Necrotizing skin and soft-tissue infections in the intensive care unit

Necrotizing Soft Tissue Infections: A Review

Importance

Necrotizing soft tissue infections (NSTIs) are severe life- and limb-threatening infections with high rates of morbidity and mortality. Unfortunately, there has been minimal improvement in outcomes over time.

Observations

NSTIs are characterized by their heterogeneity in microbiology, risk factors, and anatomical involvement. They often present with nonspecific symptoms, leading to a high rate of delayed diagnosis. Laboratory values and imaging help increase suspicion for NSTI, though ultimately, the diagnosis is clinical. Surgical exploration is warranted when there is high suspicion for NSTI, even if the diagnosis is uncertain. Thus, it is acceptable to have a certain rate of negative exploration. Immediate empirical broad-spectrum antibiotics, further tailored based on tissue culture results, are essential and should be continued at least until surgical debridement is complete and the patient shows signs of clinical improvement. Additional research is needed to determine optimal antibiotic duration. Early surgical debridement is crucial for improved outcomes and should be performed as soon as possible, ideally within 6 hours of presentation. Subsequent debridements should be performed every 12 to 24 hours until the patient is showing signs of clinical improvement and there is no additional necrotic tissue within the wound. There are insufficient data to support the routine use of adjunct treatments such as hyperbaric oxygen therapy and intravenous immunoglobulin. However, clinicians should be aware of multiple ongoing efforts to develop more robust diagnostic and treatment strategies.

Conclusions and Relevance

Given the poor outcomes associated with NSTIs, a review of clinically relevant evidence and guidelines is warranted. This review discusses diagnostic and treatment approaches to NSTI while highlighting future directions and promising developments in NSTI management.

Fatal Clostridium septicum gas gangrene complicating ECMO: case report and review of literature

Clostridium septicum gas gangrene is a severe and deadly infection caused by an anaerobic, spore-forming, Gram-positive bacillus. As previously described, two entities are observed: traumatic and spontaneous (or non-traumatic) forms. In this report, we aim to describe the case of a fulminant and ultimately fatal C. septicum myonecrosis occurring in a patient who was first admitted for refractory cardiac arrest and placed on veino-arterial extracorporeal membrane oxygenation (ECMO). Building upon prior studies that have documented cases of spontaneous gas gangrene caused by C. septicum, we provide an updated compilation, focusing on microbiological characteristics of C. septicum, along with the diagnostic and therapeutic challenges associated with spontaneous gas gangrene. Additionally, the specific clinical situation of our case illustrates the seriousness of this infectious complication that combined both spontaneous and traumatic gas gangrene risk factors. We thus, discuss the antibiotic coverage prior to the initiation of ECMO procedure.

Prevalence, resistance profiles and factors associated with skin and soft-tissue infections at Jinja regional referral hospital: A retrospective study

Skin and soft-tissue infections (SSTI) are common cases of hospital-acquired infections with aetiological agents exhibiting antimicrobial resistance (AMR). This is a global public health predicament responsible for a high burden of infectious diseases and threatens the achievement of Sustainable Development Goals (SDGs), especially in Low- and Middle-Income countries (LMICs). This study determined the prevalence of SSTI, proportion of laboratory-investigated cases, AMR-profiles, and factors associated with SSTI and multi-drug resistance (MDR). This was based on records of patients suspected of SSTI for the period of 2019-2021 at Jinja Regional Referral Hospital. The analysis involved 268 randomly selected patient reports using WHONET 2022 and Stata 17 at the 95% confidence level. The prevalence of SSTI was 66.4%. Cases that involved laboratory testing were 14.1%. Staphylococcus aureus (n = 51) was the most isolated organism. MDR pathogens explained 47% of infections. Methicillin-resistant Staphylococcus aureus (MRSA) was up to 44%. In addition, 61% of Gram-negatives had the potential to produce extended-spectrum beta-lactamases (ESBL), while 27% were non-susceptible to carbapenems. Ward of admission was significantly associated with infection (aPR = 1.78, 95% CI: 1.00-3.18, p-value = 0.04). Age category (19-35) was an independent predictor for MDR infections (aPR = 2.30, 95%CI:1.02-5.23, p-value = 0.04). The prevalence of SSTI is high with MDR pathogens responsible for almost half of the infections. Gentamicin and ciprofloxacin can be considered for empirical management of strictly emergency SSTI cases suspected of Staphylococcus aureus. Given the high resistance observed, laboratory-based diagnosis should be increased to use the most appropriate treatment. Infection Prevention and Control (IPC) strategies should be heightened to reduce the prevalence of SSTI. Recognizing SSTI under the Global Antimicrobial resistance Surveillance System (GLASS) would lead to improved preparedness and response to AMR.

Post-marketing safety surveillance of fostamatinib: an observational, pharmacovigilance study leveraging FAERS database

OBJECTIVE

Fostamatinib, an FDA-approved oral small-molecule spleen tyrosine kinase (SYK) inhibitor, is used to treat thrombocytopenia in adults with chronic immune thrombocytopenia (ITP) who have not responded to previous treatments. However, comprehensive safety data is lacking. This study uses the FDA Adverse Event Reporting System (FAERS) database to explore real-world adverse events (AEs) related to fostamatinib, aiming to inform its clinical use.

METHODS

The FAERS database was retrospectively queried to extract reports associated with fostamatinib from 2019 to 2023. To identify and evaluate potential AEs in patients receiving fostamatinib, various disproportionality analyses such as the reporting odds ratio (ROR), the proportional reporting ratio (PRR), the Bayesian confidence propagation neural network (BCPNN), and the multi-item gamma Poisson shrinker (MGPS) were employed.

RESULTS

A total of 23 AE signals were included in our analysis. Among them, hypertension, blood pressure increase, blood pressure abnormality, hepatic enzyme increase, and diarrhea were consistent with the common AEs described for fostamatinib in clinical trials. In addition, unexpected serious AEs were detected including cerebral thrombosis and necrotizing soft tissue infection. The median time to onset of fostamatinib-related AEs was 86 days.

CONCLUSION

Our investigation revealed several possibly emergent safety concerns associated with fostamatinib in real-world clinical practice, which might provide essential vigilance evidence for clinicians and pharmacists to manage the safety issues of fostamatinib.

Association between Insurance Status and Outcomes of Hospitalizations for Necrotizing Soft Tissue Infections

Background: Lack of insurance is associated with poorer outcomes in hospitalized patients. However, few studies have explored this association in hospitalizations for necrotizing soft tissue infections (NSTIs). This study examined the impact of insurance status on the outcome of NSTI admissions. Methods: All adult hospitalizations for necrotizing fasciitis, gas gangrene, and Fournier gangrene between 2016 and 2018 were examined using the Nationwide Inpatient Sample database. Insurance status was categorized as insured (including Medicare, Medicaid, and Private, including Health maintenance organization (HMO) or uninsured (Self-pay). Outcome measures included mortality rates, limb loss, length of hospital stay, prolonged hospital stay, and critical care admissions. Statistical analysis included weighted sample analysis, chi-square tests, multivariate regression analysis, and negative binomial regression modeling. Results: Approximately 29,705 adult hospitalizations for NSTIs were analyzed. Of these, 57.4% (17,065) were due to necrotizing fasciitis, 22% (6,545) to gas gangrene, and 20.5% (6,095) to Fournier gangrene. Approximately 9.7% (2,875) were uninsured, whereas 70% (26,780) had insurance coverage. Among the insured, Medicare covered 39.6% (10,605), Medicaid 29% (7,775), and private insurance 31.4% (8,400). After adjustments, Medicare insurance was associated with greater odds of mortality (adjusted odds ratio [aOR]: 1.81; 95% confidence interval [CI]: 1.33-2.47; p = 0.001). Medicaid insurance was associated with increased odds of amputation (aOR: 1.81; 95% CI: 1.33-2.47; p < 0.001), whereas private insurance was associated with lower odds of amputation (aOR: 0.70; 95% CI: 0.51-0.97; p = 0.030). Medicaid insurance was associated with greater odds of prolonged hospital stay (aOR: 1.34; 95% CI: 1.09-1.64; p < 0.001). No significant association was observed between the lack of insurance or self-pay and the odds of primary or secondary outcomes. Conclusion: Medicare insurance was correlated with greater odds of mortality, whereas Medicaid insurance was associated with increased odds of amputation and longer hospital stay. Uninsured status was not associated with significant differences in NSTI outcomes.

