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Zaghi I, Tebano G, Vanino E, Vandi G, Cricca M, Sambri V, Fantini M, Di Antonio F, Terzitta M, Russo E, Cristini F, Bassi P, Biagetti C, Tatarelli P. Non-cholera Vibrio spp. invasive infections in the summer following May 2023 flood disaster in Romagna, Italy: a case series. Eur J Clin Microbiol Infect Dis 2024; 43:1469-1474. [PMID: 38735888 DOI: 10.1007/s10096-024-04842-7] [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: 02/03/2024] [Accepted: 05/02/2024] [Indexed: 05/14/2024]
Abstract
Non-cholera Vibrio spp. includes ubiquitous organisms living in aquatic environments. Their occurrence is associated with global warming and meteorological disasters. In May 2023 the Romagna region, Italy, was affected by severe floods. In the following 15 weeks we observed 5 patients with invasive infections caused by V. vulnificus (3/5) and V. harveyi (2/5). All patients (median age 77 years) had medical comorbidities and shared exposure to seawater. Two patients needed surgery; 2 died. In conclusion, we observed an increased burden of Vibrio spp. invasive infections after May 2023 floods, affecting old patients with predisposing medical conditions.
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Affiliation(s)
- I Zaghi
- Infectious Diseases Unit, Ravenna Hospital, Ravenna, Italy.
- Unit of Microbiology, The Greater Romagna Area Hub Laboratory, 47522, Cesena, Italy.
| | - G Tebano
- Infectious Diseases Unit, Ravenna Hospital, Ravenna, Italy
| | - E Vanino
- Infectious Diseases Unit, Ravenna Hospital, Ravenna, Italy
| | - G Vandi
- Infectious Diseases Unit, Rimini Hospital, Rimini, Italy
| | - M Cricca
- Unit of Microbiology, The Greater Romagna Area Hub Laboratory, 47522, Cesena, Italy
- Department of Medical and Surgical Sciences (DIMEC)-Alma Mater Studiorum, University of Bologna, 40138, Bologna, Italy
| | - V Sambri
- Unit of Microbiology, The Greater Romagna Area Hub Laboratory, 47522, Cesena, Italy
- Department of Medical and Surgical Sciences (DIMEC)-Alma Mater Studiorum, University of Bologna, 40138, Bologna, Italy
| | - M Fantini
- Clinical and Organizational Research Unit, Romagna AUSL, Ravenna, Italy
| | - F Di Antonio
- Anesthesia and Intensive Care Unit, Ravenna Hospital, Ravenna, Italy
| | - M Terzitta
- Anesthesia and Intensive Care Unit, Ravenna Hospital, Ravenna, Italy
| | - E Russo
- Department of Surgery and Trauma, Anesthesia and Intensive Care Unit, Maurizio Bufalini Hospital, Cesena, AUSL Della Romagna, Italy
| | - F Cristini
- Infectious Diseases Unit, Forlì and Cesena Hospitals, Forlì and Cesena, Italy
| | - P Bassi
- Infectious Diseases Unit, Ravenna Hospital, Ravenna, Italy
| | - C Biagetti
- Infectious Diseases Unit, Rimini Hospital, Rimini, Italy
| | - P Tatarelli
- Infectious Diseases Unit, Ravenna Hospital, Ravenna, Italy
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Yombi JC, Munting A, Lentini A, Putineanu D, Castanares-Zapatero D, Yildiz H. Severe skin and soft tissue infection in cohort patients admitted in a teaching hospital in Belgium: identification of risk factors for surgery. Infect Dis (Lond) 2024; 56:511-520. [PMID: 38475981 DOI: 10.1080/23744235.2024.2327518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 03/02/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Necrotizing soft tissue infections (NSTIs) are associated with significant mortality if not promptly diagnosed and surgically treated. AIM This study aims to compare patients with severe skin and soft tissue infection treated with or without a surgical intervention and to identify risk factors that can predict the need for early surgery. METHODS Demographics, clinical, laboratory, Risk Indicator for Necrotizing Fasciitis (LRINEC) and imaging results were retrospectively collected. RESULTS There were 91 non-NSTI (group 1), 26 NSTI who were operated (group 2) and eight suspected NSTI who were not operated (group 3). In the multivariate analysis, skin necrosis, tachycardia, CRP value and hyperglycemia were predictive for surgery. A performance analysis revealed AUC of 0.65 (95%CI: 0.52-0.78) as to the LRINEC score for the use of surgery. The AUC for a predictive model associating four variables (heart rate, skin necrosis, CRP and glycemia at admission) was 0.71 (95%CI: 0.59-0.84). In terms of outcome, the median length of stay (LOS) was statistically higher in group 2 vs. group 1 (seven days (5-15) vs. 34 days (20-42), p < .001) and in group 2 vs. group 3 (34 days (20-42) vs. 14 days (11-19), p = .005). The overall in-hospital mortality at 30 days was 3.2% and did not statistically differ between the three groups. CONCLUSIONS Although the LRINEC score performed well in predicting surgery, the AUC of a model combining four predictive variables (glycemia, skin necrosis, CRP and heart rate) was superior. Further research is needed to validate this model.
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Affiliation(s)
- J C Yombi
- Department of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint-Luc, UClouvain, Bruxelles, Belgium
| | - A Munting
- Department of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint-Luc, UClouvain, Bruxelles, Belgium
| | - A Lentini
- Department of Plastic Surgery, Cliniques Universitaires Saint-Luc, UClouvain, Bruxelles, Belgium
| | - D Putineanu
- Department of Orthopaedic Surgery, Cliniques Universitaires Saint-Luc, UClouvain, Bruxelles, Belgium
| | - D Castanares-Zapatero
- Department of Intensive Care, Cliniques Universitaires Saint-Luc, UClouvain, Bruxelles, Belgium
| | - H Yildiz
- Department of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint-Luc, UClouvain, Bruxelles, Belgium
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Lau CH, Ling L, Zhang JZ, Ng PY, Chan CY, Yeung AWT, Fong KM, Chan JKH, Au GKF, Liong T, Dharmangadan M, Chow FL, Lam KN, Chan KM, Ling S, Lee A. Association between time to surgery and hospital mortality in patients with community-acquired limb necrotizing fasciitis: an 11-year multicenter retrospective cohort analysis. BMC Infect Dis 2024; 24:624. [PMID: 38910240 PMCID: PMC11194942 DOI: 10.1186/s12879-024-09501-y] [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: 11/07/2023] [Accepted: 06/12/2024] [Indexed: 06/25/2024] Open
Abstract
BACKGROUND Necrotizing fasciitis (NF) is a rare but potentially life-threatening soft tissue infection. The objective of this study was to assess the association between timely surgery within 6 h and hospital mortality in patients with limb NF, and to describe the trends in patients with NF, time to surgery and standardized mortality ratio (SMR) over 11 years. METHODS This was a multicenter, retrospective cohort study of all intensive care unit patients who had emergency surgery within 24 h of hospitalization for limb NF between April 1, 2008 and March 31, 2019 in Hong Kong. Timely surgery was defined as the first surgical treatment within 6 h of initial hospitalization. Appropriate antibiotics were achieved if the patient was given antibiotic(s) for all documented pathogens prior to or on day of culture results. The primary outcome was hospital mortality. RESULTS There were 495 patients (median age 62 years, 349 (70.5%) males) with limb NF treated by surgery within 24 h of hospitalization over the 11 years. Appropriate antibiotic(s) were used in 392 (79.2%) patients. There were 181 (36.5%) deaths. Timely surgery was not associated with hospital mortality (Relative Risk 0.89, 95% CI: 0.73 to 1.07) but admission year, advanced age, higher severity of illness, comorbidities, renal replacement therapy, vasopressor use, and type of surgery were significant predictors in the multivariable model. There was an upward trend in NF diagnosis (1.9 cases/year, 95% CI: 0.7 to 3.1; P < 0.01; R2 = 0.60) but there was no downward trend in median time to surgery (-0.2 h/year, 95% CI: -0.4 to 0.1; P = 0.16) or SMR (-0.02/year, 95% CI: -0.06 to 0.01; P = 0.22; R2 = 0.16). CONCLUSIONS Among patients operated within 24 h, very early surgery within 6-12 h was not associated with survival. Increasing limb NF cases were reported each year but mortality remained high despite a high rate of appropriate antibiotic use and timely surgical intervention.
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Affiliation(s)
- Chi Ho Lau
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Lowell Ling
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Jack Zhenhe Zhang
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Pauline Yeung Ng
- Critical Care Medicine Unit, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong SAR, China
- Department of Adult Intensive Care, Queen Mary Hospital, Pok Fu Lam, Hong Kong SAR, China
| | - Cheuk Yan Chan
- Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong SAR, China
| | - Alwin Wai Tak Yeung
- Department of Medicine & Geriatrics, Ruttonjee and Tang Shiu Kin Hospitals, Wan Chai, Hong Kong SAR, China
| | - Ka Man Fong
- Department of Intensive Care, Queen Elizabeth Hospital, Yau Ma Tei, Hong Kong SAR, China
| | - Jacky Ka Hing Chan
- Department of Medicine, Tseung Kwan O Hospital, Tseung Kwan O, Hong Kong SAR, China
| | - Gary Ka Fai Au
- Department of Intensive Care, Kwong Wah Hospital, Yau Ma Tei, Hong Kong SAR, China
| | - Ting Liong
- Department of Intensive Care, United Christian Hospital, Kwun Tong, Hong Kong SAR, China
| | - Manimala Dharmangadan
- Department of Intensive Care, Princess Margaret Hospital, Kwai Chung, Hong Kong SAR, China
- Department of Intensive Care, Yan Chai Hospital, Tsuen Wan, Hong Kong SAR, China
| | - Fu Loi Chow
- Department of Intensive Care Unit, Department of Medicine & Geriatrics, Caritas Medical Centre, Sham Shui Po, Hong Kong SAR, China
| | - Koon Ngai Lam
- Department of Intensive Care, North District Hospital, Sheung Shui, Hong Kong SAR, China
| | - Kai Man Chan
- Intensive Care Unit, Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Tai Po, Hong Kong SAR, China
| | - Steven Ling
- Department of Intensive Care, Tuen Mun Hospital, Tuen Mun, Hong Kong SAR, China
| | - Anna Lee
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China.
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Morgado ME, Brumfield KD, Mitchell C, Boyle MM, Colwell RR, Sapkota AR. Increased incidence of vibriosis in Maryland, U.S.A., 2006-2019. ENVIRONMENTAL RESEARCH 2024; 244:117940. [PMID: 38101724 PMCID: PMC10922380 DOI: 10.1016/j.envres.2023.117940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 11/30/2023] [Accepted: 12/11/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Vibrio spp. naturally occur in warm water with moderate salinity. Infections with non-cholera Vibrio (vibriosis) cause an estimated 80,000 illnesses and 100 fatalities each year in the United States. Climate associated changes to environmental parameters in aquatic ecosystems are largely promoting Vibrio growth, and increased incidence of vibriosis is being reported globally. However, vibriosis trends in the northeastern U.S. (e.g., Maryland) have not been evaluated since 2008. METHODS Vibriosis case data for Maryland (2006-2019; n = 611) were obtained from the COVIS database. Incidence rates were calculated using U.S. Census Bureau population estimates for Maryland. A logistic regression model, including region, age group, race, gender, occupation, and exposure type, was used to estimate the likelihood of hospitalization. RESULTS Comparing the 2006-2012 and 2013-2019 periods, there was a 39% (p = 0.01) increase in the average annual incidence rate (per 100,000 population) of vibriosis, with V. vulnificus infections seeing the greatest percentage increase (53%, p = 0.01), followed by V. parahaemolyticus (47%, p = 0.05). The number of hospitalizations increased by 58% (p = 0.01). Since 2010, there were more reported vibriosis cases with a hospital duration ≥10 days. Patients from the upper eastern shore region and those over the age of 65 were more likely (OR = 6.8 and 12.2) to be hospitalized compared to other patients. CONCLUSIONS Long-term increases in Vibrio infections, notably V. vulnificus wound infections, are occurring in Maryland. This trend, along with increased rates in hospitalizations and average hospital durations, underscore the need to improve public awareness, water monitoring, post-harvest seafood interventions, and environmental forecasting ability.
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Affiliation(s)
- Michele E Morgado
- Maryland Institute for Applied Environmental Health, University of Maryland School of Public Health, College Park, MD, USA
| | - Kyle D Brumfield
- Maryland Pathogen Research Institute, University of Maryland, College Park, MD, USA; University of Maryland Institute for Advanced Computer Studies, University of Maryland, College Park, MD, USA
| | - Clifford Mitchell
- Prevention and Health Promotion Administration, Maryland Department of Health, Baltimore, MD, USA
| | - Michelle M Boyle
- Prevention and Health Promotion Administration, Maryland Department of Health, Baltimore, MD, USA
| | - Rita R Colwell
- Maryland Pathogen Research Institute, University of Maryland, College Park, MD, USA; University of Maryland Institute for Advanced Computer Studies, University of Maryland, College Park, MD, USA
| | - Amy R Sapkota
- Maryland Institute for Applied Environmental Health, University of Maryland School of Public Health, College Park, MD, USA.
