A multicenter review of the treatment of major truncal necrotizing infections with and without hyperbaric oxygen therapy

The effect of hyperbaric oxygen therapy on the clinical outcomes of necrotizing soft tissue infections: a systematic review and meta-analysis

BACKGROUND

To determine the efficacy of hyperbaric oxygen therapy (HBO) in the treatment of necrotizing soft tissue infections (NSTI), we conducted a meta-analysis of the available evidence.

METHODS

Data sources were PubMed, Embase, Web of Science, Cochrane Library, and reference lists. The study included observational trials that compared HBO with non-HBO, or standard care. The primary outcome was the mortality rate. Secondary outcomes were the number of debridement, amputation rate and complication rate. Relative risks or standardized mean differences with 95% confidence intervals were calculated for dichotomous and continuous outcomes, respectively.

RESULTS

A total of retrospective cohort and case-control studies were included, including 49,152 patients, 1448 who received HBO and 47,704 in control. The mortality rate in the HBO group was significantly lower than that in the non-HBO group [RR = 0.522, 95% CI (0.403, 0.677), p < 0.05]. However, the number of debridements performed in the HBO group was higher than in the non-HBO group [SMD = 0.611, 95% CI (0.012, 1.211), p < 0.05]. There was no significant difference in amputation rates between the two groups [RR = 0.836, 95% CI (0.619, 1.129), p > 0.05]. In terms of complications, the incidence of MODS was lower in the HBO group than in the non-HBO group [RR = 0.205, 95% CI (0.164, 0.256), p < 0.05]. There was no significant difference in the incidence of other complications, such as sepsis, shock, myocardial infarction, pulmonary embolism, and pneumonia, between the two groups (p > 0.05).

CONCLUSION

The current evidence suggests that the use of HBO in the treatment of NSTI can significantly reduce the mortality rates and the incidence rates of complications. However, due to the retrospective nature of the studies, the evidence is weak, and further research is needed to establish its efficacy. It is also important to note that HBO is not available in all hospitals, and its use should be carefully considered based on the patient's individual circumstances. Additionally, it is still worthwhile to stress the significance of promptly evaluating surgical risks to prevent missing the optimal treatment time.

Hyperbaric oxygen treatment in the management of necrotising soft-tissue infections: results from a Danish nationwide registry study

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.

Is There a Place for Hyperbaric Oxygen Therapy?

Hyperbaric oxygen therapy (HBOT) involves treating patients by providing 100% oxygen through inhalation while inside a treatment pressurized chamber. The oxygen acts as a drug and the hyperbaric chamber as the dosing device. The effect of hyperbaric hyperoxia is dose dependent and, therefore, treatment depth and duration are important when considering its use. HBOT can either be the primary method of treatment or used adjunctively to medications or surgical techniques. The underpinning physiology is to bring oxygen-rich plasma to hypoxic tissue, preventing reperfusion injury, strengthening immune responsiveness, and encouraging new collagen deposition as well as endothelial cell formation.

Outcome of necrotizing fasciitis and Fournier's gangrene with and without hyperbaric oxygen therapy: a retrospective analysis over 10 years

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.

Necrotizing Fasciitis: Evaluation of 85 Cases and Usage of LRINEC Score

Objective

The present study aims to define the characteristics of the necrotizing fasciitis (NF) cases followed at our hospital and to compare our results with the literature.

Materials and Methods

In this study, NF cases followed and treated at our hospital from January 2005 to April 2019 were evaluated retrospectively.

Results

A total of 85 cases of NF were included in the study. Of the cases, 33 (39%) were female and the median age was 59.8±13.1 years (range: 26-92 years). Diabetes mellitus (DM) (56%) was the most prevalent comorbid condition. Extremities were the most frequently involved field found in 41 (48%) of the cases followed by Fournier's gangrene found in 34 (40%) of the cases. All of the cases had undergone surgical intervention (debridement and/or amputation) and received broad-spectrum antibiotic therapy. Laboratory risk indicator for necrotizing fasciitis (LRINEC) score was calculated for 60 cases, and it was 6 or higher in 78% of them. Nineteen (22%) of 85 cases had died.

Conclusion

Necrotizing fasciitis affects generally older male patients with DM. In NF cases to avoid the higher risk of mortality, the removal of necrotic tissue via surgical procedure together with antimicrobial therapy is required urgently; therefore, it is very important to differentiate NF from soft tissue infections as soon as possible. As the LRINEC score predicted NF among nearly 80% of our patients, this score could be used as an early diagnostic tool of NF.

Level of Evidence

Level IV, case series.

Adjunctive hyperbaric oxygen treatment for necrotising soft-tissue infections: A systematic review and meta-analysis

INTRODUCTION

Surgical intervention, broad-spectrum antibiotics and intensive care support are the standard of care in the treatment of necrotising soft-tissue infections (NSTI). Hyperbaric oxygen treatment (HBOT) may be a useful adjunctive treatment and has been used for almost 60 years, but its efficacy remains unknown and has not been systematically appraised. The aim was to systematically review and synthesise the highest level of clinical evidence available to support or refute the use of HBOT in the treatment of NSTI.

METHODS

The review was prospectively registered (PROSPERO; CRD42020148706). MEDLINE, EMBASE, CENTRAL and CINAHL were searched for eligible studies that reported outcomes in both HBOT treated and non-HBOT treated individuals with NSTI. In-hospital mortality was the primary outcome. Odds ratio (ORs) were pooled using random-effects models.

RESULTS

The search identified 486 papers of which 31 were included in the qualitative synthesis and 21 in the meta-analyses. Meta-analysis on 48,744 patients with NSTI (1,237 (2.5%) HBOT versus 47,507 (97.5%) non-HBOT) showed in-hospital mortality was 4,770 of 48,744 patients overall (9.8%) and the pooled OR was 0.44 (95% CI 0.33-0.58) in favour of HBOT. For major amputation the pooled OR was 0.60 (95% CI 0.28-1.28) in favour of HBOT. The dose of oxygen in these studies was incompletely reported.