Importance of timely and adequate source control in sepsis and septic shock

Source control is defined as the physical measures undertaken to eliminate the source of infection and control ongoing contamination, as well as restore anatomy and function at the site of infection. It is a key component of the management of patients with sepsis and septic shock and one of the main determinants of the outcome of infections that require source control. While not all infections may require source control, it should be considered in every patient presenting with sepsis; it is applicable and necessary in numerous infections, not only those occurring in the abdominal cavity. Although the biological rationale is clear, several aspects of source control remain under debate. The timing of source control may impact outcome; early source control is particularly relevant for patients with abdominal infections or necrotizing skin and soft tissue infections, as well as for those with more severe disease. Percutaneous procedures are increasingly used for source control; nevertheless, surgery-tailored to the patient and infection-remains a valid option for source control. For outcome optimization, adequate source control is more important than the strategy used. It should be acknowledged that source control interventions may often fail, posing a challenge in this setting. Thus, an individualized, multidisciplinary approach tailored to the infection and patient is preferable.

Association between time to surgery and hospital mortality in patients with community-acquired limb necrotizing fasciitis: an 11-year multicenter retrospective cohort analysis

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.

Necrotising fasciitis with extensive necrosis caused by Lactobacillus: a case report

BACKGROUND

Necrotising fasciitis (NF) is a life-threatening soft-tissue infection that rapidly destroys the epidermis, subcutaneous tissue, and fascia. Despite their low virulence, Lactobacillus spp. can cause NF, and because of its rare incidence, there is limited information about its molecular and clinicopathological characteristics. We report a rare case of NF in a patient with type 2 diabetes mellitus diagnosed on admission and severe obesity due to infection with two types of Lactobacillus spp. that manifested in extensive necrosis.

CASE PRESENTATION

A 48-year-old woman was referred to our hospital with a complaint of difficulty walking due to severe bilateral thigh pain. She presented with mild erythema, swelling, and severe skin pain extending from the pubic region to the groin. The patient was morbidly obese, had renal dysfunction, and had diabetes mellitus diagnosed on admission.; her LRINEC (Laboratory Risk Indicator for Necrotising Fasciitis) score was 9, indicating a high risk of NF. An exploratory surgical incision was made, and NF was diagnosed based on fascial necrosis. Emergent surgical debridement was performed, and cultures of the tissue culture and aspirated fluid/pus revealed two types of Lactobacillus spp.: Lactobacillus salivarius and L. iners. The patient was admitted to the intensive care unit (ICU), where antibiotics were administered and respiratory and circulatory management was performed. Diabetic ketoacidosis was detected, which was treated by controlling the blood glucose level stringently via intravenous insulin infusion. The patient underwent a second debridement on day 11 and a skin suture and skin grafting on day 36. The patient progressed well, was transferred from the ICU to the general ward on day 41, and was discharged unassisted on day 73.

CONCLUSIONS

Lactobacillus spp. are rarely pathogenic to healthy individuals and can scarcely trigger NF. However, these bacteria can cause rare infections such as NF in immunocompromised individuals, such as those with diabetes and obesity, and an early diagnosis of NF is imperative; surgical intervention may be required for the prevention of extensive necrosis. The LRINEC score may be useful for the early diagnosis of NF, even for less pathogenic bacteria such as Lactobacillus.

Necrotizing fasciitis: an update on epidemiology, diagnostic methods, and treatment

PURPOSE OF REVIEW

The aim of this review is to discuss the latest evidence of epidemiology, diagnostic methods, and treatment of necrotizing soft tissue infections (NSTIs) with a particular focus on necrotizing fasciitis (NF).

RECENT FINDINGS

NSTIs have been historically referred to as NF but encompass a broader range of infections, with variable rates ranging from 0.86 to 32.64 per 100 000 person-years, influenced by factors such as climate and seasonal variations. They have diverse microbiological profiles categorized into different types based on the involved pathogens, including polymicrobial or monomicrobial infections caused by organisms such as group A streptococcus (GAS), Staphylococcus aureus , some Gram-negative pathogens, and filamentous fungi following trauma and natural disasters. Diagnosis relies on clinical symptoms and signs, laboratory markers, and imaging. However, the gold standard for diagnosis remains intraoperative tissue culture. Treatment involves repeated surgical debridement of necrotic tissues in addition to intravenous antibiotics. Adjuvant therapies with intravenous immunoglobulin (IVIG) and hyperbaric oxygen therapy (HBOT) might have a role. Soft tissue reconstruction may be necessary following surgery.

SUMMARY

Prompt diagnosis and proper medical and surgical management of NSTI will improve outcomes.

IDENTIFICATION OF POTENTIALLY MODIFIABLE FACTORS TO IMPROVE RECOGNITION AND OUTCOME OF NECROTIZING SOFT-TISSUE INFECTIONS

ABSTRACT

Background : Necrotizing soft-tissue infections (NSTIs) present a surgical emergency of increasing incidence, which is often misdiagnosed and associated with substantial mortality and morbidity. A retrospective multicenter (11 hospitals) cohort study was initiated to identify the early predictors of misdiagnosis, mortality, and morbidity (skin defect size and amputation). Methods : Patients of all ages who presented with symptoms and were admitted for acute treatment of NSTIs between January 2013 and December 2017 were included. Generalized estimating equation analysis was used to identify early predictors (available before or during the first debridement surgery), with a significance level of P < 0.05. Results : The median age of the cohort (N = 216) was 59.5 (interquartile range = 23.6) years, of which 138 patients (63.9%) were male. Necrotizing soft-tissue infections most frequently originated in the legs (31.0%) and anogenital area (30.5%). More than half of the patients (n = 114, 54.3%) were initially misdiagnosed. Thirty-day mortality was 22.9%. Amputation of an extremity was performed in 26 patients (12.5%). Misdiagnosis was more likely in patients with a higher Charlson Comorbidity Index (β = 0.20, P = 0.001), and less likely when symptoms started in the anogenital area (β = -1.20, P = 0.003). Besides the established risk factors for mortality (septic shock and age), misdiagnosis was identified as an independent predictor of 30-day mortality (β = 1.03, P = 0.01). The strongest predictors of the final skin defect size were septic shock (β = 2.88, P < 0.001) and a skin-sparing approach to debridement (β = -1.79, P = 0.002). Conclusion : Recognition of the disease is essential for the survival of patients affected by NSTI, as is adequate treatment of septic shock. The application of a skin-sparing approach to surgical debridement may decrease morbidity.

Low attenuation areas in necrotizing soft tissue infection

Necrotizing Soft Tissue Infection can be challenging to differentiate from abscesses based on computed tomography imaging findings only, so it is crucial to perform surgical debridement as early as possible.

Practical Review of Necrotizing Fasciitis: Principles and Evidence-based Management

Necrotizing fasciitis is a severe, life-threatening soft tissue infection that presents as a surgical emergency. It is characterized by a rapid progression of inflammation leading to extensive tissue necrosis and destruction. Nonetheless, the diagnosis might be missed or delayed due to variable and nonspecific clinical presentation, contributing to high mortality rates. Therefore, early diagnosis and prompt, aggressive medical and surgical treatment are paramount. In this review, we highlight the defining characteristics, pathophysiology, diagnostic modalities, current principles of treatment, and evolving management strategies of necrotizing fasciitis.

An injectable and light curable hyaluronic acid composite gel with anti-biofilm, anti-inflammatory and pro-healing characteristics for accelerating infected wound healing

Bacterial biofilm formation and drug resistance are common issues associated with wound healing. Antimicrobial peptides (AMPs) are a new class of antimicrobial agents with the potential to solve these global health issues. New injectable adhesive antibacterial hydrogels have excellent prospects of becoming the next innovative wound-healing dressings. In this study, the hyaluronic acid was connected to the antibacterial peptide Plantaricin 149 (Pln149), obtaining HAD@AMP. HAD@AMP performed well in efficient antimicrobial activity, good histocompatibility, low drug resistance, low bacterial biofilm formation, and fast wound healing process which are essential for rapid healing of infected wound. During the hydrogel degradation process, Pln149 was released to inhibit bacterial communication and reduce bacterial biofilm formation. Meanwhile, HAD@AMP could up-regulate anti-inflammatory and pro-angiogenic factors, and down-regulate inflammatory factors to promote the healing of infected wounds, which provide a new idea for skin healing strategies.