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Ganapathy A, Ballard DH, Chen DZ, Schneider M, Lanier MH, Mazaheri P, Ilahi O, Kirby JP, Raptis CA, Mellnick VM. Preoperative computed tomography in Fournier's gangrene does not delay time to surgery. Emerg Radiol 2023; 30:711-717. [PMID: 37857761 DOI: 10.1007/s10140-023-02177-y] [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: 09/14/2023] [Accepted: 10/12/2023] [Indexed: 10/21/2023]
Abstract
PURPOSE Fournier's gangrene (FG), a rapidly progressive necrotizing soft tissue infection of the external genitalia and perineum, necessitates urgent surgical debridement. The time to surgery effect of preoperative computed tomography (CT) in managing this condition is yet to be fully explored. The purpose of this study was to assess whether obtaining a preoperative CT in patients with FG impacts the time to surgical intervention. METHODS This was a single-center retrospective study of patients who underwent CT prior to surgical debridement of FG during a 9-year period vs patients who did not undergo CT. In 76 patients (male = 39, mean age = 51.8), 38 patients with FG received a preoperative CT, and 38 patients with FG did not receive CT prior to surgical debridement. Time to operating room and outcome metrics were compared between CT and non-CT groups. RESULTS The time from hospital presentation to surgical intervention was not significantly different between patients who underwent CT and those who did not (6.65 ± 3.71 vs 5.73 ± 4.33 h, p = 0.37). There were also no significant differences in cost ($130,000 ± $102,000 vs $142,000 ± $152,000, p = 0.37), mortality (8 vs 7, p = 1), duration of hospital stay (15.5 ± 15 vs 15.7 ± 11.6 days, p = 0.95), average intensive care unit stay (5.82 ± 5.38 days vs 6.97 ± 8.58 days, p = 0.48), and APACHE score (12 ± 4.65 vs 13.9 ± 5.6, p =0.12). CONCLUSION Obtaining a preoperative CT did not delay surgical intervention in patients with FG.
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Affiliation(s)
- Aravinda Ganapathy
- School of Medicine, Washington University in St. Louis, St. Louis, MO, 63110, USA
| | - David H Ballard
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd; Campus Box 8131, St. Louis, MO, 63110, USA.
| | - David Z Chen
- School of Medicine, Washington University in St. Louis, St. Louis, MO, 63110, USA
| | - McGinness Schneider
- School of Medicine, Washington University in St. Louis, St. Louis, MO, 63110, USA
| | - M Hunter Lanier
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd; Campus Box 8131, St. Louis, MO, 63110, USA
| | - Parisa Mazaheri
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd; Campus Box 8131, St. Louis, MO, 63110, USA
| | - Obeid Ilahi
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - John P Kirby
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Constantine A Raptis
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd; Campus Box 8131, St. Louis, MO, 63110, USA
| | - Vincent M Mellnick
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd; Campus Box 8131, St. Louis, MO, 63110, USA
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Harden Waibel B, Kamien AJ. Resuscitation and Preparation of the Emergency General Surgery Patient. Surg Clin North Am 2023; 103:1061-1084. [PMID: 37838456 DOI: 10.1016/j.suc.2023.05.011] [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] [Indexed: 10/16/2023]
Abstract
Traditionally, the workflow surrounding a general surgery patient allows for a period of evaluation and optimization of underlying medical issues to allow for risk modification; however, in the emergency, this optimization period is largely condensed because of its time-dependent nature. Because the lack of optimization can lead to complications, the ability to rapidly resuscitate the patient, proceed to procedural intervention to control the situation, and manage common medical comorbidities is paramount. This article provides an overview on these subjects.
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Affiliation(s)
- Brett Harden Waibel
- Division of Acute Care Surgery, Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE 68198-3280, USA.
| | - Andrew James Kamien
- Division of Acute Care Surgery, Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE 68198-3280, USA
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Lu K, Li Y, Chen R, Yang H, Wang Y, Xiong W, Xu F, Yuan Q, Liang H, Xiao X, Huang R, Chen Z, Tian C, Wang S. Pathogenic mechanism of Vibrio vulnificus infection. Future Microbiol 2023; 18:373-383. [PMID: 37158065 DOI: 10.2217/fmb-2022-0243] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
Vibrio vulnificus is a fatal, opportunistic human pathogen transmitted through the consumption of raw/undercooked seafood or direct contact. V. vulnificus infection progresses rapidly and has severe consequences; some cases may require amputation or result in death. Growing evidence suggests that V. vulnificus virulence factors and regulators play a large role in disease progression, involving host resistance, cellular damage, iron acquisition, virulence regulation and host immune responses. Its disease mechanism remains largely undefined. Further evaluation of pathogenic mechanisms is important for selecting appropriate measures to prevent and treat V. vulnificus infection. In this review, the possible pathogenesis of V. vulnificus infection is described to provide a reference for treatment and prevention.
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Affiliation(s)
- Kun Lu
- Department of Neurosurgery, First Naval Hospital of Southern Theater Command, Zhanjiang, 524000, China
| | - Yang Li
- Department of Neurosurgery, First Naval Hospital of Southern Theater Command, Zhanjiang, 524000, China
| | - Rui Chen
- Department of Orthopedics, First Naval Hospital of Southern Theater Command, Zhanjiang, 524000, China
| | - Hua Yang
- Department of Neurosurgery, First Naval Hospital of Southern Theater Command, Zhanjiang, 524000, China
| | - Yong Wang
- Hemodialysis Center, First Naval Hospital of Southern Theater Command, Zhanjiang, 524000, China
| | - Wei Xiong
- Department of Neurosurgery, First Naval Hospital of Southern Theater Command, Zhanjiang, 524000, China
| | - Fang Xu
- Department of Neurosurgery, First Naval Hospital of Southern Theater Command, Zhanjiang, 524000, China
| | - Qijun Yuan
- Department of Neurosurgery, First Naval Hospital of Southern Theater Command, Zhanjiang, 524000, China
| | - Haihui Liang
- Department of Neurosurgery, First Naval Hospital of Southern Theater Command, Zhanjiang, 524000, China
| | - Xian Xiao
- Department of Neurosurgery, First Naval Hospital of Southern Theater Command, Zhanjiang, 524000, China
| | - Renqiang Huang
- Department of Neurosurgery, First Naval Hospital of Southern Theater Command, Zhanjiang, 524000, China
| | - Zhipeng Chen
- Department of Neurosurgery, First Naval Hospital of Southern Theater Command, Zhanjiang, 524000, China
| | - Chunou Tian
- Department of Neurosurgery, First Naval Hospital of Southern Theater Command, Zhanjiang, 524000, China
| | - Songqing Wang
- Department of Neurosurgery, First Naval Hospital of Southern Theater Command, Zhanjiang, 524000, China
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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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Sun Y, Lin YZ, Chen ZG. An Uncommon Case of Necrotizing Fasciitis and Septic Shock Caused by Vibrio vulnificus Infection-Related Freshwater Shrimp Stung. THE INTERNATIONAL JOURNAL OF LOWER EXTREMITY WOUNDS 2023; 22:152-155. [PMID: 33225768 DOI: 10.1177/1534734620973992] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Vibrio vulnificus is a deadly marine pathogen that can cause necrotizing fasciitis, septic shock, and even death in severe cases. The relatively low incidence and atypical early-stage symptoms may hinder many physicians from carrying out surgical intervention effectively, thus leading to an increase of mortality in infected patients. This article reported a patient who developed necrotizing fasciitis and septic shock after the exposure to freshwater shrimp stabbed on the limb. By reviewing and analyzing previous studies, it was found out that the timing of surgery could have a significant impact on the patients for their necrotizing fasciitis caused by Vibrio vulnificus infection. The mortality among patients undergoing early-stage surgical treatment (≤12 hours from the time of admission) was significantly lower than that of patients undergoing late surgical treatment (>12 hours).
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Affiliation(s)
- Yi Sun
- Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yu-Ze Lin
- Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zeng-Gan Chen
- Zhongshan Hospital, Fudan University, Shanghai, China
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Ling XW, Zhang TT, Ling MM, Chen WH, Huang CH, Shen GL. Th1/Th2 cytokine levels: A potential diagnostic tool for patients with necrotizing fasciitis. Burns 2023; 49:200-208. [PMID: 36195489 DOI: 10.1016/j.burns.2022.08.018] [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: 04/20/2022] [Revised: 08/06/2022] [Accepted: 08/29/2022] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Necrotizing fasciitis (NF) has emerged as rare but rapidly progressive, life-threatening severe skin and soft tissue infection. We conducted a study to investigate whether Th1/Th2 cytokines could serve as biomarkers to distinguish NF from class III skin and soft tissue infections (SSTIs). METHODS A retrospective review was performed for 155 patients suffering from serious skin and soft tissue infections from October 2020 to February 2022. Th1/Th2 cytokines were obtained from peripheral blood and wound drainage fluid samples. Data on demographic characteristics, causative microbiological organisms, Th1/Th2 cytokines, c-reactive protein, procalcitonin and white blood cell (WBC) were extracted for analysis. Factors with statistical difference(p < 0.1) were included in the multivariate logistic regression model. The clinical differential diagnostic values of interleukin-2(IL-2), IL-6, IL-10, tumor necrosis factor-α (TNF-α) and interferon-r (IFN-r) were analyzed by receiver operating characteristic (ROC) curve. RESULTS Among the 155 patients, 66(43%) patients were diagnosed as NF. We found no significant difference for sex, age, location of infection, coexisting condition, predisposition, duration of symptoms before admission and micro-organisms, WBC, procalcitonin and c-reactive protein in NF and class III SSTIs group. NF had higher levels of IL-6 in serum (50.46 [24.89, 108.89] vs. 11.87 [5.20, 25.32] pg/ml; p<0.01), IL-10 in serum (3.45 [2.03, 5.12] vs. 2.51 [1.79, 3.29] pg/ml; p<0.01), IL-2 in wound drainage fluid (0.89 [0.49, 1.33] vs. 0.63 [0.14, 1.14] pg/ml; p = 0.02), IL-6 in wound drainage fluid (5000.84 [1392.30, 13287.19] vs. 1927.82 (336.65, 6759.27) pg/ml; p<0.01), TNF-a in wound drainage fluid (5.20 [1.49, 22.97] vs. 0.96 [0.12, 3.21] pg/ml; p<0.01) and IFN-r in wound drainage fluid (1.32 [0.47, 4.62] vs. 0.68 [0.10, 1.88] pg/ml; p = 0.02) as compared to the class III SSTIs. Multivariate logistic regression analyses showed that IL-6 in serum, IL-10 in serum and TNF-a in wound drainage fluid exhibited independently significant associations with diagnosis of NF(p<0.05). In ROC curve analysis of IL-2, IL-6, IL-10, TNF-a and IFN-r for diagnosis of NF, the area under the curve (AUC) of IL-6 in serum could reach to 0.80 (p<0.001). Using 27.62 pg/ml as the cut off value, the sensitivity was 74% and the specificity was 79% in IL-6 in serum. CONCLUSIONS Th1/Th2 cytokines, IL-6 in serum in particular, are potential biomarkers for the diagnosis of NF in the early stage. However, larger patient populations with multiple centers and prospective studies are necessary to ensure the prognostic role of Th1/Th2 cytokines.
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Affiliation(s)
- Xiang-Wei Ling
- Department of Burn, The First Affiliated Hospital of Soochow University, Suzhou 215006, China
| | - Ting-Ting Zhang
- Department of Burn, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Meng-Meng Ling
- Department of Information, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Wei-Hao Chen
- Department of Burn, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Chun-Hui Huang
- Department of Burn, The First Affiliated Hospital of Soochow University, Suzhou 215006, China
| | - Guo-Liang Shen
- Department of Burn, The First Affiliated Hospital of Soochow University, Suzhou 215006, China.
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11
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Namadi P, Deng Z. Optimum environmental conditions controlling prevalence of vibrio parahaemolyticus in marine environment. MARINE ENVIRONMENTAL RESEARCH 2023; 183:105828. [PMID: 36423461 DOI: 10.1016/j.marenvres.2022.105828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 11/10/2022] [Accepted: 11/15/2022] [Indexed: 06/16/2023]
Abstract
This literature review presents major environmental indicators and their optimum variation ranges for the prevalence of Vibrio parahaemolyticus in the marine environment by critically reviewing and statistically analyzing more than one hundred studies from countries around the world. Results of this review indicated that the prevalence of Vibrio parahaemolyticus in the marine environment is primarily responsive to favorable environmental conditions that are described with environmental indicators. The importance of environmental indicators to the prevalence of Vibrio parahaemolyticus can be ranked from the highest to lowest as Sea Surface Temperature (SST), salinity, pH, chlorophyll a, and turbidity, respectively. It was also found in this study that each environmental indicator has an optimum variation range favoring the prevalence of Vibrio parahaemolyticus. Specifically, the SST range of 25.67 ± 2 °C, salinity range of 27.87 ± 3 ppt, and pH range of 7.96 ± 0.1 were found to be the optimum conditions for the prevalence of Vibrio parahaemolyticus. High vibrio concentrations were also observed in water samples with the chlorophyll a range of 16-25 μg/L. The findings provide new insights into the importance of environmental indicators and their optimum ranges, explaining not only the existence of both positive and negative associations reported in the literature but also the dynamic associations between the Vibrio presence and its environmental drivers.
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Affiliation(s)
- Peyman Namadi
- Department of Civil and Environmental Engineering, Louisiana State University, Baton Rouge, LA, 70803, United States
| | - Zhiqiang Deng
- Department of Civil and Environmental Engineering, Louisiana State University, Baton Rouge, LA, 70803, United States.
