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Christopoulos G, Khoury A, Johnson M, Sergentanis TN. Necrotizing Fasciitis Originating in the Hand: A Systematic Review and Meta-Analysis. Hand (N Y) 2024; 19:568-574. [PMID: 36544252 PMCID: PMC11141413 DOI: 10.1177/15589447221141486] [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] [Indexed: 12/24/2022]
Abstract
Necrotizing Fasciitis (NF) is a rapidly progressive and potentially lethal infection. This systematic review focused on the treatment and prognosis of the NF of the hand. The literature search was performed in PubMed database, and cohort studies and case reports were deemed eligible. Proportions were pooled to estimate overall mortality and amputation rates, and a logistic regression analysis was performed to evaluate predictors of amputation and mortality. The search algorithm resulted in 51 eligible articles including 48 case reports (54 patients) and 3 larger retrospective cohort studies (107 patients). Most patients had a monomicrobial infection, a surgical debridement on the day of admission, and hospital stay of more than 10 days. The estimated overall amputation rate was 28%, whereas overall mortality was equal to 8%. In the pooled set of case reports, mortality was significantly associated with age older than 54 years and marginally with diabetes mellitus. Necrosis expanding more proximally to the forearm correlated with both amputation and mortality. It is reiterated that early diagnosis of NF is of paramount importance and that early and decisive surgical intervention should have low threshold, especially when potential risk factors are identified.
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Megas IF, Delavari S, Marti Edo A, Habild G, Billner M, Reichert B, Breidung D. Prognostic Factors in Necrotizing Fasciitis: Insights from a Two-Decade, Two-Center Study Involving 209 Cases. Infect Dis Rep 2024; 16:472-480. [PMID: 38804445 PMCID: PMC11130844 DOI: 10.3390/idr16030035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 05/11/2024] [Accepted: 05/13/2024] [Indexed: 05/29/2024] Open
Abstract
INTRODUCTION Necrotizing fasciitis (NF) is a critical disease with high morbidity and mortality rates that poses significant challenges in diagnosis and treatment. Prognostic factors for the clinical course of NF remain unclear and are currently under research. This study aims to identify such factors in a large cohort of patients which represents a major comprehensive investigation of prognostic factors for NF. METHODS Retrospective analysis was conducted on necrotizing fasciitis cases from 2003 to 2023 at two German hospitals. Data included demographics, comorbidities, laboratory findings, infection site, causative microorganisms and outcomes. Statistical analysis involved t-tests, chi-square tests, and ROC analysis. RESULTS A total of 209 patients were included, with a mortality rate of 18%. Patients were categorized into survivors (n = 171) and non-survivors (n = 38). Non-survivors were significantly older (68.9 ± 13.9 years vs. 55.9 ± 14.3 years; p < 0.01) and exhibited a higher prevalence of peripheral vascular diseases, cancer, and heart, liver, or renal insufficiency. Laboratory findings and scoring results also varied significantly between the two groups. The ROC curve analysis identified age as a predictor of mortality, with an optimal cut-off value of 68.5 years (sensitivity: 60.5%, specificity: 81.9%). Higher age was associated with increased mortality risk. CONCLUSIONS The patient's age stands out as the primary predictive element for mortality in necrotizing fasciitis. Additionally, we advocate for employing the Laboratory and Anamnestic Risk Indicator for Necrotizing Fasciitis (LARINF-score), which holds substantial prognostic significance and is straightforward to calculate. Considering our findings, crafting a clinical algorithm or scoring mechanism to forecast mortality in NF would be a promising target for future research.
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Affiliation(s)
- Ioannis-Fivos Megas
- Department of Plastic, Reconstructive and Hand Surgery, Center for Severe Burn Injuries, Klinikum Nürnberg, Paracelsus Medical University, 90471 Nuremberg, Germany; (I.-F.M.); (S.D.); (A.M.E.); (M.B.); (B.R.)
- Department of Orthopaedic and Trauma Surgery, Center of Plastic Surgery, Hand Surgery and Microsurgery, Evangelisches Waldkrankenhaus Spandau, 13589 Berlin, Germany
| | - Sarina Delavari
- Department of Plastic, Reconstructive and Hand Surgery, Center for Severe Burn Injuries, Klinikum Nürnberg, Paracelsus Medical University, 90471 Nuremberg, Germany; (I.-F.M.); (S.D.); (A.M.E.); (M.B.); (B.R.)
- Department of General and Visceral Surgery, Hospital Martha-Maria, 90491 Nuremberg, Germany
| | - Alejandro Marti Edo
- Department of Plastic, Reconstructive and Hand Surgery, Center for Severe Burn Injuries, Klinikum Nürnberg, Paracelsus Medical University, 90471 Nuremberg, Germany; (I.-F.M.); (S.D.); (A.M.E.); (M.B.); (B.R.)
| | - Götz Habild
- Department of Orthopaedic and Trauma Surgery, Center of Plastic Surgery, Hand Surgery and Microsurgery, Evangelisches Waldkrankenhaus Spandau, 13589 Berlin, Germany
| | - Moritz Billner
- Department of Plastic, Reconstructive and Hand Surgery, Center for Severe Burn Injuries, Klinikum Nürnberg, Paracelsus Medical University, 90471 Nuremberg, Germany; (I.-F.M.); (S.D.); (A.M.E.); (M.B.); (B.R.)
| | - Bert Reichert
- Department of Plastic, Reconstructive and Hand Surgery, Center for Severe Burn Injuries, Klinikum Nürnberg, Paracelsus Medical University, 90471 Nuremberg, Germany; (I.-F.M.); (S.D.); (A.M.E.); (M.B.); (B.R.)
| | - David Breidung
- Department of Plastic, Reconstructive and Hand Surgery, Center for Severe Burn Injuries, Klinikum Nürnberg, Paracelsus Medical University, 90471 Nuremberg, Germany; (I.-F.M.); (S.D.); (A.M.E.); (M.B.); (B.R.)
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Wan M, Xu X, Zhao X, You X, Zhang G, Long H, He P, Long J, Zhu J. Giant Ulcer with Necrosis on Right Vulva, Groin, and Thigh-- A Case of Necrotizing Fasciitis Associated with Erythematous Pemphigus. Clin Cosmet Investig Dermatol 2024; 17:103-110. [PMID: 38234694 PMCID: PMC10793116 DOI: 10.2147/ccid.s443374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/06/2024] [Indexed: 01/19/2024]
Abstract
Necrotizing fasciitis is a rare, severe, rapidly progressing disease with a high mortality rate. We report a case of a 72-year female with erythematous pemphigus who developed erythema, swelling and ulceration on right vulva, groin, and thigh. The early clinical manifestations of the patient were nonspecific and easily misdiagnosed as cellulitis. However, upon the occurrence of ulceration and necrosis, deep fungal infection, pyoderma gangrenosum or lymphoproliferative disorders were considered. The pathology suggested IgG4-related diseases, plasmacytoma et al. But at last, surgical exploration and postoperative pathology confirmed the diagnosis of necrotizing fasciitis. The patient recovered after multiple aggressive surgical debridement procedures and antibiotic therapy and the patient has been followed up for 2 years without recurrence. Clinicians should be vigilant about the possibility of necrotizing fasciitis in patients with erythema, pain, rapid ulceration of skin and soft tissue, particularly in immunocompromised individuals with long-term use of immunosuppressive agents. It is crucial for saving life by early multi-disciplinary consultation, prompt diagnosis, and aggressive treatment.
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Affiliation(s)
- Miao Wan
- Department of Dermatovenerology of the First People’s Hospital of Changde City, Changde Hospital Affiliated to Xiangya School of Medicine of Central South University, Changde, 415000, People’s Republic of China
| | - Xiangrong Xu
- Department of Plastic Surgery of the First People’s Hospital of Changde City, Changde Hospital Affiliated to Xiangya School of Medicine of Central South University, Changde, 415000, People’s Republic of China
| | - Xiaojiao Zhao
- Department of Dermatovenerology of the First People’s Hospital of Changde City, Changde Hospital Affiliated to Xiangya School of Medicine of Central South University, Changde, 415000, People’s Republic of China
| | - Xia You
- Department of Dermatovenerology of the First People’s Hospital of Changde City, Changde Hospital Affiliated to Xiangya School of Medicine of Central South University, Changde, 415000, People’s Republic of China
| | - Guiying Zhang
- Department of Dermatovenerology of the Second Xiangya Hospital of Central South University, Changsha, 410000, People’s Republic of China
| | - Hai Long
- Department of Dermatovenerology of the Second Xiangya Hospital of Central South University, Changsha, 410000, People’s Republic of China
| | - Ping He
- Department of Dermatovenerology of the First People’s Hospital of Changde City, Changde Hospital Affiliated to Xiangya School of Medicine of Central South University, Changde, 415000, People’s Republic of China
| | - Jian Long
- Department of Dermatovenerology of the First People’s Hospital of Changde City, Changde Hospital Affiliated to Xiangya School of Medicine of Central South University, Changde, 415000, People’s Republic of China
| | - Jianjian Zhu
- Department of Dermatovenerology of the First People’s Hospital of Changde City, Changde Hospital Affiliated to Xiangya School of Medicine of Central South University, Changde, 415000, People’s Republic of China
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Kunwor B, Chhetri ST, Thapa N, Regmi S, Basukala S. Surviving the perilous: A case report on an urgent approach to necrotizing fasciitis. Clin Case Rep 2023; 11:e8262. [PMID: 38033680 PMCID: PMC10682240 DOI: 10.1002/ccr3.8262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/30/2023] [Accepted: 11/13/2023] [Indexed: 12/02/2023] Open
Abstract
Necrotizing fasciitis is a rare, fatal, and rapidly progressing bacterial infection of fascia and subcutaneous tissues. Skin necrosis, pain, bullae, and erythema are the common manifestations. Early diagnosis and prompt treatment can improve outcome.