Impact of Treatment with Antioxidants as an Adjuvant to Standard Therapy in Patients with Septic Shock: Analysis of the Correlation between Cytokine Storm and Oxidative Stress and Therapeutic Effects

Cellular homeostasis is lost or becomes dysfunctional during septic shock due to the activation of the inflammatory response and the deregulation of oxidative stress. Antioxidant therapy administered alongside standard treatment could restore this lost homeostasis. We included 131 patients with septic shock who were treated with standard treatment and vitamin C (Vit C), vitamin E (Vit E), N-acetylcysteine (NAC), or melatonin (MT), in a randomized trial. Organ damage quantified by Sequential Organ Failure Assessment (SOFA) score, and we determined levels of Interleukins (IL) IL1β, Tumor necrosis factor alpha (TNFα), IL-6, monocyte chemoattractant protein-1 (MCP-1), Transforming growth factor B (TGFβ), IL-4, IL-10, IL-12, and Interferon-γ (IFNγ). The SOFA score decreased in patients treated with Vit C, NAC, and MT. Patients treated with MT had statistically significantly reduced of IL-6, IL-8, MCP-1, and IL-10 levels. Lipid peroxidation, Nitrates and nitrites (NO3- and NO2-), glutathione reductase, and superoxide dismutase decreased after treatment with Vit C, Vit E, NAC, and MT. The levels of thiols recovered with the use of Vit E, and all patients treated with antioxidants maintained their selenium levels, in contrast with controls (p = 0.04). The findings regarding oxidative stress markers and cytokines after treatment with antioxidants allow us to consider to future the combined use of antioxidants in a randomized clinical trial with a larger sample to demonstrate the reproducibility of these beneficial effects.

Purulent Skin and Soft Tissue Infections, Challenging the Practice of Incision and Drainage: A Scoping Review

Aim

To generate a landscape of the current knowledge in the interventional management and outcomes of purulent skin and soft tissue infections.

Design

This study is a scoping review.

Methods

Electronic searches were undertaken using CINAHL, Medline, Cochrane Library, British Nursing Index, Science Direct, the National Health Service knowledge and library hub, ClinicalTrials.gov, and MedNar. The population, concept, context framework, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews were utilised, supporting a rigorous appraisal and synthesis of literature. Data Sources. The initial search and synthesis of literature were completed in January 2022 with repeat searches completed in March 2022 and July 2023. There were no imposed chronological parameters placed on the returned literature.

Results

Nineteen papers were reviewed. Incision and drainage with primary closure, needle aspiration, loop drainage, catheter drainage, and suction drainage are viable adjuncts or alternatives to the traditional surgical management of skin and soft tissue abscesses.

Conclusion

Despite the empirically favourable alternatives to the incision and drainage technique demonstrated, this does not appear to be driving a change in clinical practice. Future research must now look to mixed and qualitative evidence to understand the causative mechanisms of incision and drainage and its ritualistic practice. Implications. Ritual surgical practices must be challenged if nurses are to improve the treatment and management of this patient group. This will lead to further practice innovation. Impact: This study explored the challenges posed to patients, clinicians, nurses, and stakeholders, resulting from the ritualistic practice of the incision and drainage technique in purulent skin or soft tissue abscesses. Empirically and holistically viable alternatives were identified, impacting all identified entities and recommending a wider holistic study. Reporting Method. Adherence to EQUATOR guidance was achieved through the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews.

Infected Spinal Hematoma After Accidental Exteriorization of an Epidural Catheter: A Case Report

Optimal treatment and outcome after spinal hematoma remain unclear. Close neurological monitoring is the key to successful treatment. Here, we present a case of an infected spinal hematoma management. We report the case of a 51-year-old male patient, American Society of Anesthesiologists physical status I, admitted to a level I hospital due to right lower limb necrotizing fasciitis. A lumbar epidural catheter was placed for pain control without complications. On the 26th day of hospitalization, three hours after the accidental exteriorization of the epidural catheter, the patient developed severe back pain not relieved by systemic analgesia. Prophylactic low-molecular-weight heparin had been administered less than six hours before. The patient had inflammatory signs and digital pressure pain at the catheter insertion site and a positive Brudzinski sign. Sensory-motor deficits were never felt. An urgent dorsolumbar MRI exhibited a significant hematic collection at the subdural and anterior epidural level, and an infected epidural hematoma was assumed. Empirical antibiotics and hourly monitoring of sensory-motor deficits, meningeal signs, and fever were initiated. The patient remained on absolute bed rest. Low-molecular-weight heparin was stopped. The pain disappeared on the third day after the MRI. Citrobacter koseri was isolated. A re-evaluation CT scan did not show spinal compression. The patient was discharged on the 27th day after an MRI in an asymptomatic condition and was referred to acute pain consultation. Neurological deficits are usually expected at the time of spinal hematoma diagnosis. However, the classic triad of pain, sensory deficits, and motor deficits is only seen in less than half of patients. Our patient only developed severe lumbar pain. In selected cases, diagnostic MRI associated with tight monitoring and conservative management can be applied.

Fournier gangrene with concurrent multifocal necrotizing fasciitis: a systematic review and case report

PURPOSE

A patient presented to a regional surgical center with Fournier gangrene (FG) and concurrent multifocal necrotizing fasciitis (NF). Given the rarity, it was decided to undertake a systematic review to investigate the incidence and prevalence of FG with multifocal NF and consequently determine the treatment and approach to management of such presentation.

METHODS

Firstly, the report of the 56-year-old male patient is discussed regarding his surgical management. Secondly, a systematic review was undertaken according to PRISMA guidelines using MEDLINE, Scopus, and Embase databases. Searches used the following MeSH terms: ("fournier's gangrene") AND ((necrotising fasciitis) OR (necrotising soft tissue infection)). Once the search results were obtained, duplicate articles were removed. Titles, abstracts, and articles were reviewed by 2 authors.

RESULTS

The search strategy using the 3 databases revealed a total of 402 studies. Fifty-seven studies were removed due to duplication. A total of 345 records were screened via title and abstract, of which 115 were excluded. Two hundred and thirty studies were reviewed for eligibility. A total of all 230 studies were excluded; 169 were excluded as they included the incorrect patient population (patients suffered from FG or NF, but not both collectively), 60 studies were excluded due to incorrect study designs, and 1 report occurred in the wrong setting.

CONCLUSION

This highlights that while being a relatively known, uncommon infection both FG and NF are well documented separately within the literature. However, FG with concurrent multifocal NF has not been documented within the literature.

Ultrasonography for Skin and Soft Tissue Infections, Noninfectious Cysts, Foreign Bodies, and Burns in the Critical Care Setting

There are multiple opportunities for the use of ultrasonography in the diagnosis of skin and soft tissue differentials. Ultrasonography is inexpensive, easily reproducible, and able to provide real-time data in situations where condition changes and progression are common. Not only does bedside ultrasonography provide the clinician an in-depth look beyond epidermal structures into body cavities, it remains a safe, nonionizing radiating, effective, cost-efficient, reliable, and accessible tool for the emergency management of life- and limb-threatening integumentary infections. Unnecessary invasive procedures are minimized, providing improved patient outcomes. Integumentary abnormalities secondary to trauma, surgery, and hospitalization are common among critical care patients. This article provides a brief overview and evidence-based recommendations for the use of ultrasonography in the critical care setting for integumentary system conditions, including common skin and soft tissue differentials, foreign bodies, and burn depth assessment.

Diagnosis and Management of Severe Water-Related Skin and Soft Tissue Sepsis: A Summative Review of the Literature

BACKGROUND

Skin and soft tissue infections (SSTIs) are common presentations in the emergency department. However, this is less common after contact with contaminated saltwater or freshwater. This review presents the diagnosis and management of water-related soft tissue sepsis in this vulnerable and difficult-to-treat subgroup of necrotizing soft tissue sepsis.

METHODS

A summative literature overview is presented regarding bacterial and fungal SSTI after contact with contaminated water, with practical diagnostic and management aspects.

