the standard treatment of benzylpenicillin and clindamycin with or without rifampin in a tissue-like setting. Antibiotic efficacy was evaluated by CFU determination in a human organotypic skin model infected for 24 or 48 h with GAS strains isolated from NSTI patients. Antibiotic effect was also evaluated by microcalorimetric metabolic assessment in in vitro infections of cellular monolayers providing continuous measurements over time. Adjunctive rifampin resulted in enhanced antibiotic efficacy of bacterial clearance in an organotypic skin tissue model, 97.5% versus 93.9% (P = 0.006). Through microcalorimetric measurements, adjunctive rifampin resulted in decreased metabolic activity and extended lag phase for all clinical GAS strains tested (P < 0.05). In addition, a case report is presented of adjunctive rifampin treatment in an NSTI case with persistent GAS tissue infection. The findings of this study demonstrate that adjunctive rifampin enhances clearance of GAS biofilm in an in vitro tissue infection model.
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Hedetoft M, Hansen MB, Madsen MB, Johansen JS, Hyldegaard O. Associations between YKL-40 and markers of disease severity and death in patients with necrotizing soft-tissue infection. BMC Infect Dis 2021; 21:1046. [PMID: 34627195 PMCID: PMC8502346 DOI: 10.1186/s12879-021-06760-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 10/01/2021] [Indexed: 12/20/2022] Open
Abstract
Background Necrotizing soft-tissue infection (NSTI) is a severe and fast-progressing bacterial infection. Prognostic biomarkers may provide valuable information in treatment guidance and decision-making, but none have provided sufficient robustness to have a clinical impact. YKL-40 may reflect the ongoing pathological inflammatory processes more accurately than traditional biomarkers as it is secreted by the activated immune cells, but its prognostic yields in NSTI remains unknown. For this purpose, we investigated the association between plasma YKL-40 and 30-day mortality in patients with NSTI, and assessed its value as a marker of disease severity. Methods We determined plasma YKL-40 levels in patients with NSTI (n = 161) and age-sex matched controls (n = 65) upon admission and at day 1, 2 and 3. Results Baseline plasma YKL-40 was 1191 ng/mL in patients with NSTI compared with 40 ng/mL in controls (p < 0.001). YKL-40 was found to be significantly higher in patients with septic shock (1942 vs. 720 ng/mL, p < 0.001), and in patients receiving renal-replacement therapy (2382 vs. 1041 ng/mL, p < 0.001). YKL-40 correlated with Simplified Acute Physiology Score II (Rho 0.33, p < 0.001). Baseline YKL-40 above 1840 ng/mL was associated with increased risk of 30-day mortality in age-sex-comorbidity adjusted analysis (OR 3.77, 95% CI; 1.59–9.24, p = 0.003), but after further adjustment for Simplified Acute Physiology Score II no association was found between YKL-40 and early mortality. Conclusion High plasma YKL-40 to be associated with disease severity, renal-replacement therapy and risk of death in patients with NSTI. However, YKL-40 is not an independent predictor of 30-day mortality. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06760-x.
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Affiliation(s)
- Morten Hedetoft
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Marco Bo Hansen
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.,Konduto ApS, Sani nudge, Copenhagen, Denmark
| | - Martin Bruun Madsen
- Department of Intensive Care 4131, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Julia Sidenius Johansen
- Department of Medicine, Herlev and Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Oncology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ole Hyldegaard
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
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Hedetoft M, Madsen MB, Perner A, Garred P, Hyldegaard O. Effect of immunoglobulin G on cytokine response in necrotising soft-tissue infection: A post hoc analysis. Acta Anaesthesiol Scand 2021; 65:1293-1299. [PMID: 34138468 DOI: 10.1111/aas.13942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/20/2021] [Accepted: 06/02/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND A marked inflammatory response in necrotising soft-tissue infection (NSTI) may contribute to the severe clinical course. Intravenous polyspecific immunoglobulin G (IVIG) is used by some as adjuvant treatment for NSTI, but in the randomised INSTINCT trial, no effect of IVIG in NSTI patients was seen on physical quality of life. In experimental studies, IVIG may induce immunosuppressive effects by reducing the pro-inflammatory response and neutralising circulating superantigens. However, data on the potential immunomodulatory effects are sparse and remain to be investigated in a clinical setting. In this post hoc analysis of the INSTINCT trial, we aimed to assess the effect of IVIG on various inflammatory cytokines up to day 3 after randomisation. METHODS Tumour necrosis factor (TNF), interleukin-1β, interleukin-6, interleukin-10 and granulocyte colony-stimulating factor were measured at admission, days 1, 2 and 3. RESULTS A total of 100 ICU patients with NSTI were included; 50 were allocated to IVIG (25 g/d for 3 days) and 50 to placebo. No difference in the overall inflammatory response was observed between groups except from TNF, which was higher in the IVIG group as compared to the placebo group (area under curve-admission to day 3, 93.6 vs 60.2, P = .02). Similarly, no differences were observed in percentage change from baseline to day 3 in any of the studied cytokines between patients allocated to IVIG group and those allocated to placebo group. CONCLUSION In ICU patients with NSTI, IVIG did not reduce the plasma concentration of cytokines in the first 3 days.