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Affiliation(s)
- Bishal Kunwor
- Nepalese Army Institute of Health SciencesKathmanduNepal
| | | | - Niranjan Thapa
- Nepalese Army Institute of Health SciencesKathmanduNepal
| | - Shiva Regmi
- Nepalese Army Institute of Health SciencesKathmanduNepal
| | - Sunil Basukala
- Department of SurgeryNepalese Army Institute of Health SciencesKathmanduNepal
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Haykal S, Hadzimustafic N, Ghazarian D, Musgrave M. Three Ds for diagnosing necrotizing fasciitis by front-line clinicians. J Plast Reconstr Aesthet Surg 2023; 84:37-46. [PMID: 37320950 DOI: 10.1016/j.bjps.2023.05.020] [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: 08/23/2022] [Revised: 04/01/2023] [Accepted: 05/15/2023] [Indexed: 06/17/2023]
Abstract
INTRODUCTION Necrotizing fasciitis (NF) is a life-threatening infection and a surgical emergency. Not all clinicians have the experience or resources to detect NF in its early stages. OBJECTIVE To develop a diagnostic algorithm for primary care and emergency physicians to identify patients with possible NF, including an initial approach to triaging such individuals. METHODS Medline was searched to identify studies of validated algorithms for NF diagnosis and/or cohort or case series providing clinical and diagnostic features of NF. Candidate algorithms were validated via application to 3 published cases of initially misdiagnosed NF. We retrospectively reviewed NF cases between 2011 and 2022 at our center to validate our algorithm. RESULTS The search yielded 540 articles; 109 were included following a review of abstracts. No published validated diagnostic algorithm was identified. Using the reported clinical and diagnostic features of NF, we generated an algorithm of the "3Ds" of NF: Disproportionate pain, Dermatological findings, and Disorganized physiology. A larger number of Ds indicated a greater level of suspicion for NF and prioritization for urgent surgical consultation. In 3 published cases of missed NF, the 3Ds algorithm successfully identified all as having possible NF. On reviewing our cases, we identified 56 patients with NF during an 11 year period. 66% of whom had the 3Ds at their initial presentation. DISCUSSION The 3Ds algorithm, a simple and easy-to-remember tool can be easily applied in a primary or emergency care setting, and may improve the early diagnosis of NF. Retrospective analysis of NF cases allows for validation of this algorithm. However, this algorithm requires prospective validation.
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Affiliation(s)
- Siba Haykal
- Division of Plastic and Reconstructive Surgery, University Health Network, Toronto General Hospital, Department of Surgery, University of Toronto, Canada.
| | | | - Danny Ghazarian
- Department of Pathology, University Health Network, Toronto General Hospital, University of Toronto, Canada
| | - Melinda Musgrave
- Division of Plastic and Reconstructive Surgery, St. Michael's Hospital, Department of Surgery, University of Toronto, Canada
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Daniels M, Perbix W, Oberländer H, Schiefer J, Fuchs PC, Seyhan H. The performance of clinical risk scores in the diagnosis of necrotising fasciitis. J Wound Care 2023; 32:284-290. [PMID: 37094928 DOI: 10.12968/jowc.2023.32.5.284] [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: 04/26/2023]
Abstract
OBJECTIVE Necrotising fasciitis (NF) is a quickly progressing and potentially life-threatening infection, involving the fascia and subcutaneous tissues. The diagnosis of this disease is challenging, especially due to a lack of specific clinical signs. In order to ensure a better and quicker identification of NF patients, a laboratory risk indicator score has been developed for NF (LRINEC). A variant has widened this score by adding clinical parameters (modified LRINEC). This study shows current outcomes of NF and compares the two scoring systems. METHODS This study was conducted between 2011 and 2018, and included patient demographics, clinical presentations, sites of infection, comorbidities, microbiological and laboratory findings, antibiotic therapies and LRINEC as well as modified LRINEC scores. The primary outcome was in-hospital mortality. RESULTS A cohort of 36 patients, diagnosed with NF, were included in this study. The mean hospital stay was 56 days (±38.2 days). The mortality rate in the cohort was 25%. The sensitivity of the LRINEC score was 86%. Calculation of the modified LRINEC score showed an improvement of the sensitivity to 97%. The average LRINEC score and modified LRINEC score for patients who died and who survived were equal (7.4 versus 7.9 and 10.4 versus 10.0, respectively). CONCLUSION The mortality rate of NF remains high. The modified LRINEC score increased the sensitivity in our cohort to 97%, and this scoring system could be supportive in the diagnosis of NF for early surgical debridement.
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Affiliation(s)
- Marc Daniels
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Hospital Cologne Merheim, University of Witten-Herdecke, Germany
| | - Walter Perbix
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Hospital Cologne Merheim, University of Witten-Herdecke, Germany
| | - Henrik Oberländer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Hospital Cologne Merheim, University of Witten-Herdecke, Germany
| | - Jennifer Schiefer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Hospital Cologne Merheim, University of Witten-Herdecke, Germany
| | - Paul Christian Fuchs
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Hospital Cologne Merheim, University of Witten-Herdecke, Germany
| | - Harun Seyhan
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Hospital Cologne Merheim, University of Witten-Herdecke, Germany
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Alhoukail A, Alrawaf T, Alotaibi A, Alanazi H. Necrotizing Fasciitis in COVID-19 Patient: A Case Report of Atypical Early Presentation. Cureus 2023; 15:e37290. [PMID: 37168208 PMCID: PMC10166124 DOI: 10.7759/cureus.37290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2023] [Indexed: 05/13/2023] Open
Abstract
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.
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Affiliation(s)
- Amro Alhoukail
- Department of Orthopedic Surgery, King Fahad Medical City, Riyadh, SAU
| | - Talal Alrawaf
- Department of Orthopedic Surgery, King Fahad Medical City, Riyadh, SAU
| | - Abdullah Alotaibi
- Department of Orthopedic Surgery, King Fahad Medical City, Riyadh, SAU
| | - Hassan Alanazi
- Department of Orthopedic Surgery, King Fahad Medical City, Riyadh, SAU
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8
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Huang C, Zhong Y, Yue C, He B, Li Y, Li J. The effect of hyperbaric oxygen therapy on the clinical outcomes of necrotizing soft tissue infections: a systematic review and meta-analysis. World J Emerg Surg 2023; 18:23. [PMID: 36966323 PMCID: PMC10040118 DOI: 10.1186/s13017-023-00490-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 03/15/2023] [Indexed: 03/27/2023] Open
Abstract
BACKGROUND To determine the efficacy of hyperbaric oxygen therapy (HBO) in the treatment of necrotizing soft tissue infections (NSTI), we conducted a meta-analysis of the available evidence. METHODS Data sources were PubMed, Embase, Web of Science, Cochrane Library, and reference lists. The study included observational trials that compared HBO with non-HBO, or standard care. The primary outcome was the mortality rate. Secondary outcomes were the number of debridement, amputation rate and complication rate. Relative risks or standardized mean differences with 95% confidence intervals were calculated for dichotomous and continuous outcomes, respectively. RESULTS A total of retrospective cohort and case-control studies were included, including 49,152 patients, 1448 who received HBO and 47,704 in control. The mortality rate in the HBO group was significantly lower than that in the non-HBO group [RR = 0.522, 95% CI (0.403, 0.677), p < 0.05]. However, the number of debridements performed in the HBO group was higher than in the non-HBO group [SMD = 0.611, 95% CI (0.012, 1.211), p < 0.05]. There was no significant difference in amputation rates between the two groups [RR = 0.836, 95% CI (0.619, 1.129), p > 0.05]. In terms of complications, the incidence of MODS was lower in the HBO group than in the non-HBO group [RR = 0.205, 95% CI (0.164, 0.256), p < 0.05]. There was no significant difference in the incidence of other complications, such as sepsis, shock, myocardial infarction, pulmonary embolism, and pneumonia, between the two groups (p > 0.05). CONCLUSION The current evidence suggests that the use of HBO in the treatment of NSTI can significantly reduce the mortality rates and the incidence rates of complications. However, due to the retrospective nature of the studies, the evidence is weak, and further research is needed to establish its efficacy. It is also important to note that HBO is not available in all hospitals, and its use should be carefully considered based on the patient's individual circumstances. Additionally, it is still worthwhile to stress the significance of promptly evaluating surgical risks to prevent missing the optimal treatment time.
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Affiliation(s)
- Chengzi Huang
- Department of Anorectum, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yilian Zhong
- Department of Anorectum, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Chaochi Yue
- Department of Anorectum, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Bin He
- Department of Anorectum, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yaling Li
- Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, Luzhou, China.
| | - Jun Li
- Department of Anorectum, The Affiliated Hospital of Southwest Medical University, Luzhou, China.