RESULTS

The literature indicates that these wounds and infections remain difficult to treat. An approach using appropriate diagnostic tools with both medical and surgical management strategies is provided.

CONCLUSIONS

SSTIs due to water contamination of wounds involve unusual organisms with unusual resistance patterns, and require a nuanced and directed diagnostic approach with an adaptation of the usual antibiotic or antifungal selection to achieve a successful cure, along with aggressive debridement and wound care.

Factors associated with mortality in patients with extremity necrotizing soft-tissue infections: a single academic center experience

PURPOSE

Necrotizing soft-tissue infection (NSTI) is a surgical emergency associated with high mortality. This study primarily aimed to identify the factors associated with in-hospital mortality due to NSTI in the extremities at a single institution. Secondarily, we aimed to clarify the effectiveness of the optimal combination of hyperbaric oxygen therapy (HBOT) and surgery for NSTI treatment.

STUDY DESIGN

Retrospective observational study.

METHODS

This study included all patients newly diagnosed with NSTI in the extremity from 2003 to 2021 in our hospital. Factors associated with mortality, including patient's characteristics, duration from onset to hospitalization, NSTI type, and clinical data at the initial visit; acute disseminated intravascular coagulation (DIC), laboratory risk indicator for necrotizing fasciitis score, and sequential organ failure assessment score; treatment, initial surgery, surgery times, amputation, HBOT, combined surgery with HBOT, and clinical outcomes; amputation rate, mortality rate, and hospitalization duration were examined.

RESULTS

A total of 37 cases were treated for NSTIs. The median age was 64 years (range: 22-86). Five cases (13.5%) died during hospitalization. Ten patients were diagnosed with DIC at the initial visit, of whom four died. HBOT combined with surgery was performed in 23 cases, and 16 cases underwent multiple surgeries. Factors associated with mortality included DIC (p = 0.015, 95% confidence interval [CI]: 0.015-0.633) and multiple surgeries combined with HBOT (p = 0.028, 95% CI: 1.302-95.418).

CONCLUSION

This study demonstrates that DIC at the initial visit is associated with mortality in extremity NSTI. Additionally, HBOT might improve prognosis when combined with multiple surgeries.

2023 Update on Sepsis and Septic Shock in Adult Patients: Management in the Emergency Department

BACKGROUND

Sepsis/septic shock is a life-threatening and time-dependent condition that requires timely management to reduce mortality. This review aims to update physicians with regard to the main pillars of treatment for this insidious condition.

METHODS

PubMed, Scopus, and EMBASE were searched from inception with special attention paid to November 2021-January 2023.

RESULTS

The management of sepsis/septic shock is challenging and involves different pathophysiological aspects, encompassing empirical antimicrobial treatment (which is promptly administered after microbial tests), fluid (crystalloids) replacement (to be established according to fluid tolerance and fluid responsiveness), and vasoactive agents (e.g., norepinephrine (NE)), which are employed to maintain mean arterial pressure above 65 mmHg and reduce the risk of fluid overload. In cases of refractory shock, vasopressin (rather than epinephrine) should be combined with NE to reach an acceptable level of pressure control. If mechanical ventilation is indicated, the tidal volume should be reduced from 10 to 6 mL/kg. Heparin is administered to prevent venous thromboembolism, and glycemic control is recommended. The efficacy of other treatments (e.g., proton-pump inhibitors, sodium bicarbonate, etc.) is largely debated, and such treatments might be used on a case-to-case basis.

CONCLUSIONS

The management of sepsis/septic shock has significantly progressed in the last few years. Improving knowledge of the main therapeutic cornerstones of this challenging condition is crucial to achieve better patient outcomes.

Necrotizing soft tissue infections in critically ill neutropenic patients: a French multicentre retrospective cohort study

BACKGROUND

Necrotizing soft tissue infections (NSTIs) are rare life-threatening bacterial infections. Few data are available regarding neutropenic patients with NSTIs. Our objectives were to describe the characteristics and management of neutropenic patients with NSTIs in intensive care units (ICUs). We conducted a retrospective multicentre cohort study in 18 ICUs between 2011 and 2021. Patients admitted with NSTIs and concomitant neutropenia at diagnosis were included and compared to non-neutropenic patients with NSTIs. The relationship between therapeutic interventions and outcomes was assessed using Cox regression and propensity score matching.

RESULTS

76 neutropenic patients were included and compared to 165 non-neutropenic patients. Neutropenic patients were younger (54 ± 14 vs 60 ± 13 years, p = 0.002) and had less lower limb (44.7% vs 70.9%, p < 0.001) and more abdomino-perineal NSTIs (43.4% vs 18.8%, p < 0.001). Enterobacterales and non-fermenting gram-negative bacteria were the most frequently isolated microorganisms in neutropenic patients. In-hospital mortality was significantly higher in neutropenic than in non-neutropenic patients (57.9% vs 28.5%, p < 0.001). Granulocyte colony-stimulating factor (G-CSF) administration was associated with a lower risk of in-hospital mortality in univariable Cox (hazard ratio (HR) = 0.43 95% confidence interval (CI) [0.23-0.82], p = 0.010) and multivariable Cox (adjusted HR = 0.46 95% CI [0.22-0.94], p = 0.033) analyses and after overlap propensity score weighting (odds ratio = 0.25 95% CI [0.09; 0.68], p = 0.006).

CONCLUSIONS

Critically ill neutropenic patients with NSTIs present different clinical and microbiological characteristics and are associated with a higher hospital mortality than non-neutropenic patients. G-CSF administration was associated with hospital survival.

Community-acquired skin and soft-tissue infections in people who inject drugs

PURPOSE OF REVIEW

The aim of this review is to discuss the latest evidence of the epidemiology, microbiology, risk factors, diagnosis and management of community-acquired skin and soft tissue infections (SSTIs) in people who inject drug (PWID).

RECENT FINDINGS

SSTIs are common complications in PWID and a major cause of morbidity and mortality. Infections can range from uncomplicated cellulitis, to abscesses, deep tissue necrosis and necrotizing fasciitis. They are predominantly caused by Gram-positive pathogens in particular Staphylococcus aureus and Streptococcus species; however, toxin-producing organisms such as Clostridium botulism or Clostridium tetani should be considered. The pathogenesis of SSTI in the setting of intravenous drug use (IDU) is different from non-IDU related SSTI, and management often requires surgical interventions in addition to adjunctive antibiotics. Harm reduction strategies and education about safe practices should be implemented to prevent morbidity and mortality as well as healthcare burden of SSTI in PWID.

SUMMARY

Prompt diagnosis and proper medical and surgical management of SSTI will improve outcomes in PWID.

Necrotizing Fasciitis in COVID-19 Patient: A Case Report of Atypical Early Presentation

A 48-year-old male, known to have hypertension (HTN), ischemic heart disease (IHD) post-percutaneous coronary intervention (PCI) before one year, and morbid obesity (BMI: 60), presented to the emergency department complaining of right thigh pain and swelling that started two days before. The swelling got increasingly worsen over the previous days, associated with dyspnea, for which he sought medical attention in another hospital. He was found to have a picture of sepsis where they offered him irrigation and debridement (I&D) but he refused and presented to our institution in a hemodynamically unstable condition. The patient underwent immediate surgery with subsequent intensive care unit (ICU) admission as a case of necrotizing fasciitis complicated by sepsis. Later he was found to have coronavirus disease 2019 (COVID-19) infection.

The impact of necrotizing soft tissue infections on the lives of survivors: a qualitative study

PURPOSE

Necrotizing soft tissue infections (NSTI) are potentially lethal infections marked by local tissue destruction and systemic sepsis, which require aggressive treatment. Survivors often face a long recovery trajectory. This study was initiated to increase understanding of the long-term impact of NSTI on health related quality of life (HRQoL), and how care may be improved.

METHODS

Thematic analysis was applied to qualitative data from 25 NSTI-survivors obtained through two focus groups (n = 14) and semi-structured interviews (n = 11).

RESULTS

The median age of the participants was 49 years, 14 were female. The median time since diagnosis was 5 years. Initial misdiagnosis was common, causing delay to treatment. Survivors experienced long-term physical consequences (scarring, cognitive impairment, fatigue, sleeping problems, recurrent infections), psychological consequences (traumatic stress symptoms, fear of relapse, adjusting to an altered appearance, sexual issues) and social and relational consequences (changes in social contacts, a lack of understanding). The disease also had a major psychological impact on family members, as well as major financial impact in some. There was a strong desire to reflect on 'mistakes' in case of initial misdiagnosis. To improve care, patient and family centered care, smooth transitions after discharge, and the availability of understandable information were deemed important.