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12
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Poxon A, Clarfield L, Cherniak R, Page A, Po L. Delays to Surgery in Emergency Department Cases of Ectopic Pregnancy: A Quality Improvement Study. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:21-26. [PMID: 36436806 DOI: 10.1016/j.jogc.2022.11.004] [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: 09/21/2022] [Revised: 11/02/2022] [Accepted: 11/03/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Create a process map for emergency department (ED) presentations of surgical ectopic pregnancy, and identify areas of management amenable to quality improvement. METHODS A retrospective chart review of all patients undergoing surgical management of ectopic pregnancy at a large, urban, academic tertiary care centre from 2015 to 2017 was performed. RESULTS Seventy-three patients were included. There were 6 (8.2%) unstable A cases (recommended time to operating room [OR] 0-2 hours), 23 (31.5%) stable A cases, and 44 (60%) B cases (recommended time to OR 2-8 hours). The percent of patients who were in the OR within the recommended time window were 6 (100%) for unstable A cases, 13 (56%) stable A cases, and 29 (65.9%) stable B cases, respectively (P = 0.139). Notable time delays include the time from gynaecology referral to the time seen by gynaecology (29.7% of total wait time for stable A cases from ED to OR) and the time the OR was booked to the time the patient was brought to the OR (53.2% of total wait time for stable B cases). Of the patients seen by physician at the emergency department first, the time from triage to the OR was significantly shorter for patients that received bedside ultrasound only (0.67 ± 0.5 hours vs. 2.1 ± 1.8 hours [P = 0.007]). CONCLUSION This is the first study to map the ED presentation of surgical ectopic pregnancy. The management of ectopic pregnancy would benefit from the development of surgical triage decision aids, a surgical care pathway, and increased use of screening bedside ultrasound.
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Affiliation(s)
- Amanda Poxon
- Temerty School of Medicine, University of Toronto, Toronto, ON.
| | - Lauren Clarfield
- Department of Obstetrics and Gynaecology at the University of Toronto, Toronto, ON
| | - Rebecca Cherniak
- Department of Obstetrics and Gynaecology at the University of Toronto, Toronto, ON
| | - Andrea Page
- Department of Obstetrics and Gynaecology at the University of Toronto, Toronto, ON; DAN Women and Babies Program at Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
| | - Leslie Po
- Department of Obstetrics and Gynaecology at the University of Toronto, Toronto, ON; Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
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13
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Lu HY, Gao YB, Qiu XW, Wang Q, Liu CM, Huang XW, Chen HY, Zeng K, Li CX. Successful surgical treatment of polybacterial gas gangrene confirmed by metagenomic next-generation sequencing detection: A case report. World J Clin Cases 2022; 10:13064-13073. [PMID: 36568998 PMCID: PMC9782953 DOI: 10.12998/wjcc.v10.i35.13064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/02/2022] [Accepted: 11/17/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND We report on a case of Vibrio vulnificus (V. vulnificus) detected by metagenomics next-generation sequencing (mNGS) in a 53-year-old male patient with polymicrobial gas gangrene and successful treatment by surgery. This report raises awareness among dermatologists that when a patient is clinically suspected of a special type of pathogenic infection, the mNGS method should be preferred to identify the patient’s pathogen infection as soon as possible and then take effective treatment in time to save patients’ lives.
CASE SUMMARY A 53-year-old male who worked in the aquatic market complained of redness and swelling of the lower limbs, blisters and ulcers with fever for 3 d. We used mNGS to test the pathogens in ulcer secretions. The results were returned in 24 h and indicated: V. vulnificus, Fusobacterium necrophorum, Staphylococcus haemolyticus, Staphylococcus aureus, Streptococcus dysgalactiae and Klebsiella aerogenes. This patient was diagnosed with V. vulnificus infection. The emergency operation was performed immediately under combined lumbar and epidural anesthesia: Left leg expansion and exploration (August 10, 2021). After surgery, we continued to use piperacillin sodium tazobactam sodium 4.5 g every 8 h and levofloxacin 0.5 g for anti-infection treatment. The patient underwent further surgery under lumbar anesthesia on August 17, 2021 and August 31, 2021: Left leg deactivation and skin grafting, negative pressure closed drainage and right thigh skin removal. After treatment, the transplanted flap survived.
CONCLUSION We could confirm the diagnosis of Vibrio vulnificus infection within 24 h through mNGS detection and then immediately performed emergency surgery.
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Affiliation(s)
- Hong-Yan Lu
- Department of Dermatology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong Province, China
| | - Yan-Bin Gao
- Department of Burns Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong Province, China
| | - Xue-Wen Qiu
- Department of Burns Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong Province, China
| | - Qi Wang
- Department of Dermatology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong Province, China
| | - Chen-Mei Liu
- Department of Dermatology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong Province, China
| | - Xiao-Wen Huang
- Department of Dermatology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong Province, China
| | - Hong-Yu Chen
- Department of Dermatology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong Province, China
| | - Kang Zeng
- Department of Dermatology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong Province, China
| | - Chang-Xing Li
- Department of Dermatology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong Province, China
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14
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Reitz KM, Kennedy J, Li SR, Handzel R, Tonetti DA, Neal MD, Zuckerbraun BS, Hall DE, Sperry JL, Angus DC, Tzeng E, Seymour CW. Association Between Time to Source Control in Sepsis and 90-Day Mortality. JAMA Surg 2022; 157:817-826. [PMID: 35830181 PMCID: PMC9280613 DOI: 10.1001/jamasurg.2022.2761] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Importance Rapid source control is recommended to improve patient outcomes in sepsis. Yet there are few data to guide how rapidly source control is required. Objective To determine the association between time to source control and patient outcomes in community-acquired sepsis. Design, Setting, and Particpants Multihospital integrated health care system cohort study of hospitalized adults (January 1, 2013, to December 31, 2017) with community-acquired sepsis as defined by Sepsis-3 who underwent source control procedures. Follow-up continued through January 1, 2019, and data analyses were completed March 17, 2022. Exposures Early (<6 hours) compared with late (6-36 hours) source control as well as each hour of source control delay (1-36 hours) from sepsis onset. Main Outcomes and Measures Multivariable models were clustered at the level of hospital with adjustment for patient factors, sepsis severity, resource availability, and the physiologic stress of procedures generating adjusted odds ratios (aOR) and 95% CI. Results Of 4962 patients with sepsis (mean [SD] age, 62 [16] years; 52% male; 85% White; mean [SD] Sequential Organ Failure Assessment score, 3.8 [2.5]), source control occurred at a median (IQR) of 15.4 hours (5.5-21.7) after sepsis onset, with 1315 patients (27%) undergoing source control within 6 hours. The crude 90-day mortality was similar for early and late source control (n = 177 [14%] vs n = 529 [15%]; P = .35). In multivariable models, early source control was associated with decreased risk-adjusted odds of 90-day mortality (aOR, 0.71; 95% CI, 0.63-0.80). This association was greater among gastrointestinal and abdominal (aOR, 0.56; 95% CI, 0.43-0.80) and soft tissue interventions (aOR, 0.72; 95% CI, 0.55-0.95) compared with orthopedic and cranial interventions (aOR, 1.33; 95% CI, 0.96-1.83; P < .001 for interaction). Conclusions and Relevance Source control within 6 hours of community-acquired sepsis onset was associated with a reduced risk-adjusted odds of 90-day mortality. Prioritizing the rapid identification of septic foci and initiation of source control interventions can reduce the number of avoidable deaths among patients with sepsis.
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Affiliation(s)
- Katherine M. Reitz
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania,Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania,Division of Vascular Surgery, UPMC, Pittsburgh, Pennsylvania
| | - Jason Kennedy
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Shimena R. Li
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert Handzel
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Daniel A. Tonetti
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Matthew D. Neal
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania,Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Brian S. Zuckerbraun
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania,Veterans Affairs Pittsburgh Health System, Pittsburgh, Pennsylvania
| | - Daniel E. Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania,Veterans Affairs Pittsburgh Health System, Pittsburgh, Pennsylvania,Center for Health Equity Research and Promotion, Veterans Affairs, Pittsburgh, Pennsylvania,Wolff Center, UPMC, Pittsburgh, Pennsylvania
| | - Jason L. Sperry
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Derek C. Angus
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Edith Tzeng
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania,Division of Vascular Surgery, UPMC, Pittsburgh, Pennsylvania,Veterans Affairs Pittsburgh Health System, Pittsburgh, Pennsylvania
| | - Christopher W. Seymour
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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15
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Sandberg JM, Warner HL, Flynn KJ, Sexton SM, Pham HT, Kandler BW, Polgreen PM, Erickson BA. Favorable Outcomes With Early Component Separation, Primary Closure of Necrotizing Soft Tissue Infections of the Genitalia (Fournier's Gangrene) Debridement Wound Defects. Urology 2022; 166:250-256. [PMID: 35584736 DOI: 10.1016/j.urology.2022.03.042] [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: 02/03/2022] [Revised: 03/16/2022] [Accepted: 03/20/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the efficacy of early necrotizing soft-tissue infections of the genitalia (NSTIG) component separation, primary wound closure (CSC). We hypothesized that early CSC would be safe, decrease the need for split-thickness skin grafting (STSG) and decrease wound convalescence time. MATERIALS/METHODS Management of consecutive NSTIG patients from a single institution were evaluated. Three cohorts emerged: 1) those managed/closed by a reconstructive urologist (URO) using CSC principles (wide genital tissue mobilization with primary closure, when possible, +/- STSG), 2) those managed/closed by the general surgery/burn service, and 3) those managed conservatively with secondary closure. Total NSTIG anatomic extent (AE) was determined by assessing involvement of the penis, scrotum, perineum and suprapubic region, and ranged from 1 (<50% involvement of one area) to 8 (>50% involvement in all 4 areas). RESULTS Of 84 FG patients meeting study criteria, 48 (57%) were closed primarily and 36 were left to heal by secondary intention. AE was greatest in patients managed by general surgery/burn service (4.5 ± 1.5), followed by URO (2.7 ± 1.8) and secondary intention cases (1.3 ± 0.5). Secondary procedure rates were similar between closure/non-closure cohorts (6.3% v 11%; P = 0.67). STSG use was predicted by wound size (though not time to closure)-specifically with suprapubic and/or penile wounds of >50% involvement. Wound convalescence time decreased by 64% when wounds were closed versus left open, controlling for AE. CONCLUSION Early, same-admission primary closure of stable NSTIG wounds is safe and decreases wound convalescence time by over 60%.
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Affiliation(s)
- Jason M Sandberg
- University of Iowa, Carver College of Medicine, Department of Urology, Iowa City, IA
| | - Hayden L Warner
- University of Iowa, Carver College of Medicine, Department of Urology, Iowa City, IA
| | - Kevin J Flynn
- University of Iowa, Carver College of Medicine, Department of Urology, Iowa City, IA
| | - Shawn M Sexton
- University of Iowa, Carver College of Medicine, Department of Urology, Iowa City, IA
| | - Hanh Td Pham
- University of Iowa, College of Public Health, Department of Biostatistics, Iowa City, IA
| | - Blaize W Kandler
- University of Iowa, College of Public Health, Department of Biostatistics, Iowa City, IA
| | - Phillip M Polgreen
- University of Iowa, Carver College of Medicine, Department of Internal Medicine, Division of Infectious Disease, Iowa City, IA
| | - Bradley A Erickson
- University of Iowa, Carver College of Medicine, Department of Urology, Iowa City, IA.
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16
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Li J, Zhu Y, Ma Z, Yang F. Genome sequence and pathogenicity of Vibrio vulnificus strain MCCC 1A08743 isolated from contaminated prawns. Biol Open 2022; 11:275848. [PMID: 35766638 PMCID: PMC9253834 DOI: 10.1242/bio.059299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 05/19/2022] [Indexed: 12/17/2022] Open
Abstract
Vibrio vulnificus is an opportunistic pathogen that naturally inhabits sea water globally and is responsible for most vibriosis-related deaths. The consumption of V. vulnificus contaminated seafood and exposure of wounds to Vibrio can result in systemic infection, with increased risks of amputation and extremely high rates of mortality. However, the pathogenicity and virulence factors of V. vulnificus are not fully understood. The genomic characterization of V. vulnificus will be helpful to extend our understanding on V. vulnificus at a genomic level. In this manuscript, the genome of V. vulnificus strain MCCC 1A08743 isolated from contaminated prawns from Zhanjiang, China, was sequenced using Illumina HiSeq X Ten system and annotated through multiple databases. The strain MCCC 1A08743 genome included 4371 protein-coding genes and 117 RNA genes. Average nucleotide identity analysis and core genome phylogenetic analysis revealed that MCCC 1A08743 was most closely related to strains from clinical samples from the United States. Pathogenicity annotation of the MCCC 1A08743 genome, using Virulence Factor Database and Pathogen-Host Interactions database, predicted the pathogenicity of the strain, and this was confirmed using mice infection experiments, which indicated that V. vulnificus strain MCCC 1A08743 could infect C57BL/6J mice and cause liver lesions. This article has an associated First Person interview with the first author of the paper. Summary:Vibrio vulnificus strain MCCC 1A08743 was newly isolated, sequenced and tested for its pathogenicity in mice.