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Schwartz JM, Taleghani ER, Natal-Albelo EJ, Chhabra AB, Freilich AM. Successfully Treated Upper-Extremity Necrotizing Fasciitis Caused by Photobacterium damselae. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2023; 5:225-230. [PMID: 36974285 PMCID: PMC10039296 DOI: 10.1016/j.jhsg.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 10/04/2022] [Indexed: 03/19/2023] Open
Abstract
Necrotizing fasciitis is a soft-tissue infection associated with significant morbidity and mortality. The bacteria most associated with necrotizing fasciitis include Streptococcus pyogenes (group A), Clostridium species, Streptococcus species, and Staphylococcus species. Photobacterium damselae (P. damselae), formerly known as Vibrio damselae, is a halophilic, gram-negative bacillus known to infect marine organisms in warm coastal waters. Necrotizing fasciitis associated with P. damselae has been reported to have higher rates of serious complications and mortality because of an atypical presentation and a rapidly progressive course. This report presents a case of successfully treated P. damselae necrotizing fasciitis of the upper extremity and the nuances of management that led to a favorable outcome in which the patient was discharged for home without complications.
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Affiliation(s)
- Joshua M Schwartz
- Department of Orthopaedics, University of Virginia, Charlottesville, VA
| | - Eric R Taleghani
- Department of Orthopaedics, University of Virginia, Charlottesville, VA
| | | | - A Bobby Chhabra
- Department of Orthopaedics, University of Virginia, Charlottesville, VA
| | - Aaron M Freilich
- Department of Orthopaedics, University of Virginia, Charlottesville, VA
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Kay TJ, Wallace L, Bennett L, Gallagher PJ. Necrotising fasciitis: a case series set in rural Australia. J Surg Case Rep 2023; 2023:rjad031. [PMID: 36778965 PMCID: PMC9908093 DOI: 10.1093/jscr/rjad031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 01/17/2023] [Indexed: 02/11/2023] Open
Abstract
Necrotising fasciitis (NF) is a rapidly progressive infection of soft tissue and fascia. Early diagnosis and prompt extensive surgical debridement decrease mortality. This remains a challenge for rural surgeons who have limited experience with the disease, in a setting where patient transfers to tertiary centres are lengthy and often delayed. To assist clinical decision making in this setting, a case series of five NF presentations in a rural Australian hospital were retrospectively analysed for presentation, investigation, treatment and clinical outcomes. Three underwent abdominal wall debridement and two underwent below knee amputation. Results demonstrate early recognition of NF and the extent of surgical intervention prior to acute transfer are key to successful outcomes. Expedient diagnosis and early extensive debridement at the initial contact reduce mortality and should be the goal of management in this setting.
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Affiliation(s)
- Tegan J Kay
- Correspondence address. Department of General Surgery, Wimmera Health Care Group, Horsham 3400, Australia. Tel: (03) 5381 9111; Fax: (03) 53819260; E-mail:
| | - Lauren Wallace
- Department of General Surgery, Wimmera Health Care Group, Horsham, Australia
| | - Laura Bennett
- Department of General Surgery, Wimmera Health Care Group, Horsham, Australia
| | - Peter J Gallagher
- Department of General Surgery, Wimmera Health Care Group, Horsham, Australia
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11
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Chen JL, Huang TY, Kuo LT, Huang KC, Tsai YH. Monomicrobial Necrotizing Fasciitis and Sepsis Caused by Pseudomonas aeruginosa and Pseudomonas fluorescens: A Series of Ten Cases. Jpn J Infect Dis 2022; 75:554-559. [PMID: 35908872 DOI: 10.7883/yoken.jjid.2022.087] [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: 11/17/2022]
Abstract
Monomicrobial necrotizing fasciitis caused by Pseudomonas species is a rare infection. The purpose of this study was to elucidate the specific characteristics and clinical outcomes of necrotizing fasciitis caused by Pseudomonas aeruginosa and Pseudomonas fluorescens. Ten patients with monomicrobial necrotizing fasciitis caused by Pseudomonas species were retrospectively reviewed over an 8-year period. Differences in mortality, patient characteristics, clinical presentations, laboratory data, and clinical outcomes were compared between the death and the survival groups. Two patients died with the mortality rate of 20%. Pseudomonas aeruginosa accounted for 9 patients and Pseudomonas fluorescens for one patient. The most common comorbidity is type 2 diabetes mellitus in 5 patients. We found the death patients had lower albumin level and higher counts of band forms of leukocytes than those of the survival patients. Monomicrobial necrotizing fasciitis caused by Pseudomonas species needs emergent surgical intervention and aggressive intensive care due to high mortality rate. We reported the first case of monomicrobial necrotizing fasciitis with Pseudomonas fluorescens. Severe hypoalbuminemia and increased counts of banded leukocytes in initial laboratory presentations can be considered as poor prognostic factors.
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Affiliation(s)
- Jiun-Liang Chen
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital at Chia-Yi, Taiwan, Republic of China
| | - Tsung-Yu Huang
- College of Medicine, Chang Gung University at Taoyuan, Taiwan.,Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital, Taiwan
| | - Liang Tseng Kuo
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital at Chia-Yi, Taiwan, Republic of China.,College of Medicine, Chang Gung University at Taoyuan, Taiwan
| | - Kuo-Chin Huang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital at Chia-Yi, Taiwan, Republic of China.,College of Medicine, Chang Gung University at Taoyuan, Taiwan
| | - Yao-Hung Tsai
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital at Chia-Yi, Taiwan, Republic of China.,College of Medicine, Chang Gung University at Taoyuan, Taiwan
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12
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Necrotizing Fasciitis of the Upper Limb: Optimizing Management to Reduce Complications. J Clin Med 2022; 11:jcm11082182. [PMID: 35456275 PMCID: PMC9027995 DOI: 10.3390/jcm11082182] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/03/2022] [Accepted: 04/07/2022] [Indexed: 12/10/2022] Open
Abstract
Background: Necrotizing fasciitis (NF) is a severe, potentially life-threatening condition. The aim of this study is to identify strategies aimed at reducing complications in patients with NF of the upper limb. Methods: We conducted a retrospective study on patients admitted to our Unit for suspected NF of the upper limb. The analyzed data included patient characteristics, delay before primary care, clinical and biological signs upon arrival, pathogens involved, and the rate of amputations and mortality. Results: A total of 21 patients presented with confirmed necrotizing bacterial dermohypodermitis-NBDH with NF (NBDH-NF) affecting the upper limb. The mean delay between the onset of symptoms and the clinical examination in the Emergency Dermatology Unit was 48 h (range: 6 to 72 h). The mean delay between admission and primary surgery was 150 min (range: 60 min to 280 min). No amputations were performed. All patients were alive one year after the first surgical procedure. Conclusions: Our study demonstrated that it is possible to reduce mortality and morbidity rates in NF of the upper limb. Timely diagnosis and early treatment and a multidisciplinary medico-surgical dedicated team providing care can significantly modify the outcomes. Early surgical debridement is the most important factor affecting the prognosis of these infections.
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13
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Kurian GP, Korula PJ, Jacob JM, Desha AMK, Karuppusami R, Kandasamy S. Patient Characteristics and Outcomes in Necrotizing Soft-tissue Infections: Results from a Prospective Cohort Study in a Tertiary Care Center Intensive Care Unit in South India. Indian J Crit Care Med 2022; 26:452-456. [PMID: 35656036 PMCID: PMC9067491 DOI: 10.5005/jp-journals-10071-24153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Necrotizing soft tissue infections (NSTIs) are life-threatening infections characterized by progressive destruction of muscle, fascia, and overlying subcutaneous tissue. Prospective studies in the field are few, and data from the Indian subcontinent are bleak. Prompt diagnosis and timely treatment are critical for optimal outcomes. The aims of this study are to provide detailed information on the clinical profile of patients with NSTIs and to identify predictors of mortality in order to pick up reversible factors that may improve outcomes. Materials and methods This study was a prospective cohort study of adult patients with NSTIs in a tertiary center in South India. All patients who were admitted to the surgical intensive care unit (ICU) of the institute with a diagnosis of NSTI were screened and enrolled. All patients were managed according to the local protocol for treatment of NSTIs and intensive care support. Results In our cohort of patients, simple and multiple logistic regression analysis showed that four factors, namely, AKIN stage 3, shock, need for mechanical ventilation for more than 3 days, and low serum albumin values were found to be significantly associated with higher mortality. Conclusion The successful management of these patients calls for early diagnosis, resuscitation, surgical debridement, appropriate and timely antibiotics, and early ventilatory weaning before multi-organ failure associated with shock and AKI occurs. How to cite this article Kurian GP, Korula PJ, Jacob JM, Desha AMK, Karuppusami R, Kandasamy S. Patient Characteristics and Outcomes in Necrotizing Soft-tissue Infections: Results from a Prospective Cohort Study in a Tertiary Care Center Intensive Care Unit in South India. Indian J Crit Care Med 2022;26(4):452-456.