CONCLUSION

This study reveals that NSTI have a large impact on physical and psychosocial wellbeing of survivors and their relatives. Except for a few differences (misdiagnosis, fear for re-infection and actual re-infection), the patient experience of patients with NSTI is largely similar to those of burn survivors. Thus, questionnaires to assess HRQoL in burn survivors may be used in future NSTI studies.

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

OBJECTIVES

Application of hyperbaric oxygen (HBO2) treatment in the multidisciplinary setting of necrotising soft-tissue infection (NSTI) is debated as a considerable number of studies are of low quality with marked prognostication bias due to inadequately addressing disease severity. The objective of this study was to associate HBO2 treatment with mortality in patients with NSTI including disease severity as a prognostic variable.

DESIGN

Nationwide population-based register study.

SETTING

Denmark.

PARTICIPANTS

Danish residents with NSTI patients between January 2011 and June 2016.

PRIMARY AND SECONDARY OUTCOME MEASURES

Thirty-day mortality was compared between patients receiving and patients not receiving HBO2 treatment using inverse probability of treatment weighting and propensity-score matching with predetermined variables (age, sex and weighted Charlson comorbidity score, presence of septic shock and Simplified Acute Physiology Score II (SAPS II)).

RESULTS

A total of 671 NSTI patients were included with a median age of 63 (52-71), 61% male sex, 30% had septic shock and a median SAPS II of 46 (34-58). Patients who received HBO2 treatment (n=266) were younger and had lower SAPS II, but a larger fraction had septic shock compared with patients not receiving HBO2 treatment. Overall, all-cause 30-day mortality was 19% (95% CI 17% to 23%). The statistical models were in general acceptably balanced with covariates reaching <0.1 absolute standardised mean differences and patients receiving HBO2 treatment were associated with lower 30-day mortality (OR 0.40, 95% CI 0.30 to 0.53, p<0.001).

CONCLUSIONS

In analyses using inverse probability of treatment weighting and propensity score analysis, patients treated with HBO2 treatment were associated with improved 30-day survival.

Acquired reactive perforating collagenosis combined with MRSA: A case report

Acquired reactive perforating collagenosis (ARPC) is a rare chronic skin disease associated with various internal diseases, particularly diabetes and chronic renal failure. The present study describes the case of a patient with ARPC combined with methicillin-resistant Staphylococcus aureus (MRSA), in an aim to broaden the current understanding of ARPC. A 75-year-old female presented with a 5-year history of pruritus and ulcerative eruptions on the trunk of her body, which became more severe within 1 year. A cutaneous examination revealed a diffuse distribution of erythema and papules, and nodules of various sizes, some of which sagged at the center and had a dark brown crust. A histopathological analysis revealed typical perforations of the collagen fibers. The patient was initially treated with topical corticosteroids and oral antihistamines for skin lesions and pruritus. Medications for glucose control were also administered. Upon the second admission, a combination of antibiotics and acitretin was added. The keratin plug shrank, and the pruritus was relieved. To date, to the best of our knowledge, this is the first reported case of concurrent ARPC and MRSA.

UV C Light from a Light-Emitting Diode at 275 Nanometers Shortens Wound Healing Time in Bacterium- and Fungus-Infected Skin in Mice

Due to the changes in pathogenic species and the absence of research on topical skin antibiotics, the therapy of skin and soft tissue infections (SSTIs) is facing more and more severe challenges. It is particularly urgent to look for alternative therapies without induction of drug resistance. UV C (UVC) light within the range of 200 to 280 nm is one of the most common techniques used to kill and/or inactivate pathogenic microorganisms. However, the traditional most commonly used wavelength of 254 nm irradiated from a low-pressure mercury lamp is hazardous to human health, being both carcinogenic and damaging to eye tissues, which limits its applications in vivo. This research aimed to investigate the antimicrobial properties and influence of 275-nm UVC light from a light-emitting diode (UVC-LED light) on wound healing time. Five bacteria, three fungi, and scalded-mouse models combined with SSTIs were used to evaluate the antimicrobial effect in vitro and in vivo. 275-nm UVC-LED light inactivated both bacteria and fungi with a very short irradiation time in vitro and induced neither DNA damage nor epidermal lesions in the mice's skin. Furthermore, in mouse models of SSTIs induced by either methicillin-resistant Staphylococcus aureus (MRSA) or Candida albicans, the 275-nm UVC-LED light showed significant antimicrobial effects and shortened the wound healing time compared with that in the no-irradiation group. UVC-LED light at 275 nm has the potential to be a new form of physical therapy for SSTIs. IMPORTANCE As a common clinical problem, the therapy of SSTIs is facing growing challenges due to an increase in the number of drug-resistant bacteria and fungi. UV C (UVC) light sterilization has been widely used in all aspects of daily life, but there are very few reports about in vivo therapy using UVC light. It is well known that prolonged exposure to UVC light increases the possibility of skin cancer. In addition, it is also very harmful for eyes. UV irradiation with 254-nm UVC light can cause corneal damage, like thinning of the corneal epithelial layer, superficial punctate keratitis, corneal erosion, etc. In this study, we focused on looking for a more accessible light source and safer UVC wavelength, and 275-nm UVC LED light was chosen. We investigated its applicability for SSTIs therapy with relative skin safety and expected that it could be used as a new physical therapy method for SSTIs.

Healthcare trajectory of critically ill patients with necrotizing soft tissue infections: a multicenter retrospective cohort study using the clinical data warehouse of Greater Paris University Hospitals

BACKGROUND

Necrotizing skin and soft tissue infections (NSTIs) are rare but serious and rapidly progressive infections characterized by necrosis of subcutaneous tissue, fascia and even muscle. The care pathway of patients with NSTIs is poorly understood. A better characterization of the care trajectory of these patients and a better identification of patients at risk of a complicated evolution, requiring prolonged hospitalization, multiple surgical re-interventions, or readmission to the intensive care unit (ICU), is an essential prerequisite to improve their care. The main objective of this study is to obtain large-scale data on the care pathway of these patients. We performed a retrospective multicenter observational cohort study in 13 Great Paris area hospitals, including patients hospitalized between January 1, 2015 and December 31, 2019 in the ICU for surgically confirmed NSTIs.

RESULTS

170 patients were included. The median duration of stay in ICU and hospital was 8 (3-17) and 37 (14-71) days, respectively. The median time from admission to first surgical debridement was 1 (0-2) day but 69.9% of patients were re-operated with a median of 1 (0-3) additional debridement. Inter-hospital transfer was necessary in 52.4% of patients. 80.2% of patients developed organ failures during the course of ICU stay with 51.8% of patients requiring invasive mechanical ventilation, 77.2% needing vasopressor support and 27.7% renal replacement therapy. In-ICU and in-hospital mortality rates were 21.8% and 28.8%, respectively. There was no significant difference between patients with abdomino-perineal NSTIs (n = 33) and others (n = 137) in terms of in-hospital or ICU mortality. Yet, immunocompromised patients (n = 43) showed significantly higher ICU and in-hospital mortality rates than non-immunocompromised patients (n = 127) (37.2% vs. 16.5%, p = 0.009, and 53.5% vs. 20.5%, p < 0.001). Factors associated with a complicated course were the presence of a polymicrobial infection (adjusted odds ratio [aOR = 3.18 (1.37-7.35); p = 0.007], of a bacteremia [aOR = 3.29 (1.14-9.52); p = 0.028] and a higher SAPS II score [aOR = 1.05 (1.02-1.07); p < 0.0001]. 62.3% of patients were re-hospitalized within 6 months.

CONCLUSION

In this retrospective multicenter study, we showed that patients with NSTI required complex management and are major consumers of care. Two-thirds of them underwent a complicated hospital course, associated with a higher SAPS II score, a polymicrobial NSTI and a bacteremia.