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Affiliation(s)
- Morten Hedetoft
- Department of Anaesthesia RigshospitaletUniversity of Copenhagen Copenhagen Denmark
| | - Martin B. Madsen
- Department of Intensive Care RigshospitaletUniversity of Copenhagen Copenhagen Denmark
| | - Anders Perner
- Department of Intensive Care RigshospitaletUniversity of Copenhagen Copenhagen Denmark
| | - Peter Garred
- Laboratory of Molecular Medicine Department of Clinical Immunology Section 7631 RigshospitaletUniversity of Copenhagen Copenhagen Denmark
| | - Ole Hyldegaard
- Department of Anaesthesia RigshospitaletUniversity of Copenhagen Copenhagen Denmark
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Clostridium septicum-induced gangrene in the right lower extremity complicating pneumatosis in the right ventricle and the pulmonary artery and occlusion of right femoral artery: a case report. BMC Infect Dis 2021; 21:957. [PMID: 34530753 PMCID: PMC8443912 DOI: 10.1186/s12879-021-06653-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 09/01/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Gas gangrene is usually manifested as myonecrosis and subcutaneous gas accumulation, but rarely manifested as arterial occlusion or pneumatosis in the right ventricle and the pulmonary artery. CASE PRESENTATION We report a case of gas gangrene caused by Clostridium septicum. The patient developed gas gangrene after being pecked by a chicken but turned for the better following antibiotic treatment and debriment. Imaging test revealed a rare occlusion of the right femoral artery and pneumatosis in the right ventricle and the main pulmonary artery. CONCLUSIONS In the presence of gas gangrene, special care must be taken to prevent against the formation of circulatory air embolism. The gas gangrene-induced gangrene in the limb of this patient might be attributed to the combined action of infection and arterial occlusion. MDT (Multidisciplinary team)-Green Channel mode is conductive to treatment success of gas gangrene.
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Urbina T, Razazi K, Ourghanlian C, Woerther PL, Chosidow O, Lepeule R, de Prost N. Antibiotics in Necrotizing Soft Tissue Infections. Antibiotics (Basel) 2021; 10:antibiotics10091104. [PMID: 34572686 PMCID: PMC8466904 DOI: 10.3390/antibiotics10091104] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 09/08/2021] [Accepted: 09/10/2021] [Indexed: 12/23/2022] Open
Abstract
Necrotizing soft tissue infections (NSTIs) are rare life-threatening bacterial infections characterized by an extensive necrosis of skin and subcutaneous tissues. Initial urgent management of NSTIs relies on broad-spectrum antibiotic therapy, rapid surgical debridement of all infected tissues and, when present, treatment of associated organ failures in the intensive care unit. Antibiotic therapy for NSTI patients faces several challenges and should (1) carry broad-spectrum activity against gram-positive and gram-negative pathogens because of frequent polymicrobial infections, considering extended coverage for multidrug resistance in selected cases. In practice, a broad-spectrum beta-lactam antibiotic (e.g., piperacillin-tazobactam) is the mainstay of empirical therapy; (2) decrease toxin production, typically using a clindamycin combination, mainly in proven or suspected group A streptococcus infections; and (3) achieve the best possible tissue diffusion with regards to impaired regional perfusion, tissue necrosis, and pharmacokinetic and pharmacodynamic alterations. The best duration of antibiotic treatment has not been well established and is generally comprised between 7 and 15 days. This article reviews the currently available knowledge regarding antibiotic use in NSTIs.