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Affiliation(s)
- George Prashanth Kurian
- Division of Critical Care and Surgical ICU, Christian Medical College, Vellore, Tamil Nadu, India
| | - Pritish John Korula
- Division of Critical Care and Surgical ICU, Christian Medical College, Vellore, Tamil Nadu, India
| | - Jubin Merin Jacob
- Department of Anesthesiology, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Reka Karuppusami
- Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India
| | - Subramani Kandasamy
- Division of Critical Care and Surgical ICU, Christian Medical College, Vellore, Tamil Nadu, India
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[Infections of the hand and forearm]. Unfallchirurg 2021; 125:9-18. [PMID: 34820739 DOI: 10.1007/s00113-021-01106-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2021] [Indexed: 10/19/2022]
Abstract
Infections of the hand and forearm are a frequently seen surgical emergency of the hand. Patients of all age groups are affected and underlying systemic diseases are risk factors. Posttraumatic causes are the leading cause of infections. This includes cuts and stab wounds, animal and human bites but often also minor injuries. Due to the anatomical peculiarities of the hand, rapid progression of initially inconspicuous infections can occur resulting in functional limitations. If an infection is suspected, a symptom-oriented evaluation by a hand surgeon should be performed. This includes a detailed patient history, clinical examination, laboratory analyses and imaging. This is followed by the development of an individualized and interdisciplinary treatment concept with the aim of achieving the shortest possible rehabilitation period. The treatment includes surgical cleansing of the infection, accompanied by antibiotic treatment taking the expected possible spectrum of pathogens into account. Cephalosporins and aminopenicillins in combination with beta-lactamase inhibitors are the antibiotics of first choice. Follow-up treatment includes early functional exercise under the guidance of a hand therapist to minimize postinfectious restrictions in the range of motion and to enable occupational rehabilitation. In rare cases, fulminant necrotizing infections with resulting skin and soft tissue defects can occur. In these cases, secondary plastic reconstruction is usually required after cleansing of the infection.
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Utility of the Lactate/Albumin Ratio as a Predictor for Mortality in Necrotizing Fasciitis Patients. Emerg Med Int 2021; 2021:3530298. [PMID: 34691782 PMCID: PMC8528631 DOI: 10.1155/2021/3530298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 10/07/2021] [Indexed: 12/14/2022] Open
Abstract
Background The lactate/albumin (L/A) ratio has been proposed as a prognostic marker because the ratio is associated with multiple organ failure and mortality in critically ill patients. We aimed to investigate the clinical utility of the L/A ratio as a good prognostic indicator of mortality in a cohort of necrotizing fasciitis patients. Method This retrospective study was conducted in two tertiary hospitals in Taiwan between 2015 and 2020. We reviewed adult patients with measured serum lactate and albumin on the emergency department (ED) arrival to evaluate the prognostic performance of the lactate and lactate/albumin (L/A) ratio for outcome prediction. Result Of the 262 NF patients, 20 (7.63%) died in the hospital. The area under the receiver operating characteristic curve (AUROC) value of the L/A ratio (0.76, 95% confidence interval [CI] 0.69–0.81, P < 0.01) was higher than lactate alone (0.71, 95% CI 0.65–0.74 P < 0.01) for predicting in-hospital mortality. The optimal cutoff of the L/A ratio was 1.61. The AUROC value of the L/A ratio was better than lactate alone regardless of normal lactate level. The cutoff of L/A ratio and hypoalbuminemia showed further discriminative value for in-hospital mortality even in patients with normal lactate levels. Conclusion The prognostic performance of the L/A ratio was superior to a single measurement of lactate for predicting in-hospital mortality and intensive care unit (ICU) lengths in necrotizing fasciitis patients. Aggressive intervention and intensive care were necessary for high-risk NF patients upon ED arrival.
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Rampal S, Ganesan T, Sisubalasingam N, Neela VK, Tokgöz MA, Arunasalam A, Ab Halim MAH, Shamsudin ZB, Kumar S, Sinniah A. Local Trends of Antibiotic Prescriptions for Necrotizing Fasciitis Patients in Two Tertiary Care Hospitals in Central Malaysia. Antibiotics (Basel) 2021; 10:1120. [PMID: 34572702 PMCID: PMC8470198 DOI: 10.3390/antibiotics10091120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/08/2021] [Accepted: 09/11/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Necrotizing fasciitis (NF) is a rapidly progressive inflammatory infection of the soft tissue (also known as the fascia) with a secondary necrosis of the subcutaneous tissues, leading to a systemic inflammatory response syndrome (SIRS), shock and eventually death despite the availability of current medical interventions. The clinical management of this condition is associated with a significant amount of morbidity with a high rate of mortality. The prognosis of the disease is affected by multiple factors, which include the virulence of the causative pathogen, local host immunity, local wound factors and empirical antibiotics used. The local trends in the prescription of empirical antibiotics are often based on clinical practice guidelines (CPG), the distribution of the causative microorganism and the cost-effectiveness of the drug. However, there appears to be a paucity of literature on the empirical antibiotic of choice when dealing with necrotizing fasciitis in the clinical setting. This paper will outline common causative microorganisms and current trends of prescription in two tertiary centres in Central Malaysia. METHODS This was a cross-sectional study using retrospective data of patients treated for NF collected from two tertiary care hospitals (Hospital Seremban and Hospital Ampang) in Central Malaysia. A total of 420 NF patients were identified from the five years of retrospective data obtained from the two hospitals. RESULTS The top three empirical antibiotics prescribed are ampicillin + sulbactam (n = 258; 61.4%), clindamycin (n = 55; 13.1%) and ceftazidime (n = 41; 9.8%). The selection of the antibiotic significantly impacts the outcome of NF. The top three causative pathogens for NF are Streptococcus spp. (n = 79; 18.8%), Pseudomonas aeruginosa (n = 61; 14.5%) and Staphylococcus spp. (n = 49; 11.7%). The patients who received antibiotics had 0.779 times lower chances of being amputated. Patients with a lower laboratory risk indicator for necrotizing fasciitis (LRINEC) score had 0.934 times lower chances of being amputated. CONCLUSIONS In this study, the most common empirical antibiotic prescribed was ampicillin + sulbactam followed by clindamycin and ceftazidime. The antibiotics prescribed lower the risk of having an amputation and, hence, a better prognosis of the disease. Broad-spectrum empirical antibiotics following surgical debridement reduce the mortality rate of NF.
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Affiliation(s)
- Sanjiv Rampal
- Department of Orthopaedic and Traumatology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Seri Kembangan 43400, Malaysia; (N.S.); (V.K.N.); (M.A.H.A.H.)
| | - Thanusha Ganesan
- Department of Pharmacology, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia;
| | - Narresh Sisubalasingam
- Department of Orthopaedic and Traumatology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Seri Kembangan 43400, Malaysia; (N.S.); (V.K.N.); (M.A.H.A.H.)
| | - Vasantha Kumari Neela
- Department of Orthopaedic and Traumatology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Seri Kembangan 43400, Malaysia; (N.S.); (V.K.N.); (M.A.H.A.H.)
| | - Mehmet Ali Tokgöz
- Kecioren Education and Training Hospital, Pınarbaşı Quarter Sanatoryum Street Keçiören, Ankara, Turkey;
| | - Arun Arunasalam
- Urology Department, Hospital Serdang, Ministry of Health of Malaysia, Putrajaya 62590, Malaysia;
| | - Mohd Asyraf Hafizuddin Ab Halim
- Department of Orthopaedic and Traumatology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Seri Kembangan 43400, Malaysia; (N.S.); (V.K.N.); (M.A.H.A.H.)
| | | | - Suresh Kumar
- Centre for Materials Engineering and Regenerative Medicine, Bharath Institute of Higher Education and Research, Chennai 600173, India;
| | - Ajantha Sinniah
- Department of Pharmacology, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia;
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Daniels M, Oberländer H, Schiefer J, Sonnenberg P, Jörres A, Lefering R, Fuchs PC, Seyhan H. Lactate based Scoring System in the diagnosis of necrotizing fasciitis. J Burn Care Res 2021; 43:625-631. [PMID: 34324681 DOI: 10.1093/jbcr/irab148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Necrotizing fasciitis (NF) is a rare and quickly progressing infection and leads to 100% mortality if untreated. Quick diagnosis and an early and radical surgical treatment are essential for stopping bacterial progression. Unfortunately, the absence of clear clinical signs makes the diagnosis often challenging. Therefore, we searched for easy determinable predictive laboratory markers for NF. This is the first study which includes lactate values in a new score. MATERIAL AND METHODS A retrospective analysis of patients with NF (n = 44) and patients with erysipelas (n = 150) was performed. Lactate values, patients` demographics, clinical presentations, site of infection, comorbidities, microbiological and laboratory findings, antibiotic therapies and LRINEC and modified LRINEC Scores were analyzed. Logistic regression analysis was used to derive adjusted weights, and final simple point score was assessed with a ROC curve analysis. RESULTS Patients with NF had a mean age of 57 years, patients with erysipelas 65 years. The median hospital length of stay was 8 and 49 days in patients with erysipelas and NF, respectively. While only one patient (0.7 %) in the group of erysipelas died, the mortality rate of patients with NF was 9/44 (20.5 %). The lactate values were statistically significant higher in the NF group 4.1 vs. 2.0 mmol/l (p < 0.001). The new created CologNe-FaDe-Score shows the highest AUC-value with 0.907. CONCLUSION With the help of lactate values the CologNe-FaDe-Score consists of easily practicable and highly available parameters, which could sensitize diagnosis.