Necrotizing Fasciitis Presenting as Generalized Weakness, Malaise, and Acute Kidney Injury

Necrotizing fasciitis (NF) is a surgical emergency that must be diagnosed promptly in order to avoid serious consequences or death. Additionally, symptoms of this condition are similar to less severe skin and soft tissue infections such as cellulitis or erysipelas and can be easily confused. In this case, the patient presented to the emergency department with systemic symptoms, notably malaise and generalized weakness. A cutaneous complaint, a "labial cyst", was only elicited after more specific questioning. Laboratory investigations revealed abnormal renal function tests (RFTs), suggestive of an acute kidney injury. An abdominal/pelvic computed tomography (CT) showed gas in the subcutaneous tissue. These findings led to clinical suspicion of NF, prompting a general surgery consultation. The surgeon proceeded to perform extensive debridement following the discovery of necrotic tissue. The prompt diagnosis and treatment of this condition resulted in patient survival and expected recovery. It is, therefore, critical to keep this condition in mind when diagnosing apparent skin and soft tissue infections presenting with abnormal RFTs due to the possibility of rapid decline and death if the NF is left untreated. Additionally, this is a case of less frequent Fournier's gangrene in a non-diabetic female. Finally, it underlines the importance of eliciting additional symptoms, even those that may seem unrelated, or less concerning, to the patient's initial complaint.

Post-operative antibiotics for cutaneous abscess after incision and drainage: Variations in clinical practice

Background.

Acute cutaneous abscess is a common surgical condition that mostly requires incision and drainage. Despite this, there is no standardized national or international guidance on post-operative antibiotics prescription. Traditionally, antibiotics are not indicated unless complications and/or risk factors such as immunocompromisation, diabetes or cellulitis exist. We aimed to study the local practice for post-operative antibiotics prescription for cutaneous abscesses in a UK university teaching hospital.

Methods.

Retrospective data collection for emergency general surgical admissions for a period of 6 months was carried out. All patients with cutaneous abscesses were included in this analysis. Scrotal, breast and limb abscesses were excluded. Patients’ demographics, co-morbidities and complications, including local (cellulitis, necrosis) and systemic (e.g sepsis), were studied. Approval for access to patient data was granted by the local clinical governance department prior to the commencement of this study. Computations were performed using IBM SPSS version 26. Chi square (X²), Pearson correlation (r), one or two samples t-test (one or two tailed) were applied.

Results.

A total of 148 patients were included. The mean age was 40 years (55 % males). The most common site of abscess was perianal (27.7 %), followed by pilonidal (20.3 %) and axilla (16.9 %). A total of 107 (73 %) were managed surgically with incision and drainage, and of these 92 (86 %) were managed within 24 h. Altogether, 83 (76 %) were prescribed post-operative antibiotics, while only 25 (23 %) had indications. The most used post-operative empirical antibiotics was co-amoxiclav (59 %). There was a significant relationship between ‘abscess site’ × ‘antibiotics’ [X² (36)=54.8, P=0.023]. A total of 103 patients’ average duration of post-operative antibiotics was 7.2 (sd 2.9) days. Ten patients subject to readmission spent an average of 8.4 (sd 3.8) days on antibiotics.

Conclusions.

There were variations in clinical practice regarding post-operative antibiotic prescription for cutaneous abscesses. Research is required in the future in cooperation with microbiologists to develop a standardized evidence-based treatment protocol for the management of such a common surgical condition.

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

BACKGROUND

Necrotizing soft tissue infections (NSTI) require immediate radical debridement, broad-spectrum antibiotics and intensive care. Hyperbaric oxygen therapy (HBOT) may be performed adjunctively, but unequivocal evidence for its benefits is still lacking.

METHODS

We performed a retrospective single-center study including 192 patients with necrotizing fasciitis or Fournier's gangrene to assess in-hospital mortality and outcome dependent on patient, disease and treatment characteristics with or without HBOT.

RESULTS

The in-hospital mortality rate was 27.6%. Factors associated with increased mortality according to multivariate analysis were higher age, affection of multiple or problem localizations (odds ratio (OR) = 2.88, P = 0.003), ineligibility for HBOT despite clinical indication (OR = 8.59, P = 0.005), pathogens in blood cultures (OR = 3.36, P = 0.002), complications (OR = 10.35, P < 0.001) and sepsis/organ dysfunction (OR = 19.58, P < 0.001). Factors associated with better survival included vacuum-assisted wound closure (OR = 0.17, P < 0.001), larger number of debridements (OR = 0.83, P < 0.001) and defect closure with mesh graft (OR = 0.06, P < 0.001) or flap (OR = 0.09, P = 0.024). When participants were stratified into subgroups without requirement of HBOT (n = 98), treated with HBOT (n = 83) and ineligible for HBOT due to contraindications (n = 11), the first two groups had similar survival rates (75.5% vs. 73.5%) and comparable outcome, although patients with HBOT suffered from more severe NSTI, reflected by more frequent affection of multiple localizations (P < 0.001), sepsis at admission (P < 0.001) and intensive care treatment (P < 0.001), more debridements (P < 0.001) and a larger number of antibiotics (P = 0.001). In the subgroup ineligible for HBOT, survival was significantly worse (36.4%, P = 0.022).

CONCLUSION

These results point to a benefit from HBOT for treatment of NSTI in critically ill patients.

Clinical efficacy and safety of linezolid in intensive care unit patients

Background

To characterize the population of critically ill patients and infections treated with linezolid in the intensive care unit (ICU), and to evaluate the clinical efficacy and safety of linezolid therapy.

Methods

This multi-center, observational, real-world study was conducted across 52 hospitals between June 9, 2018, and December 28, 2019. Patients who met the following inclusion criteria were included: (1) admitted to the ICU, (2) of any age group, and (3) having a clinical or laboratory diagnosis of a Gram-positive bacterial infection. Clinical efficacy was categorized as success (cured or improved), failed, or non-evaluable. Adverse events and serious adverse events were recorded during treatment.

Results

A total of 366 ICU patients who met the inclusion criteria were evaluated. Linezolid was used as second- and first-line treatment in 232 (63.4%) and 134 (36.6%) patients, respectively. The most common isolated strain was Staphylococcus aureus (methicillin-resistant Staphylococcus aureus: n=37/119, 31.1%; methicillin-susceptible Staphylococcus aureus: n=15/119, 12.6%); this was followed by Enterococci (vancomycin-resistant Enterococci: n=8/119, 6.7%; vancomycin-susceptible Enterococci: n=11/119, 9.2%) and Streptococcus pneumoniae (multidrug-resistant: n=4/119, 3.4%; non-multidrug resistant: n=2/119, 1.7%). The main infection sites where pathogens were detected included the lung (n=216/366, 59.6%), skin and soft tissue (n=104/366, 28.4%), and blood (n=50/366, 13.7%). Clinical success was achieved in 301 (82.2%) patients; 34 (9.3%) were cured and 267 (73.0%) improved; treatment failure and non-evaluable outcomes were observed in 29 (7.9%) in 36 (9.8%) patients, respectively. Linezolid-related adverse events were reported in 8 (2.2%) patients. No treatment-related serious adverse events were reported.

Conclusions

Based on real-world results, linezolid was found to be effective and safe in the treatment of Gram-positive bacterial infections in critically ill patients.

Use of Clindamycin for Necrotizing Soft Tissue Infection Decreases Amputation Rate

OBJECTIVE

To identify the impact of clindamycin use on mortality and amputation rates in patients with necrotizing fasciitis.

DESIGN

Retrospective review.

SETTING

Level 1 trauma center, single-center study.

PATIENTS/PARTICIPANTS

All patients from 2008 to 2019 with a diagnosis of necrotizing fasciitis. One hundred ninety patients were included in statistical analysis.

INTERVENTION

Use of clindamycin in the initial antibiotic regimen in the treatment of necrotizing soft tissue infection.

MAIN OUTCOME MEASUREMENTS

Amputation and mortality rates.

RESULTS

Patients who received clindamycin had 2.92 times reduced odds of having an amputation when compared with their counterparts, even when American Society of Anesthesiologist scores, comorbidities, smoking, drug use, alcohol consumption, race, ethnicity, sex, and age were controlled for and regardless of other antibiotics started (P = 0.015). There was no significant difference in mortality rate between those patients who did and did not receive clindamycin as part of their initial antibiotic regimen (8.3% vs. 11.6%, respectively; P = 0.453).