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Affiliation(s)
- Jie Li
- Department of Medical Genetics, Naval Medical University, Shanghai 200433, China
| | - Yiqing Zhu
- Department of Medical Genetics, Naval Medical University, Shanghai 200433, China
| | - Zhenxia Ma
- Department of Biochemistry and Molecular Biology, Naval Medical University, Shanghai, 200433, China
| | - Fu Yang
- Department of Medical Genetics, Naval Medical University, Shanghai 200433, China
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17
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Phitsamai A, Chueansuwan W, Changpradub D. Vibrio vulnificus Necrotizing Fasciitis in Upper Limbs and Septicemia Following Pinch Injury by Mud Crab: A Case Report. Cureus 2022; 14:e24393. [PMID: 35619836 PMCID: PMC9126442 DOI: 10.7759/cureus.24393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 11/05/2022] Open
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18
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Rüddel H, Thomas-Rüddel DO, Reinhart K, Bach F, Gerlach H, Lindner M, Marshall JC, Simon P, Weiss M, Bloos F, Schwarzkopf D. Adverse effects of delayed antimicrobial treatment and surgical source control in adults with sepsis: results of a planned secondary analysis of a cluster-randomized controlled trial. Crit Care 2022; 26:51. [PMID: 35227308 PMCID: PMC8883454 DOI: 10.1186/s13054-022-03901-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 01/16/2022] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Timely antimicrobial treatment and source control are strongly recommended by sepsis guidelines, however, their impact on clinical outcomes is uncertain. METHODS We performed a planned secondary analysis of a cluster-randomized trial conducted from July 2011 to May 2015 including forty German hospitals. All adult patients with sepsis treated in the participating ICUs were included. Primary exposures were timing of antimicrobial therapy and delay of surgical source control during the first 48 h after sepsis onset. Primary endpoint was 28-day mortality. Mixed models were used to investigate the effects of timing while adjusting for confounders. The linearity of the effect was investigated by fractional polynomials and by categorizing of timing. RESULTS Analyses were based on 4792 patients receiving antimicrobial treatment and 1595 patients undergoing surgical source control. Fractional polynomial analysis identified a linear effect of timing of antimicrobials on 28-day mortality, which increased by 0.42% per hour delay (OR with 95% CI 1.019 [1.01, 1.028], p ≤ 0.001). This effect was significant in patients with and without shock (OR = 1.018 [1.008, 1.029] and 1.026 [1.01, 1.043], respectively). Using a categorized timing variable, there were no significant differences comparing treatment within 1 h versus 1-3 h, or 1 h versus 3-6 h. Delays of more than 6 h significantly increased mortality (OR = 1.41 [1.17, 1.69]). Delay in antimicrobials also increased risk of progression from severe sepsis to septic shock (OR per hour: 1.051 [1.022, 1.081], p ≤ 0.001). Time to surgical source control was significantly associated with decreased odds of successful source control (OR = 0.982 [0.971, 0.994], p = 0.003) and increased odds of death (OR = 1.011 [1.001, 1.021]; p = 0.03) in unadjusted analysis, but not when adjusted for confounders (OR = 0.991 [0.978, 1.005] and OR = 1.008 [0.997, 1.02], respectively). Only, among patients with septic shock delay of source control was significantly related to risk-of death (adjusted OR = 1.013 [1.001, 1.026], p = 0.04). CONCLUSIONS Our findings suggest that management of sepsis is time critical both for antimicrobial therapy and source control. Also patients, who are not yet in septic shock, profit from early anti-infective treatment since it can prevent further deterioration. Trial registration ClinicalTrials.gov ( NCT01187134 ). Registered 23 August 2010, NCT01187134.
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Affiliation(s)
- Hendrik Rüddel
- Integrated Research and Treatment Center - Center for Sepsis Control and Care (CSCC), Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.,Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Daniel O Thomas-Rüddel
- Integrated Research and Treatment Center - Center for Sepsis Control and Care (CSCC), Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.,Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Konrad Reinhart
- Department of Anaesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.,Berlin Institute of Health, Campus Virchow-Klinikum, Anna-Louisa-Karsch-Straße 2, 10178, Berlin, Germany
| | - Friedhelm Bach
- Department for Infectious Diseases, Protestant Hospital of Bethel Foundation University Hospital, University of Bielefeld, Bethesdaweg 10, 33617, Bielefeld, Germany
| | - Herwig Gerlach
- Department for Anaesthesia, Intensive Care Medicine and Pain Management, Vivantes - Klinikum Neukoelln, Rudower Strasse 48, 12351, Berlin, Germany
| | - Matthias Lindner
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, 24105, Kiel, Germany
| | - John C Marshall
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, 209 Victoria St, Toronto, ON, M5B 1T8, Canada
| | - Philipp Simon
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Centre, Liebigstraße 20, 04103, Leipzig, Germany
| | - Manfred Weiss
- Klinik Für Anästhesiologie Und Intensivmedizin, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Frank Bloos
- Integrated Research and Treatment Center - Center for Sepsis Control and Care (CSCC), Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.,Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Daniel Schwarzkopf
- Integrated Research and Treatment Center - Center for Sepsis Control and Care (CSCC), Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany. .,Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany. .,Center for Infectious Diseases and Infection Control, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.
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19
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McGee SA, Barnum M, Nesbit RD. The Epidemiology of Necrotizing Fasciitis at a Rural Level 1 Trauma Center During the COVID-19 Pandemic. Am Surg 2022:31348221074251. [PMID: 35128968 PMCID: PMC8819579 DOI: 10.1177/00031348221074251] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction The impact of the COVID-19 pandemic on non‐COVID-19 pathologies has been experienced worldwide. While people appropriately avoided social interactions, many also avoided essential medical care for acute and chronic conditions. This delay in seeking care has been associated with increased morbidity and mortality in several conditions, including life-threatening infections such as necrotizing fasciitis. Methods We retrospectively reviewed the records of patients that presented to the University of Vermont Medical Center for necrotizing fasciitis during the 1-year period following the declaration of a global pandemic on March 11, 2020. We subsequently compared this data with that of the previous 4 years. Results During the period of March 12, 2020 to March 12, 2021, there were 17 cases of newly diagnosed necrotizing fasciitis. Compared with an average per year of 8 cases over the previous 4 years, this represents a 113% percent increase in cases of necrotizing fasciitis during the study period ( P = .071861). Out of the 17 cases, 4 patients died during their admission, producing a case-fatality rate of 23.5%. This represents a statistically significant increase from previous years ( P = .003248), where the average case-fatality rate was 6.3%. Conclusion Our study demonstrates a substantial increase in cases of necrotizing fasciitis following the onset of the coronavirus pandemic. A significant increase in the case-fatality rate was also observed. Given the growing body of literature describing the negative impact of the pandemic on non-COVID-19 morbidity and mortality, our study posits necrotizing fasciitis as one of many affected pathologies. Level of Evidence Level IV. Epidemiological
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Affiliation(s)
- Shayan A. McGee
- Larner College of Medicine at the University of Vermont, Colchester, VT, USA
| | - Michael Barnum
- Larner College of Medicine at the University of Vermont, Colchester, VT, USA
| | - Robert D. Nesbit
- Larner College of Medicine at the University of Vermont, Colchester, VT, USA
- Departments of Plastic and Reconstructive Surgery, University of Vermont Medical Center, Burlington, VT, USA
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20
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Aksak-Wąs BJ, Ripa A, Szakoła P, Horbacka K, Niścigorska-Olsen J, Witak-Jędra M, Zając-Marczewska M, Karasińska-Cieślak M, Kot J, Parczewski M. Septic Shock Induced by Vibrio Vulnificus in Northern Poland, a Case Report. Infect Drug Resist 2021; 14:5027-5033. [PMID: 34880631 PMCID: PMC8645607 DOI: 10.2147/idr.s340991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 10/30/2021] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Vibrio vulnificus infections are a growing problem worldwide. In recent years, infections with this bacteria have been reported in Central Europe, especially in the German Baltic coast but also in France and Italy. Climate warming causes the sea temperature to increase every year, which translates to an increased risk of infections from the Vibrio group. Most of these are mild and present as wound infections, but some patients develop life-threatening sepsis from either ingestion of infected mollusks or wound lesions that develop into generalized infections. Illness may be associated with necrotizing fasciitis and may require several weeks of therapy, often based on a surgical operation, demarcation of necrosis or limb amputation. A case such as the one described in this manuscript has not been previously described in Poland and demonstrates the need for a multidisciplinary approach to infection with Vibrio vulnificus. CASE PRESENTATION A 68-year-old patient was pricked with an unknown object in the side of a lower limb during his stay at the Polish seaside. He developed a life-threatening infection in the form of severe sepsis with multiple organ failure. He required broad-spectrum antibiotic therapy, and after obtaining results for Vibrio vulnificus targeted therapy, a surgical operation with skin lesion decompression and fasciotomy was performed. Finally, hyperbaric chamber therapy was given. The patient's general condition improved, and local changes and his vital parameters stabilized. CONCLUSION Vibrio vulnificus infection may be confused with other causes of skin and subcutaneous tissue infection, although it requires a different approach and different targeted antibiotic therapies. This infection may take the form of a life-threatening disease requiring a multidisciplinary approach.
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Affiliation(s)
- Bogusz Jan Aksak-Wąs
- Department of Infectious, Tropical Diseases and Immune Deficiency, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Agnieszka Ripa
- Department of Infectious, Tropical Diseases and Immune Deficiency, Provincial Hospital, Szczecin, Poland
| | - Paweł Szakoła
- Department of General and Transplant Surgery, Department of Vascular Surgery, Provincial Hospital, Szczecin, Poland
| | - Karolina Horbacka
- Department of General and Transplant Surgery, Department of Vascular Surgery, Provincial Hospital, Szczecin, Poland
| | - Jolanta Niścigorska-Olsen
- Department of Infectious, Tropical Diseases and Immune Deficiency, Provincial Hospital, Szczecin, Poland
| | - Magdalena Witak-Jędra
- Department of Infectious, Tropical Diseases and Immune Deficiency, Provincial Hospital, Szczecin, Poland
| | | | - Malwina Karasińska-Cieślak
- Department of Infectious, Tropical Diseases and Immune Deficiency, Provincial Hospital, Szczecin, Poland
| | - Jacek Kot
- National Center for Hyperbaric Medicine, University Center for Maritime and Tropical Medicine in Gdynia, Medical University of Gdansk, Gdansk, Poland
| | - Miłosz Parczewski
- Department of Infectious, Tropical Diseases and Immune Deficiency, Pomeranian Medical University in Szczecin, Szczecin, Poland
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21
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med 2021; 49:e1063-e1143. [PMID: 34605781 DOI: 10.1097/ccm.0000000000005337] [Citation(s) in RCA: 852] [Impact Index Per Article: 284.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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22
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Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, Machado FR, Mcintyre L, Ostermann M, Prescott HC, Schorr C, Simpson S, Wiersinga WJ, Alshamsi F, Angus DC, Arabi Y, Azevedo L, Beale R, Beilman G, Belley-Cote E, Burry L, Cecconi M, Centofanti J, Coz Yataco A, De Waele J, Dellinger RP, Doi K, Du B, Estenssoro E, Ferrer R, Gomersall C, Hodgson C, Møller MH, Iwashyna T, Jacob S, Kleinpell R, Klompas M, Koh Y, Kumar A, Kwizera A, Lobo S, Masur H, McGloughlin S, Mehta S, Mehta Y, Mer M, Nunnally M, Oczkowski S, Osborn T, Papathanassoglou E, Perner A, Puskarich M, Roberts J, Schweickert W, Seckel M, Sevransky J, Sprung CL, Welte T, Zimmerman J, Levy M. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 2021; 47:1181-1247. [PMID: 34599691 PMCID: PMC8486643 DOI: 10.1007/s00134-021-06506-y] [Citation(s) in RCA: 1394] [Impact Index Per Article: 464.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/05/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Laura Evans
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA.
| | - Andrew Rhodes
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Massimo Antonelli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Flávia R Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, Hospital of São Paulo, São Paulo, Brazil
| | | | | | - Hallie C Prescott
- University of Michigan and VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | | | - Steven Simpson
- University of Kansas Medical Center, Kansas City, KS, USA
| | - W Joost Wiersinga
- ESCMID Study Group for Bloodstream Infections, Endocarditis and Sepsis, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, Emirates University, Al Ain, United Arab Emirates
| | - Derek C Angus
- University of Pittsburgh Critical Care Medicine CRISMA Laboratory, Pittsburgh, PA, USA
| | - Yaseen Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Luciano Azevedo
- School of Medicine, University of Sao Paulo, São Paulo, Brazil
| | | | | | | | - Lisa Burry
- Mount Sinai Hospital & University of Toronto (Leslie Dan Faculty of Pharmacy), Toronto, ON, Canada
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University Pieve Emanuele, Milan, Italy.,Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - John Centofanti
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Angel Coz Yataco
- Lexington Veterans Affairs Medical Center/University of Kentucky College of Medicine, Lexington, KY, USA
| | | | | | - Kent Doi
- The University of Tokyo, Tokyo, Japan
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Beijing, China
| | - Elisa Estenssoro
- Hospital Interzonal de Agudos San Martin de La Plata, Buenos Aires, Argentina
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | | | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Shevin Jacob
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Michael Klompas
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Younsuck Koh
- ASAN Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Anand Kumar
- University of Manitoba, Winnipeg, MB, Canada
| | - Arthur Kwizera
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Suzana Lobo
- Intensive Care Division, Faculdade de Medicina de São José do Rio Preto, São Paulo, Brazil
| | - Henry Masur
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD, USA
| | | | | | - Yatin Mehta
- Medanta the Medicity, Gurugram, Haryana, India
| | - Mervyn Mer
- Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark Nunnally
- New York University School of Medicine, New York, NY, USA
| | - Simon Oczkowski
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Tiffany Osborn
- Washington University School of Medicine, St. Louis, MO, USA
| | | | | | - Michael Puskarich
- University of Minnesota/Hennepin County Medical Center, Minneapolis, MN, USA
| | - Jason Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | | | | | | | - Charles L Sprung
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Tobias Welte
- Medizinische Hochschule Hannover and German Center of Lung Research (DZL), Hannover, Germany
| | - Janice Zimmerman
- World Federation of Intensive and Critical Care, Brussels, Belgium
| | - Mitchell Levy
- Warren Alpert School of Medicine at Brown University, Providence, Rhode Island & Rhode Island Hospital, Providence, RI, USA
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23
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Abstract
PURPOSE OF REVIEW The aim of the article is to present recent epidemiological, microbiological, and clinical data for the surgical, antimicrobial, and adjunctive management of necrotizing soft-tissue infections (NSTI). RECENT FINDINGS NSTI can be caused by a broad variety of organisms. Reports about NSTI caused by multidrug-resistant bacteria are increasing. Owing to the rareness of NSTI, general clinical awareness is low and prompt diagnosis is often delayed. New diagnostic instruments (scoring systems, MRI) have either a low accuracy or are time consuming and cannot guide clinicians reliable currently. The value of adjunctive measures (intravenous immunoglobulin, hyperbaric oxygen therapy) is uncertain as well. Morbidity and mortality in NSTI remain high, ranging from 20 up to over 30%. SUMMARY Early radical surgical debridement and empirical broad-spectrum antimicrobial treatment remain the cornerstones of therapy in NSTI. Further clinical research is necessary to shorten diagnostic pathways and to optimize surgical, antimicrobial, and adjunctive treatment.