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Affiliation(s)
- Marc Daniels
- Department of Plastic, Reconstructive, Hand and Burn Surgery, University of Witten-Herdecke, Cologne, Germany
| | - Henrik Oberländer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, University of Witten-Herdecke, Cologne, Germany
| | - Jennifer Schiefer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, University of Witten-Herdecke, Cologne, Germany
| | - Philipp Sonnenberg
- Department of Medicine I, Cologne Merheim Medical Center, University of Witten-Herdecke, Cologne, Germany
| | - Achim Jörres
- Department of Medicine I, Cologne Merheim Medical Center, University of Witten-Herdecke, Cologne, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne, Germany
| | - Paul Christian Fuchs
- Department of Plastic, Reconstructive, Hand and Burn Surgery, University of Witten-Herdecke, Cologne, Germany
| | - Harun Seyhan
- Department of Plastic, Reconstructive, Hand and Burn Surgery, University of Witten-Herdecke, Cologne, Germany
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Korambayil SM, Iyer S, Williams DJ. Emergency hip disarticulations for severe necrotising fasciitis of the lower limb: a series of rare cases from a rural district general hospital. Ann R Coll Surg Engl 2021; 103:e223-e226. [PMID: 34192495 DOI: 10.1308/rcsann.2021.0079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Hip disarticulation is the removal of the entire lower limb through the hip joint by detaching the femur from the acetabulum. This major ablative procedure is rarely performed for infection but may be required in severe necrotising fasciitis. We present a single centre retrospective review of all cases of emergency hip disarticulations in patients with necrotising fasciitis between 2010 and 2020. All five patients included in the review presented with acute lower limb pain and sepsis. Three patients had comorbidities predisposing them to necrotising fasciitis. Three were deemed to be high risk and two were at intermediate risk of developing necrotising fasciitis. There were two deaths in the postoperative period. Of the three survivors, two required revision surgery for a completion hindquarter amputation and one for flap closure. All three survivors had good functional outcomes after discharge from hospital. Despite its associated morbidity, emergency amputation of the entire lower limb is a life-saving treatment in cases of rapidly progressing necrotising fasciitis and should be considered as a first-line option in managing this condition.
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Affiliation(s)
| | - S Iyer
- Northern Devon Healthcare NHS Trust, Barnstaple, UK
| | - D J Williams
- Northern Devon Healthcare NHS Trust, Barnstaple, UK
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19
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Necrotizing fasciitis: Usefulness of the LRINEC score in a third-level hospital. Injury 2021; 52 Suppl 4:S8-S15. [PMID: 34011440 DOI: 10.1016/j.injury.2021.02.093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/24/2021] [Accepted: 02/25/2021] [Indexed: 02/02/2023]
Abstract
AIM To review patients seen in the emergency room, diagnosed with necrotizing fasciitis (NF) and the correlation of such complications with the Laboratory Risk Indicator for Necrotizing fasciitis scale (LRINEC). The purpose of this study is to assess the use of the LRINEC score for early diagnosis of NF and its prognostic use in a consecutive series of cases treated at our hospital. METHODS Retrospective observational study including patients with a diagnosis of NF in the emergency room of a tertiary hospital over 11 years. The results are shown as median, interquartile range and absolute range for quantitative variables. In the case of qualitative variables, the results are shown as absolute and relative frequency. The comparison between the categories of the LRINEC scale was performed through a post-hoc comparison from a non-parametric rank-ANOVA analysis. Comparisons between LRINEC groups in the qualitative variables were performed using Fisher's exact test. RESULTS A total of 45 patients with a mean age of 51 years were identified. There was a 20% mortality rate (9 cases). The highest mortality rate was registered in the high-risk group (LRINEC greater than 8) with 4 deceased individuals (44.44%), while in the low and moderate-risk groups, 3 and 2 deceased individuals (33% and 22%) were registered, respectively, without considering this result statistically significant (p=0.811). There was an amputation rate of 15.6% (7 cases). The average LRINEC score was greater in the cases that required amputation 9 (95% CI 7; 13) in comparison to the other patients, 6 (95% CI 5; 8), p=0.044. The average hospital stay lasted 32.5 days (95% CI: 25; 40); 30 days in the low-risk group, 41 days in the moderate-risk group and 40 days in the high-risk group. Mortality was associated to a smaller number of interventions (p=0.005) and was preceded by septic shock in all cases. CONCLUSIONS The LRINEC score may be useful to aid diagnosis. However, clinical suspicion is the most important in diagnosis. A LRINEC low score does not exclude NF. In this retrospective series, 35.71% of cases presented a low LRINEC score, making the rate of false negatives high. In view of these results, The LRINEC score cannot be used as a prognostic value since an initial low score does not rule out serious evolution.
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Patra AP, Kumaran M. Fatal necrotizing fasciitis in illegal abortion and the negligence tort. Leg Med (Tokyo) 2021; 53:101927. [PMID: 34130172 DOI: 10.1016/j.legalmed.2021.101927] [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: 05/17/2021] [Accepted: 06/04/2021] [Indexed: 10/21/2022]
Abstract
The present paper is a case-based review on rare complications of illegal abortion, i.e., necrotizing fasciitis missed early by the treating gynecologists which landed up into a negligence tort against the physicians. The common complications of the abortion like incomplete abortion, haemorrhage, sepsis, etc. are usually handled successfully by the gynecologists; however, early detection often missed when a rare complication like necrotising fasciitis occurs. Eventually leading to litigations in case of death of the patient. The newer techniques have reduced the complications in medically terminated pregnancies (MTP); however, the deaths due to illegal abortions carried out by the clandestine abortion practitioners (CAP) poses a challenge, especially in rural areas. A 30-year-old woman went for an illegal abortion from a CAP to avoid social stigma. She developed sepsis & necrotising fasciitis (NF) of right lower limb due to intra-vaginal use of abortifacient herbs prescribed by the CAP. She was succumbed to the complications of necrotising fasciitis allegedly due to delayed diagnosis by the gynecologists. This led to a negligence tort filed by her family members against the treating gynecologists. The prudent medicolegal and medical steps are discussed here, that could have prevented such sequel.
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Affiliation(s)
- Ambika Prasad Patra
- Department of Forensic Medicine & Toxicology, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry 605006, India; Department of Forensic Medicine & Toxicology, Jawaharlal Institute of Postgraduate Medical Education & Research, Karaikal, India.
| | - M Kumaran
- Department of Forensic Medicine & Toxicology, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry 605006, India; Department of Forensic Medicine & Toxicology, Jawaharlal Institute of Postgraduate Medical Education & Research, Karaikal, India
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21
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van Stigt S, Knubben M, Schrooten T, Tan E. Prognostic factors for mortality in 123 severe cases of necrotizing fasciitis in 5 hospitals in the Netherlands between 2003 and 2017. Eur J Trauma Emerg Surg 2021; 48:1189-1195. [PMID: 34046689 PMCID: PMC9001207 DOI: 10.1007/s00068-021-01706-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 05/17/2021] [Indexed: 11/25/2022]
Abstract
Purpose Necrotizing fasciitis (NF) is a severe soft tissue infection with a high morbidity and mortality. With early diagnosis and treatment this could be reduced. Unfortunately, the diagnosis of necrotizing fasciitis can be very difficult. In recent years many risk factors have been identified. In 2004, the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was developed. A tool that could help diagnosing NF. In this study, we search for prognostic factors for mortality in necrotizing fasciitis. Methods All adult patients with histopathological or surgical confirmed NF needed to be admitted to the intensive care unit for at least 24 h between January 2003 and December 2017 in five hospitals from the Nijmegen teaching region were included. We excluded patients with other forms of soft tissue infections or patients with an intensive care unit (ICU) stay of < 24 h because we exclusively wanted to include patients with a fulminant course of necrotizing fasciitis. Results We have included 123 cases. The overall mortality was 31.7% (N = 39). The overall mean LRINEC score was 7.4 ± 2.7. Patients who died as the result of NF had a significantly higher median LRINEC score (8 vs. 7, p = 0.034). Other parameters found to be associated with mortality are age ≥ 60 years, cardiovascular disease in the medical history, ≥ 2 comorbidities, and lactate level greater than 1.7 mmol/L. Conclusion LRINEC score should be calculated in all patients presenting with NF to provide an additional source for clinical outcome. A high LRINEC score could implicate a higher risk of mortality. Especially in elderly patients, with a cardiac history, more than two comorbidities or a lactate level greater than 1.7 mmol/L.