CONCLUSIONS

Meta-analysis of the non-random comparative data indicates patients with NSTI treated with HBOT have reduced odds of dying during the sentinel event and may be less likely to require a major amputation. The most effective dose of oxygen remains unclear.

Necrotizing myositis case report and brief literature study

Necrotizing myositis is an extremely rare soft tissue infection, mainly caused by Group A Streptococci. Although its presentation is nonspecific and seems harmless, it quickly leads to death in almost all cases. Therefore, diagnosis and treatment of necrotizing myositis are considered as medical emergencies. The 27 years old patient we report benefited from early diagnosis and care. Necrotic tissues were surgically removed 24 hours after the appearance of the first clinical signs. Intravenous antibiotherapy as well as immunoglobulin therapy were also given on the first day. Starting from this clinical case, we present a brief explanation of the pathogenesis, the key clinical features and appropriate tools for diagnosis. Then, adequate antibiotherapy, role of immunoglobulin therapy and interest of hyperbaric oxygenotherapy will be discussed.

[Necrotizing fasciitis in the head and neck region-three case reports and a review of the literature]

Necrotizing fasciitis (NF) is a life-threatening, usually bacterial, soft tissue infection that rarely affects the head and neck region. Rapid progression and systemic illness are typical for the disease and complicate diagnosis. Immediate surgical and antimicrobial therapy is required. Three cases of cervicofacial NF are presented in this case report. All patients showed a rapidly progressing, painful swelling and redness in the cervicofacial region. After diagnosing NF based on clinical symptoms, laboratory parameters, and CT, the patients were treated with systemic antibiotics and multiple extensive debridements. Two of the three patients died within 48 h from systemic illness with septic organ failure; one patient was discharged after intensive care treatment and reconstruction of the tissue defects caused by debridement. NF is a fast-developing soft tissue infection associated with high mortality and morbidity, and is often recognized too late. Diagnosis is based on clinical signs such as progressive diffuse swelling, pain, erythema, and early systemic illness. Laboratory parameters (Laboratory Risk Indicator for Necrotizing Fasciitis [LRINEC] score) and imaging via CT or MRT are helpful. CT/MRT images can show soft tissue swelling with pathognomonic gas formation. Immediate surgical debridement and antimicrobial therapy are critical for survival. Intravenously administered immunoglobulins and hyperbaric pressure therapy should only be used as supplementary treatments.

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

Objective

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

Methods

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

Results

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

Conclusion

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

The Effects of Hyperbaric Oxygen at Different Pressures on Oxidative Stress and Antioxidant Status in Rats

Background: The optimal use of oxygen at greater than atmospheric pressures in any operational or therapeutic application (hyperbaric oxygen, HBO₂) requires awareness of the fact that the beneficial effects of oxygen coexist with toxic effects depending on the pressure and duration of exposure. In this study, we aimed to investigate the effect of HBO₂ therapy on oxidative stress and antioxidant status in commonly used protocol for acute HBO₂ indications, such as carbon monoxide intoxication, central retinal artery occlusion, crush injury, gas gangrene, and to compare it with normobaric oxygen (NBO₂) in healthy rats. Materials and Methods: Fifty-six male, young adult Wistar albino rats were randomly divided into seven groups and named as Group I through Group VII. Plasma malondialdehyde (MDA), superoxide dismutase (SOD), and erythrocyte glutathione (GSH) levels in control group were compared to the levels in other groups. Results: The increases in MDA levels and the decrease in SOD activities were statistically significant in HBO₂ groups at the end of the first 24 h when compared to the control group, and the significant decrease in erythrocyte GSH level was only at 2.4 atmospheres absolute. Conclusions: The present study showed that pressure and frequency of exposure are important factors to consider when investigating HBO₂-induced oxidative stress and antioxidant response.

Scarce evidence of efficacy of hyperbaric oxygen therapy in necrotizing soft tissue infection: a systematic review

Background: Necrotizing soft tissue infection (NSTI) is a rare and potentially life-threatening disease. Rapid surgical intervention, antibiotics and intensive care are the mainstay of treatment. Hyperbaric oxygen therapy (HBOT) is used as adjuvant therapy in some centres but there is a lack of research-based evidence of efficacy. Methods: Following the PRISMA guideline we conducted a systematic review on the efficacy of HBOT on NSTI with mortality as primary outcome. Through January 2019 major databases were searched and relevant literature assessed. The criteria for study inclusion were research of any design and any period of time comparing HBOT vs. non-HBOT in a population of NSTI-patients. Studies were analysed using the modified Delphi method and risk of bias in non-randomized studies - of interventions tool. Relative risk (RR) on mortality was calculated for each study individually. Results: A number of 1733 studies were identified through database search. Ultimately, 21 studies were included of which 19 were case series with a control group. The majority of the studies performed poor in quality assessment and all featured a high to critical risk of bias. The association of HBOT on mortality was generally reported as positive, however, the results should be considered with great scepticism. Conclusions: The evidence of HBOT in NSTI is poor and biased. There is a strong need for randomized controlled trials (RCTs) to shed light on a potential life-saving treatment.

A Multi-Center Review of Care Patterns and Outcomes in Necrotizing Soft Tissue Infections

BACKGROUND

Surgical debridement and broad-spectrum empiric antibiotics are first-line therapy for necrotizing soft tissue infections (NSTI). The objective of this multi-center retrospective review was to evaluate antimicrobial agent initiation and duration and compare outcomes in the treatment of patients with NSTI.