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24
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Elnahla A, Attia AS, Toraih E, Guidry C, Akkera M, Schroll R, Killackey M, Nichols R, Kandil E. Prognostic Factors of Mortality in Vibrio vulnificus Sepsis and Soft Tissue Infections: Meta-Analysis. Surg Infect (Larchmt) 2021; 22:928-939. [PMID: 33970025 DOI: 10.1089/sur.2020.243] [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: 11/13/2022] Open
Abstract
Background: Vibrio vulnificus is a rare but life-threatening infection that effects the population near warm coastal areas. This infection could be fulminant and rapidly progress to severe sepsis and necrotizing soft tissue infection. Early diagnosis and treatment are critical to saving patients' lives. With multiple studies reporting discrepancies in prognostic factors and different treatment protocols, we aimed through this meta-analysis to assess these factors and protocols and the impact on the outcome of the infection. Materials and Methods: In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search of PubMed, Embase, and Cochrane Library databases by two independent reviewers was reported. Studies evaluating prognostic factors and treatment outcomes of Vibrio vulnificus infections were included. Comprehensive Meta-Analysis, version 3.0 was used. Results: Two hundred eleven studies were identified. Of those, eight studies met our inclusion criteria. The following factors on presentation were associated with higher mortality rates; concomitant liver disease (odds ratio [OR], 4.38; 95% confidence interval [CI], 2.43-7.87; p < 0.001), renal disease (OR, 3.90; 95% CI, 1.37-11.12; p = 0.011), septic shock (OR, 2.82; 95% CI, 1.84-4.31; p < 0.001), higher Acute Physiology and Chronic Health Evaluation (APACHE) II score (OR, 3.40; 95% CI, 2.26-5.12; p < 0.001), elevated band cells count (OR, 2.61; 95% CI, 1.13-6.0; p = 0.024), hypoalbuminemia (OR, 3.41; 95% CI, 1.58-7.35; p = 0.002), and infection involving multiple limbs (OR, 4.36; 95% CI, 1.72-11.07; p = 0.002). Interestingly, different antibiotic regimens did not have any impact on outcomes, however, delayed surgical intervention after the first 12 or 24 hours was associated with higher mortality rates (OR, 2.64; 95% CI, 1.39-5.0; p = 0.003 and OR, 2.99; 95% CI, 1.54-5.78; p = 0.001, respectively). Conclusion: The presence of liver or renal disease, higher APACHE II scores, septic shock, hypoalbuminemia, or elevated band cell on presentation should alert the physician to the higher risk of mortality. Different antibiotic regimens did not impact the outcomes in these patients and delayed surgical intervention is associated with worsening of mortality.
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Affiliation(s)
| | | | - Eman Toraih
- Tulane University, New Orleans, Louisiana, USA.,Genetics Unit, Department of Histology and Cell Biology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | | | | | | | | | | | - Emad Kandil
- Tulane University, New Orleans, Louisiana, USA
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25
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Berton P, Ghiridlian-Salvarelli T, Winter E. Fasciite nécrosante à Vibrio vulnificus. ANNALES FRANCAISES DE MEDECINE D URGENCE 2021. [DOI: 10.3166/afmu-2020-0297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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26
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MukB Is a Gene Necessary for Rapid Proliferation of Vibrio vulnificus in the Systemic Circulation but Not at the Local Infection Site in the Mouse Wound Infection Model. Microorganisms 2021; 9:microorganisms9050934. [PMID: 33925415 PMCID: PMC8145103 DOI: 10.3390/microorganisms9050934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/20/2021] [Accepted: 04/24/2021] [Indexed: 12/19/2022] Open
Abstract
Vibrio vulnificus causes rapid septicemia in susceptible individuals who have ingested contaminated foods or have open wounds exposed to seawater contaminated with the bacteria. Despite antibiotic therapy and aggressive debridement, mortality from septicemia is high. In this study, we showed that MukB mutation (mukB::Tn) affected the proliferation of V. vulnificus in the systemic circulation but not at the inoculation site in the wound infection model. A comparison of mukB::Tn with WT and a mukB complement strain (mukB::Tn/pmukB) on the bacterial burden in the muscle at the infection site showed that spreading and proliferation of the mukB::Tn strain was similar to those of the other strains. However, the bacterial burden of mukB::Tn in the spleen was reduced compared to that of the WT strain in the wound infection model. In a competition experiment, we found a lower bacterial burden of mukB::Tn in the spleen than that of the WT strain infecting the systemic circulation. Here, we report on a gene required for the rapid proliferation of V. vulnificus only in the systemic circulation and potentially required for its survival. Our finding may provide a novel therapeutic target for V. vulnificus septicemia.
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27
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Miller AS, Boyce K, Box B, Clarke MD, Duff SE, Foley NM, Guy RJ, Massey LH, Ramsay G, Slade DAJ, Stephenson JA, Tozer PJ, Wright D. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery. Colorectal Dis 2021; 23:476-547. [PMID: 33470518 PMCID: PMC9291558 DOI: 10.1111/codi.15503] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/08/2020] [Accepted: 12/12/2020] [Indexed: 12/15/2022]
Abstract
AIM There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland. METHODS Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines. RESULTS All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management. CONCLUSION These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.
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Affiliation(s)
- Andrew S. Miller
- Leicester Royal InfirmaryUniversity Hospitals of Leicester NHS TrustLeicesterUK
| | | | - Benjamin Box
- Northumbria Healthcare Foundation NHS TrustNorth ShieldsUK
| | | | - Sarah E. Duff
- Manchester University NHS Foundation TrustManchesterUK
| | | | | | | | | | | | | | - Phil J. Tozer
- St Mark’s Hospital and Imperial College LondonHarrowUK
| | - Danette Wright
- Western Sydney Local Health DistrictSydneyNew South WalesAustralia
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28
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Provenzano D, Lo Bianco S, Zanghì M, Campione A, Vecchio R, Zanghì G. Fournier's gangrene as a rare complication in patient with uncontrolled type 2 diabetes treated with surgical debridement: A case report and literature review. Int J Surg Case Rep 2021; 79:462-465. [PMID: 33757263 PMCID: PMC7868798 DOI: 10.1016/j.ijscr.2021.01.098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 01/26/2021] [Accepted: 01/26/2021] [Indexed: 12/17/2022] Open
Abstract
Fournier’s gangrene (FG) is a rare disease which usually affects men. It is characterized by progressive necrotizing fasciitis. A 66-year-old man with uncontrolled type 2 diabetes, obesity with BMI 38, chronic kidney failure and chronic heart failure, reported the onset of symptoms about 14 days before his hospitalization, without consulting any doctor due to Covid-19 pandemic. The combination therapy of surgical debridement and antibiotics infusion was effective.
Introduction Fournier’s gangrene is a potentially fatal emergency condition, supported by an infection of perineal and perianal region, characterized by necrotizing fasciitis with a rapid spread to fascial planes. FG, usually due to compromised host, may be sustained by many microbial pathogens. Case report A 66-year-old man, with a history of uncontrolled type 2 diabetes, obesity with BMI 38, chronic kidney failure and chronic heart failure, was admitted to the Emergency Department with a large area of necrosis involving the perineal and perianal regions. Discussion Fournier’s gangrene is favoured by hypertension, obesity, chronic alcoholism, renal and heart failure. Generally, Fournier’s gangrene needs other procedures in addition to wound debridement such as colostomy, cystostomy, or orchiectomy. Conclusion We report a case of FG found as complication in a patient with uncontrolled type 2 diabetes, treated with effective combination therapy with surgical debridement and antibiotics infusion.
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Affiliation(s)
- D Provenzano
- Department of General Surgery and Medical-Surgical Specialties, Policlinico - Vittorio Emanuele Hospital, University of Catania, Italy.
| | - S Lo Bianco
- Department of General Surgery and Medical-Surgical Specialties, Policlinico - Vittorio Emanuele Hospital, University of Catania, Italy
| | - M Zanghì
- Department of General Surgery and Medical-Surgical Specialties, Policlinico - Vittorio Emanuele Hospital, University of Catania, Italy
| | - A Campione
- Department of General Surgery and Medical-Surgical Specialties, Policlinico - Vittorio Emanuele Hospital, University of Catania, Italy
| | - R Vecchio
- Department of General Surgery and Medical-Surgical Specialties, Policlinico - Vittorio Emanuele Hospital, University of Catania, Italy
| | - G Zanghì
- Department of General Surgery and Medical-Surgical Specialties, Policlinico - Vittorio Emanuele Hospital, University of Catania, Italy
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29
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Ling XW, Lin K, Jiang XQ, Wu Q, Liu ZJ, Li S, Zhao S, Lin C. International normalised ratio as an independent predictor of mortality in limb necrotising fasciitis with sepsis. Ann R Coll Surg Engl 2020; 103:35-40. [PMID: 32829649 DOI: 10.1308/rcsann.2020.0189] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Necrotising fasciitis with sepsis is a life threatening disease. The aim of this study was to analyse the association between international normalised ratio (INR) and mortality in sepsis patients with necrotising fasciitis. METHODS A retrospective review was undertaken of 106 patients suffering from necrotising fasciitis with sepsis between November 2007 and December 2016. Data on comorbidities, clinical manifestations, laboratory findings, causative microbiological organisms, APACHE II (Acute Physiology and Chronic Health Evaluation II) score and outcomes were extracted. Logistic regression was carried out to examine the factors affecting mortality. RESULTS Forty patients (37.7%) died. There was no significant difference in the white blood count (WBC) for the survivor and non-survivor groups. Non-survivors had a lower mean oxygenation index (OI) (288.7mmHg vs 329.4mmHg, p=0.032) and platelet count (PC) (139.5 vs 214.8 x 109/l, p=0.028), and a higher mean INR (1.9 vs 1.3, p=0.000), activated partial thromboplastin time (APTT) (54.6 vs 44.2 seconds, p=0.005) and serum creatinine (2.3mg/dl vs 1.4mg/dl, p=0.007). Mortality in patients with INR >1.5 was significantly higher than in those with INR <1.5 when all risk factors (WBC, PC, OI, INR, APTT, creatinine) were considered (odds ratio: 4.414, 95% confidence interval: 1.263-15.428, p=0.020). Even after adjusting for age, sex, bacteraemia, diabetes and hepatic disorders, the data still exhibited elevated mortality for patients with INR >1.5 (odds ratio: 5.600, 95% confidence interval: 1.415-22.166, p=0.014). CONCLUSIONS INR is a significant independent predictor of mortality in sepsis patients diagnosed with necrotising fasciitis.