CONCLUSION

The use of clindamycin in the initial antibiotic regimen for treatment of NSTI was shown to significantly decrease rates of amputation but not mortality.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Necrotizing Skin and Soft Tissue Infection Due to Syncephalastrum Species and Fusarium solani Species Complex Following Open Tibia Fracture

Fungal necrotizing skin and soft tissue infection (NSSTI) represents a rare clinical entity. An extremely rare case of NSSTI, following an open tibia fracture in a 36-year-old male caused by both Syncephalastrum spp. and Fusarium solani species complex (SC) is presented. The infection was diagnosed through direct microscopy, cultures and histology. The disease had a long course. The patient underwent a total of seven consecutive surgical debridements, while proper and timely antifungal treatment was initiated and included liposomal amphotericin B and voriconazole. He gradually recovered and 4 years later he is completely functioning and healthy. Invasive fungal infections are well-documented causes of high morbidity and mortality in immunocompromised individuals, whereas in immunocompetent hosts, trauma-related fungal infections have also been reported. It is of note that Syncephalastrum spp. has very rarely been identified to cause infection in immunocompromised or immunocompetent hosts, whereas Fusarium spp. has rarely been involved in skin necrotic lesions in non-immunocompromised individuals. A high suspicion index, especially in necrotic lesions in trauma patients, is pivotal for early diagnosis, which may lead to lower mortality as well as lower amputation rates. Definite diagnosis through microscopy, histology and/or cultures are of paramount importance, whereas PCR testing may also be extremely useful.

Applications of Chitosan and its Derivatives in Skin and Soft Tissue Diseases

Chitosan and its derivatives are bioactive molecules that have recently been used in various fields, especially in the medical field. The antibacterial, antitumor, and immunomodulatory properties of chitosan have been extensively studied. Chitosan can be used as a drug-delivery carrier in the form of hydrogels, sponges, microspheres, nanoparticles, and thin films to treat diseases, especially those of the skin and soft tissue such as injuries and lesions of the skin, muscles, blood vessels, and nerves. Chitosan can prevent and also treat soft tissue diseases by exerting diverse biological effects such as antibacterial, antitumor, antioxidant, and tissue regeneration effects. Owing to its antitumor properties, chitosan can be used as a targeted therapy to treat soft tissue tumors. Moreover, owing to its antibacterial and antioxidant properties, chitosan can be used in the prevention and treatment of soft tissue infections. Chitosan can stop the bleeding of open wounds by promoting platelet agglutination. It can also promote the regeneration of soft tissues such as the skin, muscles, and nerves. Drug-delivery carriers containing chitosan can be used as wound dressings to promote wound healing. This review summarizes the structure and biological characteristics of chitosan and its derivatives. The recent breakthroughs and future trends of chitosan and its derivatives in therapeutic effects and drug delivery functions including anti-infection, promotion of wound healing, tissue regeneration and anticancer on soft tissue diseases are elaborated.

Necrotizing Soft Tissue Infections (NSTI): Pearls and Pitfalls for the Emergency Clinician

BACKGROUND

Skin and soft tissue infections are common emergency department (ED) presentations. These infections cover a wide spectrum of disease, from simple cellulitis to necrotizing fasciitis. Despite the commonality, a subset of skin and soft tissue infections known as necrotizing soft tissue infections (NSTIs) can cause significant morbidity and mortality.

OBJECTIVE

This review evaluates the current evidence regarding the presentation, evaluation, and management of NSTI from the ED perspective.

DISCUSSION

NSTIs are commonly missed diagnoses. History and physical examination findings are inconsistent, and the risk factors for this high mortality disease are common amongst ED populations. Laboratory evaluation and the Laboratory Risk in Necrotizing Fasciitis (LRINEC) score is helpful but is insufficient to rule out the disease. Imaging modalities including ultrasound, computed tomography, and magnetic resonance imaging are highly sensitive and specific, but may delay definitive management. The gold standard for diagnosis includes surgical exploration. Surgical intervention and empiric broad-spectrum antibiotic coverage are the foundations of treatment. Adjuvant therapies including hyperbaric oxygen and intravenous immunoglobulin have not yet been proven to be beneficial or to improve outcome.

CONCLUSION

NSTIs are associated with significant morbidity and mortality. Knowledge of the history, examination, evaluation, and management is vital for emergency clinicians.

The importance of intravenous immunoglobulin treatment in critically ill patients with necrotizing soft tissue infection: a retrospective cohort study

Background

Necrotizing soft-tissue infections are infections with high mortality. The use of immunoglobulins within a combination therapy including broad-spectrum antibiotics has been debated. We assessed potential benefits of immunoglobulins and hypothesized that they were associated with a treatment benefit in a high-resource setting.

Methods

Patients with necrotizing soft-tissue infection hospitalized in the tertiary intensive care unit of the University Hospital of Zurich, Switzerland, between 2008 and 2020 were included retrospectively. The association between immunoglobulin administration and in-hospital survival, intensive care unit length of stay, the incidences of acute renal failure, acute respiratory distress syndrome and septic shock were analyzed.

Results

After adjustment for confounders, no difference for in-hospital survival (hazard ratio 2.20, 95% confidence interval [CI] 0.24–20.20, p = 0.5), intensive care unit length of stay (subhazard ratio [SHR] 0.90, CI 0.41–1.98, p = 0.8) and the development of acute respiratory distress syndrome (SHR 1.2, CI 0.36–4.03, p = 0.77) was observed in patients with or without immunoglobulin treatment. The Simplified Acute Physiology Score II, the risk of developing acute renal failure (SHR 2.86, CI 1.33–6.15, p = 0.01) and septic shock (SHR 1.86, CI 1.02–3.40, p = 0.04) was higher in patients treated with immunoglobulins, possibly reflecting a higher disease severity beyond measured confounders.

Conclusions

No clear evidence for a benefit of immunoglobulins in our cohort with consistent antibiotic use was found. Patients receiving immunoglobulins appeared more severely ill. Complementary to high treatment standards and appropriate antibiotics including beta lactams and protein synthesis inhibitors, immunoglobulins should be administered on a case-to-case basis, at least while more evidence from larger randomized controlled trials is missing.

WSES/GAIS/WSIS/SIS-E/AAST global clinical pathways for patients with skin and soft tissue infections

Skin and soft-tissue infections (SSTIs) encompass a variety of pathological conditions that involve the skin and underlying subcutaneous tissue, fascia, or muscle, ranging from simple superficial infections to severe necrotizing infections.

Together, the World Society of Emergency Surgery, the Global Alliance for Infections in Surgery, the Surgical Infection Society-Europe, The World Surgical Infection Society, and the American Association for the Surgery of Trauma have jointly completed an international multi-society document to promote global standards of care in SSTIs guiding clinicians by describing reasonable approaches to the management of SSTIs.

An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting evidence was shared by an international task force with different clinical backgrounds.

Necrotizing Soft Tissue Infections of the Hand and Wrist

Necrotizing soft tissue infections of the upper extremity threaten life and limb. Their presentation is often difficult to recognize and multiple factors contribute to the varied presentation, speed of spread, and morbidity of the disease process. The only treatment to be definitively shown to improve outcomes is prompt surgical treatment. It should be expected to perform multiple debridements as well as reconstructive procedures once the infection and necrosis has been arrested. The use of a multidisciplinary team is mandatory to optimize care for these patients. Despite advances in knowledge and treatment, these infections still have high mortality and morbidity.

Necrotizing fasciitis of the chest wall: A clinical case report and literature review

Necrotizing fasciitis of the chest wall is a very rare pathology, but with significant mortality, representing a therapeutic challenge. All international reports indicate the need for early diagnosis and an aggressive medical-surgical attitude in order to improve the prognosis. In addition to a review of literature, we present a case developed secondary to a thoracic pleural drainage for pyopneumothorax associated with significant bronchopleural fistula in a destroyed tuberculous left lung. Along with medical treatment, extensive surgical debridement was required. Despite drainage incisions and negative pressure wound therapy (NPWT), the evolution of the fasciitis was difficult, due to bronchopleurocutaneous fistula. Thus, the Azorin procedure (transcervical mediastinoscopic closure of the left main bronchus) was performed. Once this procedure was completed, the inflammatory phenomena were controlled which allowed for a second step consisting of left pneumonectomy, with the application of specific methods for the prevention of bronchial fistula. The clinical case was a therapeutic challenge requiring a complex, staged, multidisciplinary approach due to both the immunocompromised terrain and the severity of the lesions. In conclusion, early recognition and aggressive and combined application of medical and surgical treatment methods can ensure therapeutic success.