PATIENTS AND METHODS

This review included adults with NSTI, as indicated by International Classification of Diseases, 9th Edition, Clinical Modification codes 728.86, 608.33, or 040.0, who were admitted to three academic institutions between 1/1/09 and 5/15/14. Demographics, antibiotic practices, operative management, and clinical outcomes were compared.

RESULTS

A total of 341 patients were identified at the three centers. Subjects were comparable in age (median 53 years, p = 0.14), gender (67% male, p = 0.57) and body mass index (median 31.9 (p = 0.31) between sites. No significant difference was found in time from admission to start of empiric antibiotic therapy between the three centers (median 1 d for each, p = 0.70), but duration of antibiotic therapy was significantly different (Site A = 16 d, Site B = 12 d, Site C = 9 d, medians, p < 0.001). Although total number of operations differed between sites (median of two at Sites A and B, three at Site C, p = 0.001), sites consistently operated on the day of patient arrival to their facility, and the number of debridements did not differ (median of two for all sites, p = 0.10). Mortality rate (Site A = 22%, Site B = 18%, and Site C = 9%, p = 0.02) and length of stay for survivors (Site A = 29 d, Site B = 16 d, Site C = 19 d, medians, p = 0.001) was significantly different among centers.

CONCLUSIONS

Variation in antibiotic duration between centers with expertise in the care of NSTI illustrates how little is known about best care practices for patients with NSTI. Future studies should emphasize development of evidence-based practices for NSTI management to further improve the outcomes of this complex group of patients.

Necrotizing Fasciitis Caused by Group A Streptococcus: Case Report and Therapy Update

Necrotizing fasciitis is a life-threatening infection that affects the fascia and fat tissue underlying the skin. The diagnosis is often difficult because subcutaneous changes may not be readily apparent. Toxin-producing bacteria are usually the cause, with group A streptococcus (GAS) or Streptococcus pyogenes being responsible for a significant portion of the morbidity and mortality associated with this infection. The mortality rate associated with necrotizing fasciitis varies between 30% and 60%. Toxic shock-like syndrome and multisystem organ failure are the usual causes of death. Early diagnosis and surgery have been associated with decreased morbidity and mortality, and appropriate antimicrobial (eg, penicillin plus clindamycin) and supportive therapy is of utmost importance. Intravenous immunoglobulin and hyperbaric oxygen therapy may be beneficial in treating the infection; however, these 2 therapies require further research. Clinicians need to familiarize themselves with the disease and the different treatment modalities to be able to make the appropriate therapeutic decision. The optimal treatment of necrotizing fasciitis still remains a challenge today. This article presents an illustrative case with a brief overview of necrotizing fasciitis, and the current therapeutic modalities used in the management of the disease.

Fournier's Gangrene: Epidemiology and Outcomes in the General US Population

PURPOSE

Case series reported 20-40% mortality rates for patients with Fournier's gangrene with some series as high as 88%. This literature comes almost exclusively from referral centers.

MATERIALS AND METHODS

We identified and analyzed inpatients with Fournier's gangrene who had a surgical debridement or died in the US State Inpatient Databases.

RESULTS

One thousand six hundred and forty one males and 39 females with Fournier's gangrene represented <0.02% of hospital admissions. Overall, the incidence was 1.6 cases per 100,000 males and case fatality was 7.5%. Sixty six percent of hospitals cared for no cases per year, 17% cared for 1 case per year, 10% cared for 2 cases per year, 4% cared for 3 cases per year, 1% cared for 4 cases per year, and only 1% cared for ≥5 cases per year. Teaching hospitals had higher mortality (adjusted OR 1.9) due primarily to more acutely ill patients. Hospitals treating more than 1 Fournier's gangrene case per year had an adjusted 42-84% lower mortality (p < 0.0001).

CONCLUSIONS

Most hospitals rarely care for Fournier's gangrene patients. The population-based mortality rate (7.5%) was substantially lower than the case series from tertiary care centers. Hospitals that treated more number of Fournier's gangrene patients had lower mortality rates, thereby supporting the rationale that regionalized care worked well for patients with this rare disease.

Interventions for treating gas gangrene

BACKGROUND

Gas gangrene is a rapidly progressive and severe disease that results from bacterial infection, usually as the result of an injury; it has a high incidence of amputation and a poor prognosis. It requires early diagnosis and comprehensive treatments, which may involve immediate wound debridement, antibiotic treatment, hyperbaric oxygen therapy, Chinese herbal medicine, systemic support, and other interventions. The efficacy and safety of many of the available therapies have not been confirmed.

OBJECTIVES

To evaluate the efficacy and safety of potential interventions in the treatment of gas gangrene compared with alternative interventions or no interventions.

SEARCH METHODS

In March 2015 we searched: The Cochrane Wounds Group Specialized Register, The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), Ovid MEDLINE, Ovid EMBASE, EBSCO CINAHL, Science Citation Index, the China Biological Medicine Database (CBM-disc), the China National Knowledge Infrastructure (CNKI), and the Chinese scientific periodical database of VIP INFORMATION (VIP) for relevant trials. We also searched reference lists of all identified trials and relevant reviews and four trials registries for eligible research. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We selected randomized controlled trials (RCTs) and quasi-RCTs that compared one treatment for gas gangrene with another treatment, or with no treatment.

DATA COLLECTION AND ANALYSIS

Independently, two review authors selected potentially eligible studies by reviewing their titles, abstracts and full-texts. The two review authors extracted data using a pre-designed extraction form and assessed the risk of bias of each included study. Any disagreement in this process was solved by the third reviewer via consensus. We could not perform a meta-analysis due to the small number of studies included in the review and the substantial clinical heterogeneity between them, so we produced a narrative review instead.