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Affiliation(s)
- Sander van Stigt
- Department of Surgery, Traumasurgery, Medical Spectrum Twente, Koningsstraat 1, 7512 KZ, Enschede, The Netherlands.
| | - Merel Knubben
- Department of Surgery, Traumasurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Tim Schrooten
- Department of Surgery, Traumasurgery, Medical Spectrum Twente, Koningsstraat 1, 7512 KZ, Enschede, The Netherlands
| | - Edward Tan
- Department of Surgery, Traumasurgery, Radboud University Medical Center, Nijmegen, The Netherlands
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Grier JT, Arivett BA, Ramírez MS, Chosed RJ, Bigner JA, Ohneck EJ, Metz ML, Wood CR, Arce S, Tartaro A, Relich RF, Actis LA, Fiester SE. Two Acinetobacter baumannii Isolates Obtained From a Fatal Necrotizing Fasciitis Infection Display Distinct Genomic and Phenotypic Characteristics in Comparison to Type Strains. Front Cell Infect Microbiol 2021; 11:635673. [PMID: 33912474 PMCID: PMC8072282 DOI: 10.3389/fcimb.2021.635673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 03/11/2021] [Indexed: 11/23/2022] Open
Abstract
Acinetobacter baumannii has been recognized as a critical pathogen that causes severe infections worldwide not only because of the emergence of extensively drug-resistant (XDR) derivatives, but also because of its ability to persist in medical environments and colonize compromised patients. While there are numerous reports describing the mechanisms by which this pathogen acquires resistance genes, little is known regarding A. baumannii’s virulence functions associated with rare manifestations of infection such as necrotizing fasciitis, making the determination and implementation of alternative therapeutic targets problematic. To address this knowledge gap, this report describes the analysis of the NFAb-1 and NFAb-2 XDR isolates, which were obtained at two time points during a fatal case of necrotizing fasciitis, at the genomic and functional levels. The comparative genomic analysis of these isolates with the ATCC 19606T and ATCC 17978 strains showed that the NFAb-1 and NFAb-2 isolates are genetically different from each other as well as different from the ATCC 19606T and ATCC 17978 clinical isolates. These genomic differences could be reflected in phenotypic differences observed in these NFAb isolates. Biofilm, cell viability and flow cytometry assays indicate that all tested strains caused significant decreases in A549 human alveolar epithelial cell viability with ATCC 17978, NFAb-1 and NFAb-2 producing significantly less biofilm and significantly more hemolysis and capacity for intracellular invasion than ATCC 19606T. NFAb-1 and NFAb-2 also demonstrated negligible surface motility but significant twitching motility compared to ATCC 19606T and ATCC 17978, likely due to the presence of pili exceeding 2 µm in length, which are significantly longer and different from those previously described in the ATCC 19606T and ATCC 17978 strains. Interestingly, infection with cells of the NFAb-1 isolate, which were obtained from a premortem blood sample, lead to significantly higher mortality rates than NFAb-2 bacteria, which were obtained from postmortem tissue samples, when tested using the Galleria mellonella in vivo infection model. These observations suggest potential changes in the virulence phenotype of the A. baumannii necrotizing fasciitis isolates over the course of infection by mechanisms and cell processes that remain to be identified.
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Affiliation(s)
- Jennifer T Grier
- Department of Biomedical Sciences, University of South Carolina School of Medicine Greenville, Greenville, SC, United States
| | - Brock A Arivett
- Department of Biology, Middle Tennessee State University, Murfreesboro, TN, United States
| | - Maria S Ramírez
- Department of Biological Science, California State University Fullerton, Fullerton, CA, United States
| | - Renee J Chosed
- Department of Biomedical Sciences, University of South Carolina School of Medicine Greenville, Greenville, SC, United States
| | - Jessica A Bigner
- Department of Biomedical Sciences, University of South Carolina School of Medicine Greenville, Greenville, SC, United States
| | - Emily J Ohneck
- Department of Microbiology, Miami University, Oxford, OH, United States
| | - Maeva L Metz
- Department of Microbiology, Miami University, Oxford, OH, United States
| | - Cecily R Wood
- Department of Microbiology, Miami University, Oxford, OH, United States
| | - Sergio Arce
- Department of Biomedical Sciences, University of South Carolina School of Medicine Greenville, Greenville, SC, United States.,Cancer Institute, Prisma Health, Greenville, SC, United States
| | - Andrea Tartaro
- Computer Science Department, Furman University, Greenville, SC, United States
| | - Ryan F Relich
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Luis A Actis
- Department of Microbiology, Miami University, Oxford, OH, United States
| | - Steven E Fiester
- Department of Biomedical Sciences, University of South Carolina School of Medicine Greenville, Greenville, SC, United States.,Department of Pathology, Prisma Health, Greenville, SC, United States
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Somasundaram J, Wallace DL, Cartotto R, Rogers AD. Flap coverage for necrotising soft tissue infections: A systematic review. Burns 2021; 47:1608-1620. [PMID: 34172327 DOI: 10.1016/j.burns.2021.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 12/05/2020] [Accepted: 01/20/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Necrotising soft tissue infections (NSTI) are destructive and often life-threatening infections of the skin and soft tissue, necessitating prompt recognition and aggressive medical and surgical treatment. After debridement, the aim of surgical closure and reconstruction is to minimize disability and optimize appearance. Although skin grafting may fulfil this role, techniques higher on the reconstructive ladder, including local, regional and free flaps, are sometimes undertaken. This systematic review sought to determine the circumstances when this is true, which flaps were most commonly employed, and for which anatomical areas. METHODS A systematic review of the literature was conducted utilising electronic databases (Medline, Embase, Cochrane Library). Full text studies of flaps used for the management of NSTI's (including Necrotising Fasciitis and Fournier Gangrene) were included. The web-based program 'Covidence' facilitated storage of references and data management. Data obtained in the search included reference details (journal, date and title), the study design, the purpose of the study, the study findings, number of patients with NSTI included, the anatomical areas of NSTI involved, the types of flaps used, and the complication rate. RESULTS After screening 4555 references, 501 full text manuscripts were assessed for eligibility after duplicates and irrelevant studies were excluded. 230 full text manuscripts discussed the use of 888 flap closures in the context of NSTI in 733 patients; the majority of these were case series published in the last 20 years in a large variety of journals. Reconstruction of the perineum following Fournier's gangrene accounted for the majority of the reported flaps (58.6%). Free flaps were used infrequently (8%), whereas loco-regional muscle flaps (18%) and loco-regional fasciocutaneous flaps (71%) were employed more often. The reported rate of partial or complete flap loss was 3.3%. CONCLUSION Complex skin and soft tissue defects from NSTIs, not amenable to skin grafting, can be more effectively and durably covered using a spectrum of flaps. This systematic review highlights the important contribution that the plastic surgeon makes as an integral member of multidisciplinary teams managing these patients.
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Affiliation(s)
- J Somasundaram
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - D L Wallace
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - R Cartotto
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - A D Rogers
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, Toronto, Canada.
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Abstract
Necrotizing fasciitis is a fulminant and potentially life-threatening infection of the skin and soft tissue. It is usually caused by a combination of different bacteria and is often due to assumed minor trauma. Clinically, only relatively insignificant skin changes are initially present, such as blistering or erythema. They are often accompanied by excessive pain. In the further course, the massive systemic reaction becomes predominant. The diagnosis of necrotizing fasciitis is primarily clinical, which can be supported by laboratory parameters (LRINEC score) and computed tomography imaging. Decisive for the prognosis is the immediate initiation of surgical treatment by radical debridement. Additionally, the calculated administration of a combination of different antibiotics should be initiated. As part of the further complex intensive care treatment, a regular reevaluation of the wounds is carried out. Multiple débridements are always necessary until plastic surgery for defect coverage can be carried out.
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Affiliation(s)
- V M Hösl
- Hochschulzentrum für Plastische‑, Ästhetische, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland.
| | - A Kehrer
- Hochschulzentrum für Plastische‑, Ästhetische, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - L Prantl
- Hochschulzentrum für Plastische‑, Ästhetische, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
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Abstract
Necrotizing soft tissue infections of the upper extremity have varying microbiologies and etiologies. Risk factors for development include diabetes mellitus, intravenous drug use, peripheral arterial disease, smoking, alcohol abuse, and immunocompromised state. Although clinical examination is the mainstay of diagnosis, laboratory tests and imaging can aid in diagnosis. Surgical débridements usually are needed for treatment, with resultant defects that often require reconstruction. Rates of amputation are reported as 22% to 37.5% and mortality from necrotizing soft tissue infections of the upper extremity from 22% to 34%. Prompt surgical and antimicrobial treatment is necessary to decrease risk of loss of limb or life.
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Affiliation(s)
- Atlee Melillo
- Division of Plastic Surgery, Cooper University Health Care, 3 Cooper Plaza, Suite 411, Camden, NJ 08103, USA
| | - Kamal Addagatla
- Division of Plastic Surgery, Cooper University Health Care, 3 Cooper Plaza, Suite 411, Camden, NJ 08103, USA
| | - Nicole J Jarrett
- Division of Plastic Surgery, Cooper University Health Care, 3 Cooper Plaza, Suite 411, Camden, NJ 08103, USA.
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Irianto KA, Martanto TW, Nugroho RP, Sindrawati O, Kloping YP. Traditional herbal treatment induced bilateral amputation of the feet in a five-year-old child: A case report. Int J Surg Case Rep 2020; 70:110-114. [PMID: 32416479 PMCID: PMC7229236 DOI: 10.1016/j.ijscr.2020.04.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/13/2020] [Accepted: 04/20/2020] [Indexed: 11/25/2022] Open
Abstract
Bilateral gangrene usually progress to a systemic infection and death if not treated properly. The development of bilateral gangrene to acute limb ischemia and eventually leading to auto amputation of both feet in this patient was unusual as she did not receive any medical or surgical interventions. The rare occurrence of bilateral autoamputation without any underlying vascular or neurological disorders in this patient is likely caused by vasospasm and thrombosis triggered by the herbal treatments, which possibly contain ergot alkaloids, given by the traditional healer. This phenomenon may play a part in future considerations for performing amputation to patients with possible necrotizing fasciitis.