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Affiliation(s)
- X W Ling
- First Affiliated Hospital of Wenzhou Medical University, China
| | - K Lin
- First Affiliated Hospital of Wenzhou Medical University, China
| | - X Q Jiang
- First Affiliated Hospital of Wenzhou Medical University, China
| | - Q Wu
- First Affiliated Hospital of Wenzhou Medical University, China
| | - Z J Liu
- First Affiliated Hospital of Wenzhou Medical University, China
| | - S Li
- First Affiliated Hospital of Wenzhou Medical University, China
| | - S Zhao
- First Affiliated Hospital of Wenzhou Medical University, China
| | - C Lin
- First Affiliated Hospital of Wenzhou Medical University, China
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30
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May AK, Talisa VB, Wilfret DA, Bulger E, Dankner W, Bernard A, Yende S. Estimating the Impact of Necrotizing Soft Tissue Infections in the United States: Incidence and Re-Admissions. Surg Infect (Larchmt) 2020; 22:509-515. [PMID: 32833599 DOI: 10.1089/sur.2020.099] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: Previous estimates of the incidence of necrotizing soft tissue infections (NSTI) in the United States have substantial limitations and underestimate its occurrence. Improvements in hospital mortality after NSTI have increased the number of survivors at risk for long-term sequelae. This study estimates the incidence of NSTI and the burden of re-admission and associated healthcare spending in patients who survived admission for NSTI. Methods: Index admissions for NSTI were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes combined with either Current Procedural Technology (CPT) or diagnosis-related group codes to increase specificity. Two separate datasets were used to provide primary and secondary estimates of the annual incidence of NSTIs in the United States: the National Inpatient Sample (NIS) for the years 2012-2016 and the Watson Health dataset for 2009-2013, respectively, and extrapolated to estimate the incidence for 2018. The Nationwide Readmissions Database (NRD) from 2013-2015 was used to estimate of the risk for re-admission, cost of re-admissions, and to compare 90-day re-admission rates for NSTI to common medical conditions. Results: National Inpatient Sample and Watson Health datasets demonstrated an increasing annual incidence and estimated 33,600 and 28,500 cases in 2018, respectively. The estimated annual incidences in the United States in 2018 were 10.3 and 8.7 per 100,000 persons, respectively. Risk of 90-day re-admission ranged from 24%-29% over the 3 years, 89% of which were unplanned. Of those re-admitted, 90% had one or more comorbidities, the most common diagnoses associated with re-admission were infection in 65%, acute kidney injury in 22%, and shock in 10%. The median re-admission length of stay was seven days (interquartile range [IQR]: 4-13 days) with a median cost of re-admission of $13,590 (IQR: $7186-$27440). Conclusion: The incidence of NSTI is more common than generally reported. Re-admission within 90 days is common, occurring in more than one in four survivors resulting in high healthcare costs.
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Affiliation(s)
- Addison K May
- Carolinas Medical Center, Atrium Health, Charlotte, North Carolina, USA
| | - Victor B Talisa
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center and Department of Critical Care Medicine, University of Pittsburgh, Pennsylvania, USA
| | | | - Eileen Bulger
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | | | - Andrew Bernard
- Department of Surgery, University of Kentucky, Lexington, Kentucky, USA
| | - Sachin Yende
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center and Department of Critical Care Medicine, University of Pittsburgh, Pennsylvania, USA
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Eguia E, Vivirito V, Cobb AN, Janjua H, Cheung M, Kuo PC. Predictors of Death in Necrotizing Skin and Soft Tissue Infection. World J Surg 2020; 43:2734-2739. [PMID: 31312952 DOI: 10.1007/s00268-019-05087-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Necrotizing skin and soft tissue infection (NSTI) is a surgical emergency that is associated with high morbidity and mortality. This study aims to identify predictors of in-hospital death following a NSTI. MATERIAL AND METHODS We queried the Healthcare Cost and Utilization Project (HCUP) State Inpatient Database (SID) for California between 2006 and 2011. We used conventional and advanced statistical methods to identify predictors of in-hospital mortality, which included: logistic regression, stepwise logistic regression, decision trees, and K-nearest neighbor (KNN) algorithms. RESULTS A total of 10,158 patients had a NSTI. The full and stepwise logistic regression models had a ROC AUC in the validation dataset of 0.83 (95% CI [0.80, 0.86]) and 0.81 (95% CI [0.78, 0.83]), respectively. The KNN and decision tree model had a ROC AUC of 0.84 (95% CI [0.81, 0.85]) and 0.69 (95% CI [0.65, 0.72]), respectively. The top predictors of in-hospital mortality in the KNN and stepwise logistic model included: (1) the presence of in-hospital coagulopathy, (2) having an infectious or parasitic diagnoses, (3) electrolyte disturbances, (4) advanced age, and (5) the total number of beds in a hospital. CONCLUSION Patients with a NSTI have high rates of in-hospital mortality. This study highlights the important factors in managing patients with a NSTI which include: correcting coagulopathy and electrolyte imbalances, treating underlying infectious processes, providing adequate resources to the elderly population, and managing patients in high-volume centers.
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Affiliation(s)
- Emanuel Eguia
- Department of Surgery, Burn Shock Trauma Research Institute, Loyola University Medical Center, 2160 S. 1st Avenue, Maywood, IL, 60153, USA.
| | - Vincent Vivirito
- Department of Surgery, Burn Shock Trauma Research Institute, Loyola University Medical Center, 2160 S. 1st Avenue, Maywood, IL, 60153, USA
| | - Adrienne N Cobb
- Department of Surgery, Burn Shock Trauma Research Institute, Loyola University Medical Center, 2160 S. 1st Avenue, Maywood, IL, 60153, USA
| | - Haroon Janjua
- Department of Surgery, University of South Florida, Tampa, FL, USA
| | - Matthew Cheung
- Department of Surgery, Burn Shock Trauma Research Institute, Loyola University Medical Center, 2160 S. 1st Avenue, Maywood, IL, 60153, USA
| | - Paul C Kuo
- Department of Surgery, University of South Florida, Tampa, FL, USA
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Escobar MF, Echavarría MP, Zambrano MA, Ramos I, Kusanovic JP. Maternal sepsis. Am J Obstet Gynecol MFM 2020; 2:100149. [PMID: 33345880 DOI: 10.1016/j.ajogmf.2020.100149] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 05/16/2020] [Accepted: 05/23/2020] [Indexed: 12/11/2022]
Abstract
Maternal sepsis is "a life-threatening condition defined as an organ dysfunction caused by an infection during pregnancy, delivery, puerperium, or after an abortion," with the potential to save millions of lives if a proper approximation is made. Undetected or poorly managed maternal infections can lead to sepsis, death, or disability for the mother, and an increased likelihood of early neonatal infection and other adverse outcomes. Physiological, immunologic, and mechanical changes that occur in pregnancy make pregnant women more susceptible to infections than nonpregnant women and may obscure signs and symptoms of infection and sepsis, resulting in a delay in the recognition and treatment of sepsis. Prioritization of the creation and validation of tools that allow the development of clear and standardized diagnostic criteria of maternal sepsis and septic shock, according to the changes inherent to pregnancy, correspond to highly effective strategies to reduce the impact of these conditions on maternal health worldwide. After an adequate diagnostic approach, the next goal is achieving stabilization, trying to stop the progression from sepsis to septic shock, and improving tissue perfusion to limit cell dysfunction. Management protocol implementation during the first hour of treatment will be the most important determinant for the reduction of maternal mortality associated with sepsis and septic shock.
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Affiliation(s)
- María Fernanda Escobar
- High Complexity Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia.
| | - María Paula Echavarría
- High Complexity Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia
| | - María Andrea Zambrano
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia; Faculty of Health Sciences, Universidad Icesi, Cali, Colombia
| | - Isabella Ramos
- Faculty of Health Sciences, Universidad Icesi, Cali, Colombia
| | - Juan Pedro Kusanovic
- Center for Research and Innovation in Maternal-Fetal Medicine (CIMAF), Department of Obstetrics and Gynecology, Hospital Sótero del Río, Santiago, Chile; Division of Obstetrics and Gynecology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
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Stephen AH, Montoya RL, Aluisio AR. Sepsis and Septic Shock in Low- and Middle-Income Countries. Surg Infect (Larchmt) 2020; 21:571-578. [PMID: 32401160 DOI: 10.1089/sur.2020.047] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: The greatest burden of sepsis- and septic shock-related morbidity and mortality is in low- and middle-income countries (LMICs). Accurate tracking of incidence and outcomes of patients in LMICs with sepsis has been limited by changing definitions, lack of diagnosis coding and health records, and deficits in personnel. Improving sepsis care in LMICs requires studying outcomes prospectively so that setting appropriate definitions, scoring systems, and treatment guidelines can be created. Our goal is to review the burden of sepsis and septic shock in LMICs, the evolution and applicability of definitions to LMICs, and management. Methods: The literature was searched through PubMed using a Boolean approach and the following terms: sepsis, septic shock, low- and middle-income countries. Articles were read by the authors and relevant information was abstracted and included with citations to create a narrative review. Results: The estimated worldwide incidence of sepsis admissions is 31.5 million cases per year leading to 5.3 million deaths. The World Health Organization (WHO) has urged LMICs to establish sepsis prevalence and outcomes. Most authors and societies involved in creating sepsis and septic shock definitions have been from high-income countries (HICs). Applicability of sepsis definitions in LMICs is uncertain. Quick-Sequential Organ Failure Assessment (qSOFA) and universal vital assessment (UVA) are useful screening and triage tools in LMICs because they can be done at the bedside. The key tenets of management of sepsis and septic shock in LMICs include early fluid resuscitation and antibiotic therapy coupled with source control when there is a surgical process. Surgical causes of sepsis should be identified rapidly. Scaling up surgical capacity in LMICs is an important step to improve source control of sepsis. Conclusion: Management guidelines specific to LMICs for sepsis and septic shock need to be refined further and studied prospectively. Improving access to surgery will improve outcomes of surgical cases of sepsis.
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Affiliation(s)
- Andrew H Stephen
- Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Rachel L Montoya
- Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Adam R Aluisio
- Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Nawijn F, Smeeing DPJ, Houwert RM, Leenen LPH, Hietbrink F. Time is of the essence when treating necrotizing soft tissue infections: a systematic review and meta-analysis. World J Emerg Surg 2020; 15:4. [PMID: 31921330 PMCID: PMC6950871 DOI: 10.1186/s13017-019-0286-6] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 12/24/2019] [Indexed: 12/18/2022] Open
Abstract
Background Although the phrase “time is fascia” is well acknowledged in the case of necrotizing soft tissue infections (NSTIs), solid evidence is lacking. The aim of this study is to review the current literature concerning the timing of surgery in relation to mortality and amputation in patients with NSTIs. Methods A systematic search in PubMed/MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Controlled Register of Trials (CENTRAL) was performed. The primary outcomes were mortality and amputation. These outcomes were related to the following time-related variables: (1) time from onset symptoms to presentation; (2) time from onset symptoms to surgery; (3) time from presentation to surgery; (4) duration of the initial surgical procedure. For the meta-analysis, the effects were estimated using random-effects meta-analysis models. Result A total of 109 studies, with combined 6051 NSTI patients, were included. Of these 6051 NSTI patients, 1277 patients died (21.1%). A total of 33 studies, with combined 2123 NSTI patients, were included for quantitative analysis. Mortality was significantly lower for patients with surgery within 6 h after presentation compared to when treatment was delayed more than 6 h (OR 0.43; 95% CI 0.26–0.70; 10 studies included). Surgical treatment within 6 h resulted in a 19% mortality rate compared to 32% when surgical treatment was delayed over 6 h. Also, surgery within 12 h reduced the mortality compared to surgery after 12 h from presentation (OR 0.41; 95% CI 0.27–0.61; 16 studies included). Patient delay (time from onset of symptoms to presentation or surgery) did not significantly affect the mortality in this study. None of the time-related variables assessed significantly reduced the amputation rate. Three studies reported on the duration of the first surgery. They reported a mean operating time of 78, 81, and 102 min with associated mortality rates of 4, 11.4, and 60%, respectively. Conclusion Average mortality rates reported remained constant (around 20%) over the past 20 years. Early surgical debridement lowers the mortality rate for NSTI with almost 50%. Thus, a sense of urgency is essential in the treatment of NSTI.
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Affiliation(s)
- Femke Nawijn
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Diederik P J Smeeing
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Roderick M Houwert
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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Annoni F, Grimaldi D, Taccone FS. Individualized antibiotic therapy in the treatment of severe infections. Expert Rev Anti Infect Ther 2019; 18:27-35. [PMID: 31755789 DOI: 10.1080/14787210.2020.1696192] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: Sepsis is a frequent and life-threatening clinical entity and antibiotic treatment is one of the most important interventions, together with source control and hemodynamic resuscitation. Guidelines have highlighted the importance of an early (i.e. within 1-3 h from recognition) and appropriate (i.e. the pathogen is sensitive in vitro to the administered drug) antimicrobial therapy in this setting.Areas covered: Antibiotic therapy should be individualized according to several issues, including early pathogen identification, optimal drug regimens based on pharmacokinetic/pharmacodynamics (PK/PD) and adequate duration using both clinical and biological biomarkers. This narrative review has considered the most relevant studies evaluating these issues.Expert opinion: Rapid identification pathogen resistance profile (i.e. the minimal inhibitory concentration for the available antimicrobials), real-time measurement of drug concentrations with regimen adjustment on MIC and daily measurement of procalcitonin to guide duration of therapy are the main issues to individualize the antibiotic management in critically ill patients.
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Affiliation(s)
- Filippo Annoni
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - David Grimaldi
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Hepatic disease and the risk of mortality of Vibrio vulnificus necrotizing skin and soft tissue infections: A systematic review and meta-analysis. PLoS One 2019; 14:e0223513. [PMID: 31652263 PMCID: PMC6814278 DOI: 10.1371/journal.pone.0223513] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 09/22/2019] [Indexed: 12/14/2022] Open
Abstract
Background Vibrio vulnificus necrotizing skin and soft tissue infections (VNSSTIs) are associated with a high mortality rate that varies remarkably with host susceptibility. Hepatic disease (HD) is considered the key risk factor for high VNSSTIs incidence and mortality; however, there is limited evidence in the literature to support this observation. Methodology We examined all reported cases of VNSSTIs and associated mortality rates between 1966 and mid-2018. The PubMed, Medline and Cochrane Library databases were systematically searched for observational studies on patients with VNSSTIs. Twelve studies with 1157 total patients with VNSSTIs were included in the analysis. From the pooled dataset, nearly half (46.8%) of the patients with VNSSTIs had HD. The mortality rate in HD patients with VNSSTIs was 53.9% (n = 292/542), which was considerably higher than the mortality rate of 16.1% (n = 99/615) in non-HD patients. Patients with HD contracted VNSSTIs were found to be two or more times (RR = 2.61, 95% CI = 2.14–3.19) as likely to die compared with those without HD. Besides, liver cirrhosis (LC), the end-stage HD, was confirmed to be a significant risk factor, with risk ratios of 1.84 (95% CI 1.21–2.79) and 2.00 (95% CI 1.41–2.85) when compared to non-LC and non-HD, respectively. Conclusions HD with or without LC can be associated with infections and complications from V. vulnificus. Clinicians should aggressively approach care and management of acutely and/or critically ill patients with VNSSTIs.