MAIN RESULTS

We included two RCTs with a total of 90 participants. Both RCTs assessed the effect of interventions on the 'cure rate' of gas gangrene; 'cure rate' was defined differently in each study, and differently to the way we defined it in this review.One trial compared the addition of Chinese herbs to standard treatment (debridement and antibiotic treatment; 26 participants) against standard treatment alone (20 participants). At the end of the trial the estimated risk ratio (RR) of 3.08 (95% confidence intervals (CI) 1.00 to 9.46) favoured Chinese herbs. The other trial compared standard treatment (debridement and antibiotic treatment) plus topical hyperbaric oxygen therapy (HBOT; 21 participants) with standard treatment plus systemic HBOT (23 participants). There was no evidence of difference between the two groups; RR of 1.10 (95% CI 0.25 to 4.84). For both comparisons the GRADE assessment was very low quality evidence due to risk of bias and imprecision so further trials are needed to confirm these results.Neither trial reported on this review's primary outcomes of quality of life, and amputation and death due to gas gangrene, or on adverse events. Trials that addressed other therapies such as immediate debridement, antibiotic treatment, systemic support, and other possible treatments were not available.

AUTHORS' CONCLUSIONS

Re-analysis of the cure rate based on the definition used in our review did not show beneficial effects of additional use of Chinese herbs or topical HBOT on treating gas gangrene. The absence of robust evidence meant we could not determine which interventions are safe and effective for treating gas gangrene. Further rigorous RCTs with appropriate randomisation, allocation concealment and blinding, which focus on cornerstone treatments and the most important clinical outcomes, are required to provide useful evidence in this area.

Necrotising Soft Tissue Infections: The Effect of Hyperbaric Oxygen on Mortality

In a single-centre, retrospective, case-controlled study of patients attending the Alfred Hospital in Prahran, Victoria, we assessed the effect of hyperbaric oxygen therapy (HBOT) in reducing mortality or morbidity in patients with necrotising fasciitis (NF) over a 13-year period from 2002 to 2014. A total of three hundred and forty-one patients with NF were included in the study, of whom 275 received HBOT and 66 did not. The most commonly involved sites were the perineum (33.7%), lower limb (29.9%) and trunk (18.2%). The commonest predisposing factor was diabetes mellitus (34.8%). Polymicrobial NF (type 1 NF) occurred in 50.7% and Group A streptococcal fasciitis (type 2 NF) occurred in 25.8% of patients. Mortality was 14.4% overall, 12% in those treated with, and 24.3% in those not treated with, HBOT. ICU support was required in 248 (72.7%) patients. Independent factors impacting on mortality included HBOT (odds ratio [OR] 0.42 [0.22 to 0.83], P=0.01), increased age (OR 1.06 [1.03 to 1.08], P=0.001) and immunosuppression (OR 2.6 [1.23 to 5.51], P=0.01). Mortality was linked to illness severity at presentation, however when adjusted for severity score and need for intensive care management, HBOT was associated with significant reduction in mortality.

Prognostic factors in necrotizing soft-tissue infections (NSTI): A cohort study

BACKGROUND

Necrotizing soft-tissue infection (NSTI) is uncommon but life-threatening. A recent meta-analysis estimated the overall mortality at 23.5%.

OBJECTIVE

We sought to identify risk factors associated with mortality in a cohort of patients with NSTI in a tertiary care center.

METHODS

We identified 512 patients with NSTI between 1996 and 2012 in the national hospital database Program for Medicalization of Information Systems and examined risk factors of mortality with NSTI by univariate and multivariate analysis.

RESULTS

We included 109 patients with a confirmed diagnosis of NSTI; 31 (28%) died at a median follow-up of 274 days (range 2-6135 days). On multivariate analysis, independent risk factors of mortality were age older than 75 years (hazard ratio [HR] 4.4, 95% confidence interval [CI] 1.8-10.3), multifocal NSTI (HR 5.9, 95% CI 1.9-18.5), severe peripheral vascular disease (HR 5.1, 95% CI 1.5-17.0), hospital-acquired infection (HR 3.9, 95% CI 1.4-10.7), severe sepsis (HR 7.4, 95% CI 1.7-33.1), and septic shock on hospital admission (HR 13.9, 95% CI 3.8-50.4).

LIMITATIONS

This was a retrospective cohort, which disallows a precise record of the delay between diagnosis and surgery.

CONCLUSION

Our findings for this robust cohort of patients with a definite diagnosis of NSTI could help clinicians stratify NSTI severity at clinical course onset.

Respiratory Infections in the U.S. Military: Recent Experience and Control

This comprehensive review outlines the impact of military-relevant respiratory infections, with special attention to recruit training environments, influenza pandemics in 1918 to 1919 and 2009 to 2010, and peacetime operations and conflicts in the past 25 years. Outbreaks and epidemiologic investigations of viral and bacterial infections among high-risk groups are presented, including (i) experience by recruits at training centers, (ii) impact on advanced trainees in special settings, (iii) morbidity sustained by shipboard personnel at sea, and (iv) experience of deployed personnel. Utilizing a pathogen-by-pathogen approach, we examine (i) epidemiology, (ii) impact in terms of morbidity and operational readiness, (iii) clinical presentation and outbreak potential, (iv) diagnostic modalities, (v) treatment approaches, and (vi) vaccine and other control measures. We also outline military-specific initiatives in (i) surveillance, (ii) vaccine development and policy, (iii) novel influenza and coronavirus diagnostic test development and surveillance methods, (iv) influenza virus transmission and severity prediction modeling efforts, and (v) evaluation and implementation of nonvaccine, nonpharmacologic interventions.

Adjunctive hyperbaric oxygen for necrotizing fasciitis

BACKGROUND

Hyperbaric oxygen therapy (HBOT) involves the therapeutic administration of 100% oxygen in a pressure chamber at pressures above one atmosphere absolute. This therapy has been used as an adjunct to surgery and antibiotics in the treatment of patients with necrotizing fasciitis with the aim of reducing morbidity and mortality.