Introduction Bilateral gangrene of both legs in a child is a rare condition which may lead to sepsis when improperly treated. In certain rare cases, autoamputation may occur instead. We report a case of bilateral symmetrical autoamputation of the feet following necrotizing fasciitis after a fall injury which was treated with herbal medicine in a five-year-old child. Presentation of case A five-year-old girl fell from a bicycle and was treated by a traditional healer by wrapping her legs with herbs and leaves. Within 24 h, the skin of both lower limbs darkened. Her vital signs show tachycardia and fever. Physical examination revealed bluish black sharp discoloration of both her lower extremities. On the 3rd day of systemic antibiotic administration, her feet, distal portion of both legs, and part of the thighs darkened progressively. The parents refused any additional intervention due to financial constraints and went back to the traditional healer. A month later, the patient returned to the hospital with both lower extremities autoamputated. The parents denied further treatment. Two months later, the patient was admitted to receive prostheses funded by the city council. Debridement of necrotic bone and soft tissue and skin grafting was performed. In the present day, the patient is in a healthy condition. Conclusion The rare occurrence of bilateral autoamputation without any underlying vascular or neurological disorders in this patient is likely caused by vasospasm and thrombosis induced by the herbal treatments which prevent the systemic spread of infection.
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Affiliation(s)
- Komang Agung Irianto
- Department of Orthopedics and Traumatology, Dr Soetomo General Hospital, Medical Faculty of Universitas Airlangga, Jl. Prof. Dr Moestopo 6-8 Surabaya, 60115, Indonesia.
| | - Tri Wahyu Martanto
- Department of Orthopedics and Traumatology, Dr Soetomo General Hospital, Medical Faculty of Universitas Airlangga, Jl. Prof. Dr Moestopo 6-8 Surabaya, 60115, Indonesia
| | - Rendra Praliestyo Nugroho
- Department of Orthopedics and Traumatology, Dr Soetomo General Hospital, Medical Faculty of Universitas Airlangga, Jl. Prof. Dr Moestopo 6-8 Surabaya, 60115, Indonesia
| | - Oen Sindrawati
- Pathology Department, Medical Faculty Widya Mandala Catholic University, Indonesia
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27
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Abstract
Necrotizing fasciitis is a fulminant and potentially life-threatening infection of the skin and soft tissue. It is usually caused by a combination of different bacteria and is often due to assumed minor trauma. Clinically, only relatively insignificant skin changes are initially present, such as blistering or erythema. They are often accompanied by excessive pain. In the further course, the massive systemic reaction becomes predominant. The diagnosis of necrotizing fasciitis is primarily clinical, which can be supported by laboratory parameters (LRINEC score) and computed tomography imaging. Decisive for the prognosis is the immediate initiation of surgical treatment by radical debridement. Additionally, the calculated administration of a combination of different antibiotics should be initiated. As part of the further complex intensive care treatment, a regular reevaluation of the wounds is carried out. Multiple débridements are always necessary until plastic surgery for defect coverage can be carried out.
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Affiliation(s)
- V M Hösl
- Hochschulzentrum für Plastische‑, Ästhetische, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland.
| | - A Kehrer
- Hochschulzentrum für Plastische‑, Ästhetische, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - L Prantl
- Hochschulzentrum für Plastische‑, Ästhetische, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
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28
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Dahmam A, Devinck F, Choughri H, Pelissier P. Finger necrotizing fasciitis caused by Vibriovulnificus. HAND SURGERY & REHABILITATION 2020; 39:336-338. [PMID: 32251740 DOI: 10.1016/j.hansur.2020.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 03/03/2020] [Accepted: 03/16/2020] [Indexed: 11/30/2022]
Affiliation(s)
- A Dahmam
- Department of plastic, reconstructive and aesthetic surgery - burns and hand surgery unit, François-Xavier Michelet Center, Bordeaux university hospital, place Amélie Raba-Léon, 33000 Bordeaux, France.
| | - F Devinck
- Department of plastic, reconstructive and aesthetic surgery - burns and hand surgery unit, François-Xavier Michelet Center, Bordeaux university hospital, place Amélie Raba-Léon, 33000 Bordeaux, France
| | - H Choughri
- Department of plastic, reconstructive and aesthetic surgery - burns and hand surgery unit, François-Xavier Michelet Center, Bordeaux university hospital, place Amélie Raba-Léon, 33000 Bordeaux, France
| | - P Pelissier
- Department of plastic, reconstructive and aesthetic surgery - burns and hand surgery unit, François-Xavier Michelet Center, Bordeaux university hospital, place Amélie Raba-Léon, 33000 Bordeaux, France
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29
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Ward JA, Gibson JAG, Nguyen DQ. Management of necrotising fasciitis within a burns centre: do outcomes differ? Scars Burn Heal 2020; 6:2059513120924749. [PMID: 32655900 PMCID: PMC7328481 DOI: 10.1177/2059513120924749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Many similarities exist between the care of necrotising fasciitis (NF) and burn injury patients. Each group represents a small but complex cohort requiring multiple theatre trips, specialist reconstruction, meticulous wound care and multidisciplinary management. Over a six-year period, we sought to examine the clinical outcomes of NF patients managed within a burns centre against those managed by a plastic surgery service. METHODS A retrospective case-note review was performed for all identifiable patients referred to our institution's designated burns centre or plastic surgery service between 2008-2014. Patient characteristics, length of stay, wound-related and clinical outcomes were extracted and descriptively presented with statistical analysis performed for survival and length of stay. RESULTS Twenty-nine patients were included in the study (burns centre [B]: 17 patients; plastic surgery service [P]: 12 patients). Median total length of stay (B: 37 vs. P: 50 days, P=0.38), local length of stay (27 vs. 19 days, P=0.29) and survival till discharge (94.4% vs. 100%, P=0.73) demonstrated no statistically significant difference. CONCLUSION Caring for NF patients within a burns centre facilitated easier access to specialist reconstructive expertise and multidisciplinary care but did not lead to statistically significant differences in length of stay or survival. The management of NF within a burns centre facilitated provision of high-quality care to a highly challenging patient group.
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Affiliation(s)
- Joseph A Ward
- Department of Plastic Surgery,
Royal Marsden Hospital, Chelsea, London, UK
| | - John A G Gibson
- Welsh Centre for Burns and Plastic
Surgery, Morriston Hospital, Heol Maes Eglwys, Morriston, Swansea, UK
| | - Dai Q Nguyen
- Welsh Centre for Burns and Plastic
Surgery, Morriston Hospital, Heol Maes Eglwys, Morriston, Swansea, UK
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30
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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 2019; 43:2734-2739. [PMID: 31312952 PMCID: PMC6778025 DOI: 10.1007/s00268-019-05087-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [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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31
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Vilallonga R, Mazarro A, Rodríguez-Luna MR, Caubet E, Fort JM, Armengol M, Guirao X. Massive necrotizing fasciitis: a life threatening entity. J Surg Case Rep 2019; 2019:rjz269. [PMID: 31719969 PMCID: PMC6830038 DOI: 10.1093/jscr/rjz269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 09/10/2019] [Indexed: 11/15/2022] Open
Abstract
Necrotizing fasciitis (NF) is a complicated soft tissue infection frequently associated with severe sepsis if an early medical and surgical treatment is not performed. We report two postoperative cases of severe NF after oophorectomy and colorectal resection. Because of the similarity with more benign skin infections at the early steps, clinical suspicion is crucial. Surgical exploration and resection will provide both the diagnosis confirming necrotizing infection of the fascia with vessels and treatment. Also, empirical broad-spectrum antibiotics must be initiated as soon as possible. Regardless of the presence of risk factors, NF is a condition with a high mortality rate and only an expeditious and undelayed treatment may improve the patient's outcome. Surgical focus control requires wide and repeated resections, and planned reconstructive plastic surgery might be necessary.
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Affiliation(s)
- Ramon Vilallonga
- Endocrine Bariatric and Metabolic Unit, General Surgery Department, Universitary Hospital Vall d’Hebron, European Center of Excellence (EAC-BS), Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
- ELSAN, Clinique St-Michel, Toulon, France
| | - Alejandro Mazarro
- General Surgery Department, Hospital Universitari de la Vall d’Hebron, Barcelona, Spain
| | | | - Enric Caubet
- Endocrine Bariatric and Metabolic Unit, General Surgery Department, Universitary Hospital Vall d’Hebron, European Center of Excellence (EAC-BS), Barcelona, Spain
| | - José Manuel Fort
- Endocrine Bariatric and Metabolic Unit, General Surgery Department, Universitary Hospital Vall d’Hebron, European Center of Excellence (EAC-BS), Barcelona, Spain
| | - Manuel Armengol
- General Surgery Department, Hospital Universitari de la Vall d’Hebron, Barcelona, Spain
| | - Xavier Guirao
- Department of General Surgery Parc Tauli, Hospital Universitari, Sabadell, Hospital General de Granollers, Barcelona, Spain
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32
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Nawijn F, Verhiel SH, Lunn KN, Eberlin KR, Hietbrink F, Chen NC. Factors Associated with Mortality and Amputation Caused by Necrotizing Soft Tissue Infections of the Upper Extremity: A Retrospective Cohort Study. World J Surg 2019; 44:730-740. [DOI: 10.1007/s00268-019-05256-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Abstract
Background
It is unclear what the exact short-term outcomes of necrotizing soft tissue infections (NSTIs), also known and necrotizing fasciitis of the upper extremity, are and whether these are comparable to other anatomical regions. Therefore, the aim of this study is to assess factors associated with mortality within 30-days and amputation in patients with upper extremity NSTIs.
Methods
A retrospective study over a 20-year time period of all patients treated for NSTIs of the upper extremity was carried out. The primary outcomes were the 30-day mortality rate and the amputation rate in patients admitted to the hospital for upper extremity NSTIs.