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Kim H, Chung SP, Choi SH, Kang GH, Shin TG, Kim K, Park YS, Han KS, Choi HS, Suh GJ, Kim WY, Lim TH, Ko BS. Impact of timing to source control in patients with septic shock: A prospective multi-center observational study. J Crit Care 2019; 53:176-182. [DOI: 10.1016/j.jcrc.2019.06.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 04/26/2019] [Accepted: 06/14/2019] [Indexed: 12/17/2022]
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Guo K, Gong W, Zheng T, Hong Z, Wu X, Ren H, Wang G, Gu G, Nthumba P, Ren J, Li J. Clinical parameters and outcomes of necrotizing soft tissue infections secondary to gastrointestinal fistulas. BMC Infect Dis 2019; 19:597. [PMID: 31288746 PMCID: PMC6617561 DOI: 10.1186/s12879-019-4248-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 07/01/2019] [Indexed: 12/14/2022] Open
Abstract
Background Necrotizing soft tissue infections (NSTIs) is severe surgical infections which can occur following trauma or abdominal surgery. NSTIs secondary to gastrointestinal (GI) fistula is a rare but severe complication. Methods A retrospective cohort study was performed on all subjects presenting with GI fistulas associated NSTIs were included. Clinical characteristics, microbiological profile, operations performed, and outcomes of patients were analyzed. Results Between 2014 and 2017, 39 patients were finally enrolled. The mean age were 46.9 years and male were the dominant. For the etiology of fistula, 25 (64.1%) of the patients was due to trauma. Overall, in-hospital death occurred in 15 (38.5%) patients. Microbiologic findings were obtained from 31 patients and Klebsiella pneumoniae was the most common species (41.0%). Eight patients were treated with an open abdomen; negative pressure wound therapy was used in 33 patients and only 2 patients received hyperbaric oxygen therapy. Younger age and delayed abdominal wall reconstruction repair were more common in trauma than in non-trauma. Non-survivors had higher APACHE II score, less source control< 48 h and lower platelet count on admission than survivors. Multiple organ dysfunction syndrome, multidrug-resistant organisms and source control failure were the main cause of in-hospital mortality. Conclusions Trauma is the main cause of GI fistulas associated NSTIs. Sepsis continues to be the most important factor related to mortality. Our data may assist providing enlightenment for quality improvement in these special populations.
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Affiliation(s)
- Kun Guo
- Department of General Surgery, Medical School of Nanjing University, Jinling Hospital, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
| | - Wenbin Gong
- Department of General Surgery, School of Medicine, Southeast University, Jinling Hospital, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
| | - Tao Zheng
- Department of General Surgery, Medical School of Nanjing University, Jinling Hospital, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
| | - Zhiwu Hong
- Department of General Surgery, Medical School of Nanjing University, Jinling Hospital, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
| | - Xiuwen Wu
- Department of General Surgery, Medical School of Nanjing University, Jinling Hospital, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
| | - Huajian Ren
- Department of General Surgery, Medical School of Nanjing University, Jinling Hospital, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
| | - Gefei Wang
- Department of General Surgery, Medical School of Nanjing University, Jinling Hospital, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
| | - Guosheng Gu
- Department of General Surgery, Medical School of Nanjing University, Jinling Hospital, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
| | | | - Jianan Ren
- Department of General Surgery, Medical School of Nanjing University, Jinling Hospital, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China.
| | - Jieshou Li
- Department of General Surgery, Medical School of Nanjing University, Jinling Hospital, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu Province, People's Republic of China
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Peetermans M, de Prost N, Eckmann C, Norrby-Teglund A, Skrede S, De Waele JJ. Necrotizing skin and soft-tissue infections in the intensive care unit. Clin Microbiol Infect 2019; 26:8-17. [PMID: 31284035 DOI: 10.1016/j.cmi.2019.06.031] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 06/19/2019] [Accepted: 06/22/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Necrotizing skin and soft-tissue infections (NSTI) are rare but potentially life-threatening and disabling infections that often require intensive care unit admission. OBJECTIVES To review all aspects of care for a critically ill individual with NSTI. SOURCES Literature search using Medline and Cochrane library, multidisciplinary panel of experts. CONTENT The initial presentation of a patient with NSTI can be misleading, as features of severe systemic toxicity can obscure sometimes less impressive skin findings. The infection can spread rapidly, and delayed surgery worsens prognosis, hence there is a limited role for additional imaging in the critically ill patient. Also, the utility of clinical scores is contested. Prompt surgery with aggressive debridement of necrotic tissue is required for source control and allows for microbiological sampling. Also, prompt administration of broad-spectrum antimicrobial therapy is warranted, with the addition of clindamycin for its effect on toxin production, both in empirical therapy, and in targeted therapy for monomicrobial group A streptococcal and clostridial NSTI. The role of immunoglobulins and hyperbaric oxygen therapy remains controversial. IMPLICATIONS Close collaboration between intensive care, surgery, microbiology and infectious diseases, and centralization of care is fundamental in the approach to the severely ill patient with NSTI. As many aspects of management of these rare infections are supported by low-quality data only, multicentre trials are urgently needed.
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Affiliation(s)
- M Peetermans
- Department of Critical Care, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - N de Prost
- Service de Réanimation Médicale, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris, Créteil, France; Groupe de Recherche Clinique CARMAS, Université Paris-Est Créteil, IMRB, Créteil, France
| | - C Eckmann
- Department of General, Visceral and Thoracic Surgery, Klinikum Peine, Academic Hospital of Medical University Hannover, Germany
| | - A Norrby-Teglund
- Centre for Infectious Medicine, Karolinska Institute, Karolinska University Hospital, Huddinge, Sweden
| | - S Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway
| | - J J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium.
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Kim SE, Shin SU, Oh TH, Kim UJ, Darboe KS, Kang SJ, Jang HC, Jung SI, Shin HY, Park KH. Outcomes of Third-Generation Cephalosporin Plus Ciprofloxacin or Doxycycline Therapy in Patients with Vibrio vulnificus Septicemia: A Propensity Score-Matched Analysis. PLoS Negl Trop Dis 2019; 13:e0007478. [PMID: 31188821 PMCID: PMC6590838 DOI: 10.1371/journal.pntd.0007478] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 06/24/2019] [Accepted: 05/20/2019] [Indexed: 12/14/2022] Open
Abstract
Background Combination therapy with a third-generation cephalosporin (TGC) and a tetracycline analogue is recommended for Vibrio vulnificus infection. The combination of a TGC and ciprofloxacin has synergistic in vitro bactericidal activity against V. vulnificus. No clinical study has compared the standard regimen with TGC plus ciprofloxacin therapy for V. vulnificus infection. Methods Patients with a confirmed V. vulnificus infection at two medical centers in Korea from 1991 to 2016 were enrolled in this study. The patients were grouped according to the type of antibiotic administered. A retrospective propensity-score-matched case-control study of patients treated with TGC plus doxycycline or TGC plus ciprofloxacin was performed. The clinical characteristics and outcomes of the patients were analyzed. Results A total of 218 patients were confirmed to have V. vulnificus septicemia during the study, and the 30-day survival rate was 39% (85/218). The patients were classified into the following six treatment groups: TGC monotherapy (n = 82), TGC plus doxycycline therapy (n = 42), TGC plus ciprofloxacin therapy (n = 39), ciprofloxacin monotherapy (n = 14), other β-lactam monotherapy (n = 10), and other (n = 31). The survival rates of these groups were as follows: TGC monotherapy (35%), TGC plus doxycycline (38%), TGC plus ciprofloxacin (54%), ciprofloxacin monotherapy (29%), other β-lactam (20%), and other (39%). The 30-day survival rate showed no significant difference between the TGC plus doxycycline and TGC plus ciprofloxacin groups (log-rank test, P = 0.18). Among the 81 patients treated with TGC plus doxycycline or TGC plus ciprofloxacin, 12 per treatment group were selected by propensity-score matching. There was no significant difference in the baseline characteristics or the frequency of fasciotomy between the two groups. The 30-day survival rate showed no significant difference between the TGC plus doxycycline (50%) and TGC plus ciprofloxacin (67%) groups (log-rank test, P = 0.46). Conclusion Our data suggest that the outcome of TGC plus ciprofloxacin therapy was comparable to that of TGC plus doxycycline therapy in patients with V. vulnificus septicemia. The combination of a third-generation cephalosporin (TGC) and ciprofloxacin has synergy in vitro bactericidal activity against V. vulnificus. No clinical study has compared the standard regimen with TGC plus ciprofloxacin therapy for V. vulnificus infection. A total of 218 patients were enrolled who are confirmed to have V. vulnificus septicemia in two medical centers in Korea from 1991 to 2016. The 30-day survival rate was 39% (85/218) for all patients, 38% (16/42) for TGC plus doxycycline and 54% (21/39) for TGC plus ciprofloxacin (log rank test, P = 0.18). A propensity score-matched analysis was performed and 12 per treatment groups were selected. The 30-day survival rate showed no significant difference between the TGC plus doxycycline (50%, 6/12) and TGC plus ciprofloxacin (67%, 4/12) groups (log-rank test, P = 0.46). The outcome of TGC plus ciprofloxacin therapy was comparable to that of TGC plus doxycycline therapy in patients with V. vulnificus septicemia.
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Affiliation(s)
- Seong Eun Kim
- Department of Infectious Diseases, Chonnam National University Hospital, Gwang-ju, Republic of Korea
| | - Sung Un Shin
- Department of Infectious Diseases, Chonnam National University Hospital, Gwang-ju, Republic of Korea
| | - Tae Hoon Oh
- Department of Infectious Diseases, Chonnam National University Hospital, Gwang-ju, Republic of Korea
| | - Uh Jin Kim
- Department of Infectious Diseases, Chonnam National University Hospital, Gwang-ju, Republic of Korea
| | - Kalifa Sanneh Darboe
- Department of Biomedical Science, Chonnam National University Medical School, Gwang-ju, Republic of Korea
| | - Seung-Ji Kang
- Department of Infectious Diseases, Chonnam National University Hospital, Gwang-ju, Republic of Korea
- Department of Infectious Diseases, Chonnam National University Medical School, Gwang-ju, Republic of Korea
| | - Hee-Chang Jang
- Department of Infectious Diseases, Chonnam National University Hospital, Gwang-ju, Republic of Korea
- Department of Infectious Diseases, Chonnam National University Medical School, Gwang-ju, Republic of Korea
| | - Sook-In Jung
- Department of Infectious Diseases, Chonnam National University Hospital, Gwang-ju, Republic of Korea
- Department of Infectious Diseases, Chonnam National University Medical School, Gwang-ju, Republic of Korea
| | - Hee-Young Shin
- Department of Biomedical Science, Chonnam National University Medical School, Gwang-ju, Republic of Korea
- Department of Infectious Diseases, Chonnam National University Medical School, Gwang-ju, Republic of Korea
| | - Kyung-Hwa Park
- Department of Infectious Diseases, Chonnam National University Hospital, Gwang-ju, Republic of Korea
- Department of Infectious Diseases, Chonnam National University Medical School, Gwang-ju, Republic of Korea
- * E-mail:
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Abstract
Objective: Sepsis is a deadly infection that causes injury to tissues and organs. Infection and anti-infective treatment are the eternal themes of sepsis. The successful control of infection is a key factor of resuscitation for sepsis and septic shock. This review examines evidence for the treatment of sepsis. This evidence is combined with clinical experiments to reveal the rules and a standard flowchart of anti-infection therapy for sepsis. Data Sources: We retrieved information from the PubMed database up to October 2018 using various search terms and their combinations, including sepsis, septic shock, infection, antibiotics, and anti-infection. Study Selection: We included data from peer-reviewed journals printed in English on the relationships between infections and antibiotics. Results: By combining the literature review and clinical experience, we propose a 6Rs rule for sepsis and septic shock management: right patients, right time, right target, right antibiotics, right dose, and right source control. This rule encompasses rational decisions regarding the timing of treatment, the identification of the correct pathogen, the selection of appropriate antibiotics, the formulation of a scientifically based antibiotic dosage regimen, and the adequate control of infectious foci. Conclusions: This review highlights how to recognize and treat sepsis and septic shock and provides rules and a standard flowchart for anti-infection therapy for sepsis and septic shock for use in the clinical setting.