OBJECTIVES

To review the evidence concerning the use of HBOT as an adjunctive treatment for patients with necrotizing fasciitis (NF). Specifically, we wish to address the following questions.1. Does administration of HBOT reduce mortality or morbidity associated with NF?2. What adverse effects are associated with use of HBOT in the treatment of individuals with NF?

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE Ovid (1966 to September 2014); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) Ovid (1982 to September 2014); EMBASE Ovid (1980 to September 2014); and the Database of Randomised Controlled Trials in Hyperbaric Medicine (DORCTHIM, M Bennett) (from inception to September 2014). In addition, we performed a systematic search of specific hyperbaric literature sources. This included handsearching of relevant hyperbaric textbooks; hyperbaric journals (Hyperbaric Medicine Review, South Pacific Underwater Medicine Society Journal, European Journal of Underwater and Hyperbaric Medicine, Aviation Space and Environmental Medicine Journal); and conference proceedings of the major hyperbaric societies (Undersea and Hyperbaric Medical Society, South Pacific Underwater Medicine Society, European Underwater and Baromedical Society, International Congress of Hyperbaric Medicine).

SELECTION CRITERIA

We included all randomized and pseudo-randomized trials (trials in which an attempt at randomization has been made but the method was inappropriate, for example, alternate allocation) that compared the effects of HBOT with the effects of no HBOT (no treatment or sham) in the treatment of children and adults with necrotizing fasciitis.

DATA COLLECTION AND ANALYSIS

We planned independent data collection by two review authors using standardized forms.

MAIN RESULTS

We found no trials that met the inclusion criteria.

AUTHORS' CONCLUSIONS

This systematic review failed to locate relevant clinical evidence to support or refute the effectiveness of HBOT in the management of necrotizing fasciitis. Good quality clinical trials are needed to define the role, if any, of HBOT in the treatment of individuals with necrotizing fasciitis.

Management of invasive group A streptococcal infections

Invasive group A streptococcal (GAS) disease in children includes deep soft tissue infection, bacteraemia, bacteraemic pneumonia, meningitis and osteomyelitis. The expression of toxins and super antigens by GAS can complicate infection by triggering an overwhelming systemic inflammatory response, referred to as streptococcal toxic shock syndrome (STSS). The onset and progression of GAS disease can be rapid, and the associated mortality high. Prompt antibiotics therapy and early surgical debridement of infected tissue are essential. Adjunctive therapy with intravenous immunoglobulin and hyperbaric therapy may improve outcomes in severe disease. Nosocomial outbreaks and secondary cases in close personal contacts are not uncommon; infection control measures and consideration of prophylactic antibiotics to those at high risk are important aspects of disease control. To reduce a substantial part of the global burden of GAS disease, an affordable GAS vaccine with efficacy against a broad number of strains is needed.

A series of severe necrotising soft-tissue infections in a regional centre in Sweden

BACKGROUND

Necrotising soft-tissue infections (NSTIs) are rare conditions with high morbidity and mortality. Patients with NSTIs are often transferred to tertiary hospitals, but the question of whether the potential benefits of highly specialised care outweigh the risks associated with inter-hospital transfers has been raised.

METHODS

Prospective study including all patients with NSTIs treated at the intensive care unit at Sahlgrenska University Hospital/East between January 2008 and December 2011.

RESULTS

Twenty-nine patients with NSTIs were identified. Their median age was 54 years and 69% were men. Major co-morbidities were present in 45%. Seventeen patients (59%) were referred from other hospitals. Only 33% of the patients were correctly diagnosed or suspected of having NSTIs in the emergency department. Group A Streptococcus was the most common microbiological finding (41%), followed by Enterobacteriaceae (17%). The median time from hospitalisation to the first dose of antibiotics was 6 h and the median time to primary surgery was 16 h. Hyperbaric oxygen therapy was given to 86%, and intravenous immunoglobulin was given in 52% of the cases. The 30-day mortality was 14% (4/29). The times to the first dose of antibiotics, intensive care unit admission and primary surgery did not differ between transferred and directly admitted patients, and there was no difference in outcome between the groups.

CONCLUSIONS

Patients with NSTIs develop severe local and systemic symptoms and require extremely resource-demanding hospitalisation. Inter-hospital transfer was not associated with a delay in key interventions and could not be identified as a risk factor for adverse outcome.

Not just full of hot air: hyperbaric oxygen therapy increases survival in cases of necrotizing soft tissue infections

BACKGROUND

The utility of hyperbaric oxygen therapy (HBOT) in the treatment of necrotizing soft tissue infections (NSTIs) has not been proved. Previous studies have been subject to substantial selection bias because HBOT is not available universally at all medical centers, and there is often considerable delay associated with its initiation. We examined the utility of HBOT for the treatment of NSTI in the modern era by isolating centers that have their own HBOT facilities.

METHODS

We queried all centers in the University Health Consortium (UHC) database from 2008 to 2010 that have their own HBOT facilities (n=14). Cases of NSTI were identified by International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes, which included Fournier gangrene (608.83), necrotizing fasciitis (728.86), and gas gangrene (040.0). Status of HBOT was identified by the presence (HBOT) or absence (control) of ICD-9 procedure code 93.95. Our cohort was risk-stratified and matched by UHC's validated severity of illness (SOI) score. Comparisons were then made using univariate tests of association and multivariable logistic regression.

RESULTS

There were 1,583 NSTI cases at the 14 HBOT-capable centers. 117 (7%) cases were treated with HBOT. Univariate analysis showed that there was no difference between HBOT and control groups in hospital length of stay, direct cost, complications, and mortality across the three less severe SOI classes (minor, moderate, and major). However, for extreme SOI the HBOT group had fewer complications (45% vs. 66%; p<0.01) and fewer deaths (4% vs. 23%; p<0.01). Multivariable analysis showed that patients who did not receive HBOT were less likely to survive their index hospitalization (odds ratio, 10.6; 95% CI 5.2-25.1).