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Affiliation(s)
- Tomas Urbina
- Médecine Intensive Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 75571 Paris, France;
- Sorbonne Université, Université Pierre-et-Marie Curie, 75001 Paris, France
| | - Keyvan Razazi
- Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), 94010 Créteil, France;
- Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est Créteil, 94010 Créteil, France
| | - Clément Ourghanlian
- Service de Pharmacie, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), 94010 Créteil, France;
- Unité Transversale de Traitement des Infections, Département de Prévention, Diagnostic et Traitement des Infections, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), 94010 Créteil, France;
| | - Paul-Louis Woerther
- Département de Prévention, Diagnostic et Traitement des Infections, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), 94010 Créteil, France;
- Research Group Dynamic, Faculté de Santé de Créteil, Université Paris-Est Créteil Val de Marne (UPEC), 94010 Créteil, France;
| | - Olivier Chosidow
- Research Group Dynamic, Faculté de Santé de Créteil, Université Paris-Est Créteil Val de Marne (UPEC), 94010 Créteil, France;
- Service de Dermatologie, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), 94010 Créteil, France
| | - Raphaël Lepeule
- Unité Transversale de Traitement des Infections, Département de Prévention, Diagnostic et Traitement des Infections, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), 94010 Créteil, France;
| | - Nicolas de Prost
- Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), 94010 Créteil, France;
- Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est Créteil, 94010 Créteil, France
- Correspondence: ; Tel.: +33-1-49-81-23-94
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Palma Medina LM, Rath E, Jahagirdar S, Bruun T, Madsen MB, Strålin K, Unge C, Hansen MB, Arnell P, Nekludov M, Hyldegaard O, Lourda M, dos Santos VAM, Saccenti E, Skrede S, Svensson M, Norrby-Teglund A. Discriminatory plasma biomarkers predict specific clinical phenotypes of necrotizing soft-tissue infections. J Clin Invest 2021; 131:149523. [PMID: 34263738 PMCID: PMC8279592 DOI: 10.1172/jci149523] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 05/25/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUNDNecrotizing soft-tissue infections (NSTIs) are rapidly progressing infections frequently complicated by septic shock and associated with high mortality. Early diagnosis is critical for patient outcome, but challenging due to vague initial symptoms. Here, we identified predictive biomarkers for NSTI clinical phenotypes and outcomes using a prospective multicenter NSTI patient cohort.METHODSLuminex multiplex assays were used to assess 36 soluble factors in plasma from NSTI patients with positive microbiological cultures (n = 251 and n = 60 in the discovery and validation cohorts, respectively). Control groups for comparative analyses included surgical controls (n = 20), non-NSTI controls (i.e., suspected NSTI with no necrosis detected upon exploratory surgery, n = 20), and sepsis patients (n = 24).RESULTSThrombomodulin was identified as a unique biomarker for detection of NSTI (AUC, 0.95). A distinct profile discriminating mono- (type II) versus polymicrobial (type I) NSTI types was identified based on differential expression of IL-2, IL-10, IL-22, CXCL10, Fas-ligand, and MMP9 (AUC >0.7). While each NSTI type displayed a distinct array of biomarkers predicting septic shock, granulocyte CSF (G-CSF), S100A8, and IL-6 were shared by both types (AUC >0.78). Finally, differential connectivity analysis revealed distinctive networks associated with specific clinical phenotypes.CONCLUSIONSThis study identifies predictive biomarkers for NSTI clinical phenotypes of potential value for diagnostic, prognostic, and therapeutic approaches in NSTIs.TRIAL REGISTRATIONClinicalTrials.gov NCT01790698.FUNDINGCenter for Innovative Medicine (CIMED); Region Stockholm; Swedish Research Council; European Union; Vinnova; Innovation Fund Denmark; Research Council of Norway; Netherlands Organisation for Health Research and Development; DLR Federal Ministry of Education and Research; and Swedish Children's Cancer Foundation.
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Affiliation(s)
- Laura M. Palma Medina
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
| | - Eivind Rath
- Department of Medicine, Division for Infectious Diseases, Haukeland University Hospital, Bergen, Norway
| | - Sanjeevan Jahagirdar
- Laboratory of Systems and Synthetic Biology, Wageningen University and Research, Wageningen, Netherlands
| | - Trond Bruun
- Department of Medicine, Division for Infectious Diseases, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Martin B. Madsen
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Kristoffer Strålin
- Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
- Department of Infectious Diseases and
| | - Christian Unge
- Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
- Functional Area of Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Marco Bo Hansen
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Per Arnell
- Department of Anaesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Michael Nekludov
- Department of Anaesthesia, Surgical Services and Intensive Care, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Ole Hyldegaard
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Magda Lourda
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
- Childhood Cancer Research Unit, Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
| | - Vitor A.P. Martins dos Santos
- Laboratory of Systems and Synthetic Biology, Wageningen University and Research, Wageningen, Netherlands
- LifeGlimmer GmbH, Berlin, Germany
| | - Edoardo Saccenti
- Laboratory of Systems and Synthetic Biology, Wageningen University and Research, Wageningen, Netherlands
| | - Steinar Skrede
- Department of Medicine, Division for Infectious Diseases, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Mattias Svensson
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
| | - Anna Norrby-Teglund
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
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