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Essentials in the management of necrotizing soft-tissue infections. Infection 2019; 47:677-679. [DOI: 10.1007/s15010-019-01316-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 04/30/2019] [Indexed: 12/17/2022]
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Optimal timing of initial debridement for necrotizing soft tissue infection: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2019; 85:208-214. [PMID: 29485428 DOI: 10.1097/ta.0000000000001857] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Necrotizing soft tissue infections (NSTI) are rare, life-threatening, soft-tissue infections characterized by rapidly spreading inflammation and necrosis of the skin, subcutaneous fat, and fascia. While it is widely accepted that delay in surgical debridement contributes to increased mortality, there are currently no practice management guidelines regarding the optimal timing of surgical management of this condition. Although debridement within 24 hours of diagnosis is generally recommended, the time ranges from 3 hours to 36 hours in the existing literature. Therefore, the objective of this article is to provide evidence-based recommendations for the optimal timing of surgical management of NSTI. METHODS The MEDLINE database using PubMed was searched to identify English language articles published from January 1990 to September 2015 regarding adult and pediatric patients with NSTIs. A systematic review of the literature was performed, and the Grading of Recommendations Assessment, Development and Evaluation framework were used. A single population [P], intervention [I], comparator [C], and outcome [O] (PICO) question was applied: In patients with NSTI (P), should early (<12 hours) initial debridement (I) versus late (≥12 hours) initial debridement (C) be performed to decrease mortality (O)? RESULTS Two hundred eighty-seven articles were identified. Of these, 42 papers underwent full text review and 6 were selected for guideline construction. A total of 341 patients underwent debridement for NSTI. Of these, 143 patients were managed with early versus 198 with late operative debridement. Across all studies, there was an overall mortality rate of 14% in the early group versus 25.8% in the late group. CONCLUSION For NSTIs, we recommend early operative debridement within 12 hours of suspected diagnosis. Institutional and regional systems should be optimized to facilitate prompt surgical evaluation and debridement. LEVEL OF EVIDENCE Systematic review/meta-analysis, level IV.
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Lin TY, Cheng IH, Ou CH, Tsai YS, Tong YC, Cheng HL, Yang WH, Lin YM, Cheng YS. Incorporating Simplified Fournier's Gangrene Severity Index with early surgical intervention can maximize survival in high-risk Fournier's gangrene patients. Int J Urol 2019; 26:737-743. [PMID: 31001902 DOI: 10.1111/iju.13989] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 03/25/2019] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To determine the optimal surgical timing in high-risk patients with Fournier's gangrene by the Simplified Fournier's Gangrene Severity Index. METHODS From 1989 to 2018, 118 male patients diagnosed with Fournier's gangrene with complete medical records were retrospectively reviewed. Patients' demographics, laboratory parameters at initial diagnosis, Fournier's Gangrene Severity Index and Simplified Fournier's Gangrene Severity Index, and the time interval from emergency room arrival to surgical intervention were collected. The Fournier's gangrene patients were categorized into low-risk (Simplified Fournier's Gangrene Severity Index ≤2) and high-risk groups (Simplified Fournier's Gangrene Severity Index >2). Differences between the variables within the two groups were analyzed. The optimal surgical timing was analyzed with the receiver operating characteristic curve in high-risk Fournier's gangrene patients. RESULTS The overall mortality of 118 Fournier's gangrene patients was 14.4%. After risk stratification with the Simplified Fournier's Gangrene Severity Index scoring system, the mortality of low-risk and high-risk Fournier's gangrene patients was 1.3% and 41.0%, respectively. In the high-risk group, the time interval from emergency room arrival to surgical intervention was the only variable with a significant difference between survivors and non-survivors (P = 0.039). The optimal surgical timing was determined at 14.35 h, which allowed the highest sensitivity (0.688) and specificity (0.762) to affect mortality. The mortality was significantly lower in high-risk Fournier's gangrene patients with early surgical intervention compared with late intervention (23.8% vs 68.8%, P = 0.007). CONCLUSIONS The Simplified Fournier's Gangrene Severity Index is a quick and reliable screening tool for first-line physicians to identify high-risk patients with Fournier's gangrene (Simplified Fournier's Gangrene Severity Index >2) who have poor survival outcomes. We recommended early surgical intervention within 14.35 h to maximize the survival of high-risk Fournier's gangrene patients.
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Affiliation(s)
- Tsung-Yen Lin
- Department of Urology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - I-Hung Cheng
- Division of Urology, Department of Surgery, National Cheng Kung University Hospital, Dou-Liou Branch, College of Medicine, National Cheng Kung University, Yunlin, Taiwan
| | - Chien-Hui Ou
- Department of Urology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yuh-Shyan Tsai
- Department of Urology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yat-Ching Tong
- Department of Urology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hong-Lin Cheng
- Department of Urology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wen-Horng Yang
- Department of Urology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yung-Ming Lin
- Department of Urology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Sheng Cheng
- Department of Urology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Wong RM, Chau LTC, Mak MCK, Tse WL, Ho PC. Necrotizing fasciitis induced by Vibrio vulnificus in patients without marine contact in Hong Kong. J Orthop Translat 2019; 19:151-154. [PMID: 31844623 PMCID: PMC6896480 DOI: 10.1016/j.jot.2019.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/30/2019] [Accepted: 03/08/2019] [Indexed: 12/17/2022] Open
Abstract
Necrotizing fasciitis caused by Vibrio species is a life-threatening soft tissue infection with rapid progression and high mortality. The classic history of Vibrio species–induced necrotizing fasciitis is the infection of wounds by direct invasion or contact with contaminated seawater or raw seafood, especially in immunocompromised patients. We present two cases of Vibrio vulnificus necrotizing fasciitis in the upper limb without any wounds or seawater contact and with good past medical history. Both underwent timely surgical debridement and resulted with good functional outcome. Although rare, as clinicians, we need to have a high index of suspicion for the possibility of V. vulnificus necrotizing fasciitis despite no risk factors and give timely and appropriate treatment and, more importantly, patient survival.
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Affiliation(s)
- Ronald M.Y. Wong
- Corresponding author. Department of Orthopaedics and Traumatology, 5/F Lui Che Woo Clinical Sciences Building, Prince of Wales Hospital, N.T. Shatin, Hong Kong.
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Validation of the American Association for the Surgery of Trauma emergency general surgery grade for skin and soft tissue infection. J Trauma Acute Care Surg 2019; 84:939-945. [PMID: 29794690 DOI: 10.1097/ta.0000000000001860] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Skin and soft tissue infections (SSTIs) present with variable severity. The American Association for the Surgery of Trauma (AAST) developed an emergency general surgery (EGS) grading system for several diseases. We aimed to determine whether the AAST EGS grade corresponds with key clinical outcomes. METHODS Single-institution retrospective review of patients (≥18 years) admitted with SSTI during 2012 to 2016 was performed. Patients with surgical site infections or younger than 18 years were excluded. Laboratory Risk Indicator for Necrotizing Fasciitis score and AAST EGS grade were assigned. The primary outcome was association of AAST EGS grade with complication development, duration of stay, and interventions. Secondary predictors of severity included tissue cultures, cross-sectional imaging, and duration of inpatient antibiotic therapy. Summary and univariate analyses were performed. RESULTS A total of 223 patients were included (mean ± SD age of 55.1 ± 17.0 years, 55% male). The majority of patients received cross sectional imaging (169, 76%) or an operative procedure (155, 70%). Skin and soft tissue infection tissue culture results included no growth (51, 24.5%), monomicrobial (83, 39.9%), and polymicrobial (74, 35.6%). Increased AAST EGS grade was associated with operative interventions, intensive care unit utilization, complication severity (Clavien-Dindo index), duration of hospital stay, inpatient antibiotic therapy, mortality, and hospital readmission. CONCLUSION The AAST EGS grade for SSTI demonstrates the ability to correspond with several important outcomes. Prospective multi-institutional study is required to determine its broad generalizability in several populations. LEVEL OF EVIDENCE Prognostic, level IV.
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Li X, Zhou Y, Jiang Q, Yang H, Pi D, Liu X, Gao X, Chen N, Zhang X. Virulence properties of Vibrio vulnificus isolated from diseased zoea of freshness shrimp Macrobrachium rosenbergii. Microb Pathog 2019; 127:166-171. [DOI: 10.1016/j.micpath.2018.12.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Revised: 12/03/2018] [Accepted: 12/03/2018] [Indexed: 12/17/2022]
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Timsit JF, Bassetti M, Cremer O, Daikos G, de Waele J, Kallil A, Kipnis E, Kollef M, Laupland K, Paiva JA, Rodríguez-Baño J, Ruppé É, Salluh J, Taccone FS, Weiss E, Barbier F. Rationalizing antimicrobial therapy in the ICU: a narrative review. Intensive Care Med 2019; 45:172-189. [PMID: 30659311 DOI: 10.1007/s00134-019-05520-5] [Citation(s) in RCA: 138] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 01/04/2019] [Indexed: 12/13/2022]
Abstract
The massive consumption of antibiotics in the ICU is responsible for substantial ecological side effects that promote the dissemination of multidrug-resistant bacteria (MDRB) in this environment. Strikingly, up to half of ICU patients receiving empirical antibiotic therapy have no definitively confirmed infection, while de-escalation and shortened treatment duration are insufficiently considered in those with documented sepsis, highlighting the potential benefit of implementing antibiotic stewardship programs (ASP) and other quality improvement initiatives. The objective of this narrative review is to summarize the available evidence, emerging options, and unsolved controversies for the optimization of antibiotic therapy in the ICU. Published data notably support the need for better identification of patients at risk of MDRB infection, more accurate diagnostic tools enabling a rule-in/rule-out approach for bacterial sepsis, an individualized reasoning for the selection of single-drug or combination empirical regimen, the use of adequate dosing and administration schemes to ensure the attainment of pharmacokinetics/pharmacodynamics targets, concomitant source control when appropriate, and a systematic reappraisal of initial therapy in an attempt to minimize collateral damage on commensal ecosystems through de-escalation and treatment-shortening whenever conceivable. This narrative review also aims at compiling arguments for the elaboration of actionable ASP in the ICU, including improved patient outcomes and a reduction in antibiotic-related selection pressure that may help to control the dissemination of MDRB in this healthcare setting.
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Affiliation(s)
- Jean-François Timsit
- Medical and Infectious Diseases ICU, APHP, Bichat-Claude Bernard Hospital, 46 Rue Henri-Huchard, 75877, Paris Cedex 18, France.
- INSERM, IAME, UMR 1137, Paris-Diderot Sorbonne-Paris Cité University, Paris, France.
| | - Matteo Bassetti
- Infectious Diseases Division, Department of Medicine, University of Udine and Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Olaf Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - George Daikos
- Scool of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Jan de Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Andre Kallil
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Eric Kipnis
- Surgical Critical Care Unit, Department of Anesthesiology, Critical Care and Perioperative Medicine, CHU Lille, Lille, France
| | - Marin Kollef
- Critical Care Research, Washington University School of Medicine and Respiratory Care Services, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Kevin Laupland
- Department of Medicine, Royal Inland Hospital, Kamloops, Canada
| | - Jose-Artur Paiva
- Intensive Care Medicine Department, Centro Hospitalar São João and Faculty of Medicine, University of Porto, Porto, Portugal
| | - Jesús Rodríguez-Baño
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Hospital Universitario Virgen Macarena, Departament of Medicine, University of Sevilla, Biomedicine Institute of Seville (IBiS), Seville, Spain
| | - Étienne Ruppé
- INSERM, IAME, UMR 1137, Paris-Diderot Sorbonne-Paris Cité University, Paris, France
- Bacteriology Laboratory, Bichat-Claude Bernard Hospital, APHP, Paris, France
| | - Jorge Salluh
- Department of Critical Care and Graduate Program in Translational Medicine, D'Or Institute for Research and Education, IDOR, Rio De Janeiro, Brazil
| | | | - Emmanuel Weiss
- Department of Anesthesiology and Critical Care, Beaujon Hospital, AP-HP, Clichy, France
- INSERM, CRI, UMR 1149, Paris-Diderot Sorbonne-Paris Cité University, Paris, France
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Yun NR, Kim DM. Vibrio vulnificus infection: a persistent threat to public health. Korean J Intern Med 2018; 33:1070-1078. [PMID: 29898575 PMCID: PMC6234401 DOI: 10.3904/kjim.2018.159] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 05/07/2018] [Indexed: 12/19/2022] Open
Abstract
Vibrio vulnificus is a gram-negative bacterium that can cause serious, potentially fatal infections. V. vulnificus causes three distinct syndromes: an overwhelming primary septicemia caused by consuming contaminated seafood, wound infections acquired when an open wound is exposed to contaminated warm seawater, and gastrointestinal tract-limited infections. Case-fatality rates are higher than 50% for primary septicemia, and death typically occurs within 72 hours of hospitalization. Risk factors for V. vulnificus infection include chronic liver disease, alcoholism, and hematological disorders. When V. vulnificus infection is suspected, appropriate antibiotic treatment and surgical interventions should be performed immediately. Third-generation cephalosporin with doxycycline, or quinolone with or without third-generation cephalosporin, may be potential treatment options for patients with V. vulnificus infection.
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Affiliation(s)
- Na Ra Yun
- Division of Infectious Disease, Department of Internal Medicine, Chosun University College of Medicine, Gwangju, Korea
| | - Dong-Min Kim
- Division of Infectious Disease, Department of Internal Medicine, Chosun University College of Medicine, Gwangju, Korea
- Correspondence to Dong-Min Kim, M.D. Division of Infectious Disease, Department of Internal Medicine, Chosun University College of Medicine, 365 Pilmun-daero, Dong-gu, Gwangju 61453, Korea Tel: +82-62-220-3108 Fax: +82-62-234-9653 E-mail:
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