CONCLUSION

At HBOT-capable centers, receiving HBOT was associated with a significant survival benefit. Use of HBOT in conjunction with current practices for the treatment of NSTI can be both a cost-effective and life-saving therapy, in particular for the sickest patients.

The medical use of oxygen: a time for critical reappraisal

Oxygen treatment has been a cornerstone of acute medical care for numerous pathological states. Initially, this was supported by the assumed need to avoid hypoxaemia and tissue hypoxia. Most acute treatment algorithms, therefore, recommended the liberal use of a high fraction of inspired oxygen, often without first confirming the presence of a hypoxic insult. However, recent physiological research has underlined the vasoconstrictor effects of hyperoxia on normal vasculature and, consequently, the risk of significant blood flow reduction to the at-risk tissue. Positive effects may be claimed simply by relief of an assumed local tissue hypoxia, such as in acute cardiovascular disease, brain ischaemia due to, for example, stroke or shock or carbon monoxide intoxication. However, in most situations, a generalized hypoxia is not the problem and a risk of negative hyperoxaemia-induced local vasoconstriction effects may instead be the reality. In preclinical studies, many important positive anti-inflammatory effects of both normobaric and hyperbaric oxygen have been repeatedly shown, often as surrogate end-points such as increases in gluthatione levels, reduced lipid peroxidation and neutrophil activation thus modifying ischaemia-reperfusion injury and also causing anti-apoptotic effects. However, in parallel, toxic effects of oxygen are also well known, including induced mucosal inflammation, pneumonitis and retrolental fibroplasia. Examining the available 'strong' clinical evidence, such as usually claimed for randomized controlled trials, few positive studies stand up to scrutiny and a number of trials have shown no effect or even been terminated early due to worse outcomes in the oxygen treatment arm. Recently, this has led to less aggressive approaches, even to not providing any supplemental oxygen, in several acute care settings, such as resuscitation of asphyxiated newborns, during acute myocardial infarction or after stroke or cardiac arrest. The safety of more advanced attempts to deliver increased oxygen levels to hypoxic or ischaemic tissues, such as with hyperbaric oxygen therapy, is therefore also being questioned. Here, we provide an overview of the present knowledge of the physiological effects of oxygen in relation to its therapeutic potential for different medical conditions, as well as considering the potential for harm. We conclude that the medical use of oxygen needs to be further examined in search of solid evidence of benefit in many of the current clinical settings in which it is routinely used.

Necrotizing skin and soft tissue infections

Necrotizing skin and soft tissue infections are severe bacterial infections resulting in rapid and life-threatening soft tissue destruction and necrosis along soft tissue planes.

A I. Necrotising soft tissue infection-risk factors for mortality

Necrotising Soft Tissue Infection is a rapidly progressing fatal disorder, the prognosis of which depends on early diagnosis and management.

OBJECTIVE

In this study, our objective was to assess the factors contributing to mortality due to NSTI.

METHODS

A retrospective review of the records of all patients with NSTI involving fascia, skin or muscle between January 2007 and December 2011, was performed. The atiology, predisposing factors, risk factors, causative microbiological organisms and the clinical outcomes associated with mortality were studied. Statistical Data: Descriptive statistics comprising of proportion(%) presented. Chi-square test was employed to assess the statistical significance in the distribution of various known risk factors between the survivors and non-survivors. A 'p' value less than 0.05 was considered significant.

RESULTS

Sixty patients records were reviewed. Fifty-one patients (85%) were males and nine (15%) were females. Mean age was 46.57 years (+/- 20.60) ranging from 15-83 years. All the patients were treated by debridement & wide spectrum antibiotics. Mono-microbial atiology being found in 27 patients (63.3%) and polymicrobial culture was isolated in 13 patients (36.7%), with E-coli and staphylococci being the most common organisms to be isolated. In most patients, multiple debridements were done. The overall mortality rate was estimated to be 25%. Age, aatiology, diabetes mellitus, hypoalbuminemia, alcohol, site of infection, bacteriology etc. were the risk factors associated with mortality, that were evaluated. Diabetes mellitus was the most common associated risk factor found in 32 patients (53.3%), though not statistically significant. Increasing age (>50 years, p value = 0.016), raised Serum Creatinine (>1.2mg/dl, p-value = 0.023) and delayed surgical intervention(>24 hours p value= 0.006) were the risk factors associated with Mortality in NSTI that were statistically significant.

CONCLUSION

Despite the use of appropriate antibiotic treatment, aggressive debridement & resuscitation, NSTI still leads to a high mortality & morbidity. In this series, there is high mortality associated with increasing age, raised serum creatinine and delayed surgical intervention. The mortality rate (25%) is comparable with other studies.

[Hyperbaric oxygen therapy for necrotizing soft tissue infections: contra]

INTRODUCTION

Hyperbaric oxygen therapy (HBOT) is discussed as an adjuvant option to treat necrotizing soft tissue infections (NSTI). While the Federal Joint Committee decided in 2007 not to support HBOT for the indication necrotizing fasciitis and Fournier's gangrene, it was decided to accept HBOT for treatment of clostridial myonecrosis for the German health insurance. Thus, in Germany necrotizing fasciitis (NF) is not a confirmed indication for HBOT. Against this background the cons of the clinical benefits of HBOT should be formulated.

METHODS

A literature search (MEDLINE/EMBASE/COCHRANE/manual search) using the keywords "necrotizing fasciitis", "Fournier's gangrene", "necrotizing cellulitis", "necrotizing soft tissue infections" as well as "hyperbaric medicine", "hyperbaric therapy" and "hyperbaric treatment" was carried out. An analysis of the spatial distribution of German hyperbaric oxygen chambers enabling intensive care (HOC-IC) was made.