From Chemical Burn to Below Knee Amputation: Amputation Secondary to Application of Over-the-Counter Topical Analgesic With Menthol and Methyl Salicylate

Topical analgesics and topical rubefacients are widely used to control acute as well as chronic pain every day. Due to their availability without a prescription, consumers often overlook any potentially harmful effects and consider them largely benign. Here, we present a rare case of chemical burn triggered by a typical over-the-counter (OTC) analgesic containing menthol and methyl salicylate resulting in chemical burn, complicated by necrotizing infection treated by below the knee amputation.

Association between adjunct clindamycin and in-hospital mortality in patients with necrotizing soft tissue infection due to group A Streptococcus: a nationwide cohort study

Necrotizing soft tissue infection (NSTI) due to group A Streptococcus (GAS) is a severe life-threatening microbial infection. The administration of adjunct clindamycin has been recommended in the treatment of NSTIs due to GAS. However, robust evidence regarding the clinical benefits of adjunct clindamycin in NSTI patients remains controversial. We aimed to investigate the association between early administration of adjunct clindamycin and in-hospital mortality in patients with NSTI attributed to GAS. The present study was a nationwide retrospective cohort study, using the Japanese Diagnosis Procedure Combination inpatient database focusing on the period between 2010 and 2018. Data was extracted on patients diagnosed with NSTI due to GAS. We compared patients who were administered clindamycin on the day of admission (clindamycin group) with those who were not (control group). A propensity score overlap weighting method was adopted to adjust the unbalanced backgrounds. The primary endpoint was in-hospital mortality and survival at 90 days after admission. We identified 404 eligible patients during the study period. After adjustment, patients in the clindamycin group were not significantly associated with reduced in-hospital mortality (19.2% vs. 17.5%; odds ratio, 1.11; 95% confidence interval, 0.59-2.09; p = 0.74) or improved survival at 90 days after admission (hazard ratio, 0.92; 95% confidence interval, 0.51-1.68; p = 0.80). In this retrospective study, early adjunct clindamycin does not appear to improve survival. Therefore, the present study questions the benefits of clindamycin as an adjunct to broad spectrum antibiotics in patients with NSTI due to GAS.

Adjunctive Rifampicin Increases Antibiotic Efficacy in Group A Streptococcal Tissue Infection Models

Biofilm has recently been highlighted as a complicating feature of necrotizing soft tissue infections (NSTI) caused by Streptococcus pyogenes (i.e., group A Streptococcus [GAS]) contributing to a persistence of bacteria in tissue despite prolonged antibiotic therapy. Here, we assessed the standard treatment of benzylpenicillin and clindamycin with or without rifampin in a tissue-like setting. Antibiotic efficacy was evaluated by CFU determination in a human organotypic skin model infected for 24 or 48 h with GAS strains isolated from NSTI patients. Antibiotic effect was also evaluated by microcalorimetric metabolic assessment in in vitro infections of cellular monolayers providing continuous measurements over time. Adjunctive rifampin resulted in enhanced antibiotic efficacy of bacterial clearance in an organotypic skin tissue model, 97.5% versus 93.9% (P = 0.006). Through microcalorimetric measurements, adjunctive rifampin resulted in decreased metabolic activity and extended lag phase for all clinical GAS strains tested (P < 0.05). In addition, a case report is presented of adjunctive rifampin treatment in an NSTI case with persistent GAS tissue infection. The findings of this study demonstrate that adjunctive rifampin enhances clearance of GAS biofilm in an in vitro tissue infection model.

Associations between YKL-40 and markers of disease severity and death in patients with necrotizing soft-tissue infection

Background

Necrotizing soft-tissue infection (NSTI) is a severe and fast-progressing bacterial infection. Prognostic biomarkers may provide valuable information in treatment guidance and decision-making, but none have provided sufficient robustness to have a clinical impact. YKL-40 may reflect the ongoing pathological inflammatory processes more accurately than traditional biomarkers as it is secreted by the activated immune cells, but its prognostic yields in NSTI remains unknown. For this purpose, we investigated the association between plasma YKL-40 and 30-day mortality in patients with NSTI, and assessed its value as a marker of disease severity.

Methods

We determined plasma YKL-40 levels in patients with NSTI (n = 161) and age-sex matched controls (n = 65) upon admission and at day 1, 2 and 3.

Results

Baseline plasma YKL-40 was 1191 ng/mL in patients with NSTI compared with 40 ng/mL in controls (p < 0.001). YKL-40 was found to be significantly higher in patients with septic shock (1942 vs. 720 ng/mL, p < 0.001), and in patients receiving renal-replacement therapy (2382 vs. 1041 ng/mL, p < 0.001). YKL-40 correlated with Simplified Acute Physiology Score II (Rho 0.33, p < 0.001). Baseline YKL-40 above 1840 ng/mL was associated with increased risk of 30-day mortality in age-sex-comorbidity adjusted analysis (OR 3.77, 95% CI; 1.59–9.24, p = 0.003), but after further adjustment for Simplified Acute Physiology Score II no association was found between YKL-40 and early mortality.

Conclusion

High plasma YKL-40 to be associated with disease severity, renal-replacement therapy and risk of death in patients with NSTI. However, YKL-40 is not an independent predictor of 30-day mortality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06760-x.

Impact of prior antibiotic therapy on severe necrotizing soft-tissue infections in ICU patients: results from a French retrospective and observational study

Necrotizing soft-tissue infection (NSTI) is a life-threatening pathology that often requires management in intensive care unit (ICU). Therapies consist of early diagnosis, adequate surgical source control, and antimicrobial therapy. Whereas guidelines underline the need for appropriate routine microbiological cultures before starting antimicrobial therapy in patients with suspected sepsis or septic shock, delaying adequate therapy also strongly increases mortality. The aim of the present study was to compare the characteristics and outcomes of patients hospitalized in ICU for NSTI according to their antimicrobial therapy exposure > 24 h before surgery (called the exposed group) or not (called the unexposed group) before surgical microbiological sampling. We retrospectively included 100 consecutive patients admitted for severe NSTI. The exposed group consisted of 23(23%) patients, while 77(77%) patients belonged to the unexposed group. The demographic and underlying disease conditions were similar between the two groups. Microbiological cultures of surgical samples were positive in 84 patients and negative in 16 patients, including 3/23 (13%) patients and 13/77 (17%) patients in the exposed and unexposed groups, respectively (p = 0.70). The distribution of microorganisms was comparable between the two groups. The main antimicrobial regimens for empiric therapy were also similar, and the proportions of adequacy were comparable (n = 60 (84.5%) in the unexposed group vs. n = 19 (86.4%) in the exposed group, p = 0.482). ICU and hospital lengths of stay and mortality rates were similar between the two groups. In conclusion, in a population of severe ICU NSTI patients, antibiotic exposure before sampling did not impact either culture sample positivity or microbiological findings.

Antibiotics in Necrotizing Soft Tissue Infections

Necrotizing soft tissue infections (NSTIs) are rare life-threatening bacterial infections characterized by an extensive necrosis of skin and subcutaneous tissues. Initial urgent management of NSTIs relies on broad-spectrum antibiotic therapy, rapid surgical debridement of all infected tissues and, when present, treatment of associated organ failures in the intensive care unit. Antibiotic therapy for NSTI patients faces several challenges and should (1) carry broad-spectrum activity against gram-positive and gram-negative pathogens because of frequent polymicrobial infections, considering extended coverage for multidrug resistance in selected cases. In practice, a broad-spectrum beta-lactam antibiotic (e.g., piperacillin-tazobactam) is the mainstay of empirical therapy; (2) decrease toxin production, typically using a clindamycin combination, mainly in proven or suspected group A streptococcus infections; and (3) achieve the best possible tissue diffusion with regards to impaired regional perfusion, tissue necrosis, and pharmacokinetic and pharmacodynamic alterations. The best duration of antibiotic treatment has not been well established and is generally comprised between 7 and 15 days. This article reviews the currently available knowledge regarding antibiotic use in NSTIs.

Current management of necrotizing soft-tissue infections

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.