RESULTS

A total of 250 articles with n=2,556 NSTI patients (n=993 treated by HBOT) was found and 50% of the articles were case reports or series. There were only ten retrospective studies comparing the effects of HBOT with non-HBO treatment and none of them verified the benefit of HBOT in NF patients. In Germany only nine hyperbaric oxygen chambers (HOC-IC) enable intensive care. Currently, patient data are not included in scientific studies or multicenter studies, while studies assessing the benefit with higher evidence levels have been required for more than 15 years.

CONCLUSIONS

The previously published human clinical studies do not confirm any therapeutic benefit of HBOT in NF patients. Any time delay in the start of surgical therapy by HBOT would not be acceptable. In Germany a comprehensive clinical care with HOC is not possible. On average the additional costs of HBO treatment for NF patients is approximately 8,000-25,000 <euro>/patient which is not generally reimbursed by health insurance companies. Initializing a register study to assess the benefit of HBOT in NF patients appears feasible and is urgently needed.

Necrotizing soft tissue infections

Necrotising soft tissue infection (NSTI) presents unique challenges in diagnosis and management. The key to a successful outcome is a high index of suspicion in appropriate clinical settings. Type II NSTI tends to occur on an extremity in younger, healthier patients with a history of known trauma, and to be monomicrobial. Type I NSTI tends to occur on the trunk of older, less healthy patients without an obvious history of trauma, and tends to be polymicrobial. Other, rarer types exist as well. The pathophysiology of both types involves superantigen acticivty, as well as a number of microbial byproducts which collectively decrease the viscosity of pus, facilitating its spread along deep tissue planes and ultimately causing diffuse deep thrombosis and aggressive systemic sepsis. The most important physical finding is tenderness to palpation beyond the area of redness, and the lack of crepitus should not be seen as a reassuring sign. Suspected cases should undergo early surgical exploration for diagnosis, which may be performed at bedside through a small incision. Most imaging techniques are not sufficiently specific to warrant a delay in surgical exploration. The Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) shows promise as a tool for excluding suspected cases. Successful outcomes in cases of NSTI require early and aggressive serial debridement and a multidisciplinary critical care approach.

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

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

[Cosmetic blepharoplasty complicated by necrotizing periorbital fasciitis: a case report]

Necrotizing periorbital or palpebro-orbital fasciitis represents a unique anatomical site for necrotizing fasciitis, which is an extremely rare and very severe, potentially devastating bacterial infection, rapidly leading to facial necrosis with loss of vision and even death of the patient from toxic shock. In this paper, we report a case of necrotizing periorbital fasciitis as a complication of cosmetic lower eyelid blepharoplasty. Necrotizing fasciitis most often affects the upper and lower limbs, the trunk and the perineal area. It is rarely observed in the facial region due to the rich blood supply in this area. The most commonly implicated pathogen is group A, β-hemolytic "pyogenic"Streptococcus, either alone or in combination with other bacteria, such as staphylococcus or pseudomonas. Mortality varies according to the series and anatomical site. The mortality rate for necrotizing fasciitis is approximately 28 %. It is slightly lower in the periorbital area (15 %). Risk factors for death include alcoholism, diabetes mellitus, immunocompromise, hematologic or pulmonary diseases, and the identity of the causative agent (group A Streptococcus), although approximately 50 % of patients have no predisposing conditions. Management of periorbital necrotizing fasciitis is based on early detection of initial symptoms and on aggressive multidisciplinary treatment including surgical debridement of necrotic areas and antibiotic coverage. The timeliness of treatment and the multidisciplinary approach are considered to be the two essential factors in influencing the mortality and morbidity of this condition.

Hyperbaric oxygen therapy in necrotizing soft tissue infections

BACKGROUND

Surgical debridement and antibiotics are the mainstays of therapy for patients with necrotizing soft tissue infections (NSTIs), but hyperbaric oxygen therapy (HBO) is often used as an adjunctive measure. Despite this, the efficacy of HBO remains unclear. We hypothesized that HBO would have no effect on mortality or amputation rates.

METHODS

We performed a retrospective analysis of our institutional experience from 2005 to 2009. Inclusion criteria were age > 18 y and discharge diagnosis of NSTI. We abstracted baseline demographics, physiology, laboratory values, and operative course from the medical record. The primary endpoint was in-hospital mortality; the secondary endpoint was extremity amputation rate. We compared baseline variables using Mann-Whitney, chi-square, and Fisher's exact test, as appropriate. Significance was set at P < 0.05.

RESULTS

We identified 80 cases over the study period. The cohort was 54% male (n = 43) and 53% white (n = 43), and had a mean age of 55 ± 16 y. There were no significant differences in demographics, physiology, or comorbidities between groups. In-hospital mortality was not different between groups (16% in the HBO group versus 19% in the non-HBO group; P = 0.77). In patients with extremity NSTI, the amputation rate did not differ significantly between patients who did not receive HBO and those who did (17% versus 25%; P = 0.46).

CONCLUSIONS

Hyperbaric oxygen therapy does not appear to decrease in-hospital mortality or amputation rate after in patients with NSTI. There may be a role for HBO in treatment of NSTI; nevertheless, consideration of HBO should never delay operative therapy. Further evidence of efficacy is necessary before HBO can be considered the standard of care in NSTI.

Superiority of medial circumflex femoral artery perforator flap in scrotal reconstruction

Scrotal skin has unique cosmetic and functional features that make its reconstruction difficult. Coverage of the testicles and constituting a good cosmetic appearance are major expectations from a successful reconstruction. Usually flaps are the choice for scrotal reconstruction, but every single flap has its own characteristics. In our series, between January 2006 and January 2010, the medial circumflex femoral artery perforator flap was used in 7 male patients for scrotal coverage after Fournier gangrene. Six flaps were raised based on a single perforator from the gracilis muscle; however in one flap 2 perforators were used. Flaps were carried to the defect either by transposition or by V-Y advancement. Donor areas were closed directly in all patients, and stable scrotal coverage was achieved with an acceptable scrotal contour and cosmesis. No major complication was seen due the perforator flap surgery, in 2 patients wound dehiscence were noted and they healed by secondary intention or by secondary suturing. For scrotal reconstruction, the medial circumflex femoral artery perforator flap is a good option with its good mobility, thinness for scrotal contour, possibility for muscle preservation, and direct closure of the donor site. All these advantages can be accomplished in 1 procedure.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Necrotizing fasciitis of the thoracoabdominal wall complicating Dujarier's bandage: a case report]

The necrotizing fasciitis (NF) means a serious infection of the subcutis, the fascia and superficial dermis secondarily. We report the case of a patient with cellulitis NF of the thoracoabdominal wall complicating Dujarier's bandage. It was monobacterial NF caused by β hemolytic streptococcus, whose development was supported through an appropriate medical and surgical care. The situation mentioned is the occurrence of secondary infection of skin necrosis occurred in the bandage too tight opposite the support zone of the elbow on the trunk. We point out, through this case, the importance of the medicosurgical and also the importance of making any thoracoabdominal bandage, which could lead, if it is tight, a pressure sore can be a door entry for any NF plus a late diagnosis.

Necrotizing fasciitis of the extremities: 34 cases at a single centre over the past 5 years

BACKGROUND

Worldwide the incidence of necrotizing fasciitis (NF) is on the rise. This rapidly progressive infection is a true infectious disease emergency due to its high morbidity and mortality. The mainstay of therapy is prompt surgical debridement, intravenous antibiotics, and supportive care with fluid and electrolyte management. Because of its high mortality rate, patients are increasingly referred to burn centres for specialized wound and critical care issues.

METHODS

A retrospective chart review was performed of 34 consecutive patients over a 5-year period with NF of the upper and/or lower extremities that required surgical debridement and reconstruction.

RESULTS

The overall survival rate was 96%, with an average length of hospital stay of 64.0 ± 5.5 days. The time until the first operation was 1.3 days. The average age of the patients was 56.7 ± 10.6 years. The patients averaged 1.6 relevant comorbidities. One patient who had five comorbidities died. The affected total body surface (TBS) averaged 8.2 ± 2.1%.

CONCLUSION

Early recognition and treatment remain the most important factors influencing survival in NF. Yet, early diagnosis of the condition is difficult due to its similarities with other soft-tissue disorders. Repeated surgical debridement and incisional drainage continues to be essential for the survival. However, these infections continue to be a source of high morbidity, mortality and significant healthcare resource consumption. These challenging patients are best served with prompt diagnosis, immediate radical surgical debridement and aggressive critical care management. Referral to a major burn centre may help to provide optimal surgical intervention, wound care and critical care management.

Necrotizing soft tissue infections in the intensive care unit

Necrotizing soft tissue infection is a severe illness that is associated with significant morbidity and mortality. It is often caused by a wide spectrum of pathogens and is most frequently polymicrobial. Care for patients with necrotizing soft tissue infection requires a team approach with expertise from critical care, surgery, reconstructive surgery, and rehabilitation specialists. The early diagnosis of necrotizing soft tissue infection is challenging, but the keys to successful management of patients with necrotizing soft tissue infection are early recognition and complete surgical debridement. Early initiation of appropriate broad-spectrum antibiotic therapy must take into consideration the potential pathogens. Critical care management components such as the initial fluid resuscitation, end-organ support, pain management, nutrition support, and wound care are all important aspects of the care of patients with necrotizing soft tissue infection. Soft tissue reconstruction should take into account both functional and cosmetic outcome.

An algorithm for early diagnosis of cervicofacial necrotising fasciitis

Cervicofacial necrotising fasciitis (CNF) is a potentially fatal infection which can occasionally present in the head and neck. An early diagnosis and aggressive treatment is imperative for minimising the associated mortality and morbidity. The early clinical features are usually non-specific which makes it difficult to differentiate it from other less serious infections. Necrosis of the skin is a late feature. Although it is more common in the immunocompromised, it can also affect normal individuals. We discuss our experience of five patients with CNF, review of literature and algorithm for early diagnosis of CNF. With experience, we were able to diagnose the subsequent cases early and minimise the mortality and morbidity. In conclusion, the incidence of CNF has increased in the last decade partly due to an increased clinical awareness. Early intervention is essential to minimise the mortality and morbidity. It should be managed by a team of at least otolaryngologists, intensivist, microbiologist and plastic surgeons; cardiothoracic surgeons may be required. Treatment involves early aggressive surgical debridement/fasciotomy, intravenous antibiotics and general metabolic support in the intensive care unit.

Severe soft tissue infections

Severe skin and soft tissue infections (SSTIs) frequently require management in the ICU, in part related to associated septic shock or toxic shock syndrome or associated organ failure. Four fundamental management principles are key to a successful outcome in caring for patients who have severe SSTIs, including (1) early diagnosis and differentiation of necrotizing versus nonnecrotizing SSTI, (2) early initiation of appropriate empiric broad-spectrum antimicrobial therapy with consideration of risk factors for specific pathogens and mandatory coverage for methicillin-resistant Staphylococcus aureus (MRSA), (3) source control (ie, early aggressive surgical intervention for drainage of abscesses and debridement of necrotizing soft tissue infections), and (4) pathogen identification and appropriate de-escalation of antimicrobial therapy. MRSA has emerged as the most common identifiable cause of severe SSTIs; therefore, initiation of empiric anti-MRSA antimicrobials is warranted in all cases of severe SSTIs. In addition, appropriate critical care management-including fluid resuscitation, organ support and nutritional support-is a necessary component in treating severe SSTIs.