Results
Within 20 years, 122 patients with NSTIs of the upper extremity were identified. Thirteen patients (11%) died and 17 patients (14%) underwent amputation. Independent risk factors for mortality were an American Society of Anesthesiologists (ASA) classification of 3 or higher (OR 9.26, 95% CI 1.64–52.31) and a base deficit of 3 meq/L or greater (OR 10.53, 95% CI 1.14–96.98). The independent risk factor for amputation was a NSTI of the non-dominant arm (OR 3.78, 95% CI 1.07–13.35). Length of hospital stay was 15 (IQR 9–21) days.
Conclusion
Upper extremity NSTIs have a relatively low mortality rate, but a relatively high amputation rate compared to studies assessing NSTIs of all anatomical regions. ASA classification and base deficit at admission predict the prognosis of patients with upper extremity NSTIs, while a NSTI of the non-dominant side is a risk factor for limb loss.
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33
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Vella JX, Jeavons RP. Necrotising fasciitis in a patient with monoclonal gammopathy of undetermined significance. JRSM Open 2019; 10:2054270419849352. [PMID: 31413855 PMCID: PMC6676256 DOI: 10.1177/2054270419849352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
To consider the potential risk of an unprovoked infectious disease, such as necrotising fasciitis, being present in patients whereby monoclonal gammopathy of undetermined significance is an active co-morbidity.
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Affiliation(s)
- John X Vella
- University Hospital of North Tees, Stockton-on-Tees TS19 8PE, UK
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Okkabaz N, Turgut MA. Necrotising fasciitis of the thigh caused by duodenum invasion of renal cell carcinoma: A case report. Int Wound J 2019; 16:1195-1198. [PMID: 31407501 DOI: 10.1111/iwj.13186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Accepted: 07/28/2019] [Indexed: 01/01/2023] Open
Abstract
Necrotising fasciitis, widespread necrosis of the skin, subcutaneous tissue, and superficial fascia, may be caused by many factors, among which underlying malignancy is observed rarely. We report a case with necrotising fasciitis of the lower extremity because of a duodenum to retroperitoneum fistula caused by renal cell carcinoma invasion. A 62-year-old male with newly diagnosed renal cell carcinoma was diagnosed with necrotising fasciitis at the end of 2 days in hospital. One day after debridement surgery, biliary contamination of dressings and tomography demonstrated fistulation from the duodenum to retroperitoneum and then to the right thigh because of renal tumour invasion. The second operation was performed to repair the duodenum. Intravenous antibiotics and hydration were maintained postoperatively. Although there was no surgical complication, the patient died because of respiratory collapse at the 12th day postoperatively. Renal cell carcinoma may invade the duodenum and, with retroperitoneal fistulation, may be the cause of necrotising fasciitis of the thigh. Laparotomy may be needed to control the origin of infection. However, necrotising fasciitis may be fatal in spite of aggressive treatment. The fasciitis should be diagnosed early to initiate timely aggressive treatment, and a possible endogenous source should be kept in mind.
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Affiliation(s)
- Nuri Okkabaz
- Department of General Surgery, Istanbul Bagcilar Education and Research Hospital, Istanbul, Turkey
| | - Mehmet Alim Turgut
- Department of General Surgery, Istanbul Bagcilar Education and Research Hospital, Istanbul, Turkey
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35
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Tong KS, Williams DC, Seifman MA, Hunter-Smith DJ, Rozen WM. Synchronous multifocal necrotizing soft tissue infections: a case report and literature review. EUROPEAN JOURNAL OF PLASTIC SURGERY 2019. [DOI: 10.1007/s00238-019-1503-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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36
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Risk factors of synchronous multifocal necrotizing fasciitis: a case control study in comparison with monofocal necrotizing fasciitis in Taiwan. BMC Infect Dis 2019; 19:513. [PMID: 31185920 PMCID: PMC6558844 DOI: 10.1186/s12879-019-4103-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 05/16/2019] [Indexed: 11/23/2022] Open
Abstract
Background Monofocal necrotizing fasciitis (MONF) involves a single site in a rapidly progressing infection and necrosis of the fascia and surrounding soft tissue. Synchronous multifocal necrotizing fasciitis (SMNF), the simultaneous development of NF in multiple noncontiguous sites, is rarely reported. This study aimed to compare the clinical characteristics and outcomes between patients with SMNF and MONF, and to determine the risk factors of SMNF. Methods Our retrospective case-control study compared the clinical characteristics and outcomes, between January 2006 and January 2013, of patients with SMNF and of patients with MONF of the extremities. Results We enrolled 144 patients with NF of the extremities: 19 with SMNF and 125 with MONF. The duration of symptoms before admission was significantly shorter for the former than for the latter (1.7 days vs. 3.3 days, p = 0.001); the prevalence of shock at the initial visit significantly higher (73.7% vs. 36%, p = 0.002); and the total-case postoperative mortality rate significantly higher (68.4% vs. 14.4%, p < 0.001). In further analysis of the total-case mortality, 9 in 13 SMNF deaths (69.2%) within 7 days after fasciotomy were in the majority while 13 with 28-day mortality (72.2%) was the majority of MONF deaths (p < 0.001). SMNF was significantly more likely to involve bacteremia (89.5% vs. 36%, p < 0.001). Independent risk factors for SMNF were liver cirrhosis (LC) (odds ratio [OR] 6.0, p = 0.001) and end-stage renal disease (ESRD) (OR 7.1, p = 0.035). Gram-negative bacteria were most common in SMNF, and Gram-positive bacteria in MONF (83.3% vs. 53.3%, p = 0.005). Vibrio species were the most common single microbial cause (35.4%) of all NF patients and were the overwhelming cause (73.7%) of SMNF. Staphylococcus aureus and group A β-hemolytic streptococcus (45.6%) were the other predominant causes of MONF while both (10.5%) rarely caused multifocal NF. Conclusions SMNF was more fulminant than was MONF. SMNF was attributable primarily to marine Gram-negative bacteria. Physicians should be aware of SMNF because of its extremely high mortality rate.
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Collins J. Surgical intervention and customised dressings in an extremity wound caused by necrotising fasciitis: a case study. J Wound Care 2019; 28:S21-S27. [PMID: 31067168 DOI: 10.12968/jowc.2019.28.sup5.s21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Necrotising fasciitis can result in extensive loss of soft tissue and limb function. Therefore, surgical intervention requires a balance between extensive tissue removal and saving the limb. A 56-year-old male presented with necrotising fasciitis of the upper extremity. Debridement resulted in a full-thickness wound of the forearm and upper arm, an exposed olecranon and two proximally-based skin flaps. Reconstruction required multiple debridements to optimise the wound for skin grafting and to obtain flap adherence to underlying tissues of the upper arm. Conventional dressings over the flaps proved unsuccessful. Therefore, a customised versatile dressing to address each area of the wound was developed. Negative pressure wound therapy (NPWT) was applied over the exposed muscle (no exposed bone or tendon) of the lower arm and anterior upper arm; a hydropolymer foam dressing covered the elbow region. Closed incision negative pressure wound therapy (ciNPT) was applied over the incision on the posterior upper arm. Ultimately, complete wound closure was achieved, with normal/near-normal range of motion for all joints of the affected limb. There was complete take of skin grafts on the wrist, lower arm and anterior upper arm. ciNPT was effective in holding the incision together and promoting healing of the posterior upper arm, and the hydropolymer foam dressing aided with healing and coverage of the elbow region. In this case, healing of a large, complex upper extremity wound and restored limb function were achieved following use of a combination of surgical techniques and customisation of wound therapy modalities.
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Affiliation(s)
- Jessica Collins
- Plastic & Reconstructive Surgery, OasisMD Lifestyle Healthcare, San Diego, CA, US
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38
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Neilly DW, Smith M, Woo A, Bateman V, Stevenson I. Necrotising fasciitis in the North East of Scotland: a 10-year retrospective review. Ann R Coll Surg Engl 2019; 101:363-372. [PMID: 30855976 PMCID: PMC6513372 DOI: 10.1308/rcsann.2019.0013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2018] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Necrotising fasciitis is a life-threatening rapidly progressing bacterial infection of the skin requiring prompt diagnosis and treatment. Optimum care warrants a combination of surgical debridement, antibiotics and intensive care support. All cases of necrotising fasciitis in 10 years in the North East of Scotland were reviewed to investigate and improve patient care. METHODS Cases between August 2006 and February 2016 were reviewed using case notes and electronic hospital records. Data including mode of admission, clinical observations, investigations, operative interventions, microbiological and clinical outcomes was collected and reviewed. Analysis required multidisciplinary input including microbiology, infectious disease, trauma and orthopaedics, plastic surgery and intensive care teams. RESULTS A total of 36 cases were identified. The mean laboratory risk indicator for necrotising fasciitis (LRINEC) score was 7 and 86% of patients fulfilled the criteria for necrotising fasciitis. Patients were commonly haemodynamically stable upon admission but deteriorated rapidly; 36% of patients had a temperature of over 37.5 degrees C on initial observations; 29/36 patients were discharged, 6 patients died acutely (acute mortality rate of 17%); 18/31 of cases were polymicrobial with Streptococcus pyogenes, the common organism. Six amputations or disarticulations were performed from a total of 82 operations in this group, with radical debridement the usual primary operation. The mean time to theatre was 3.54 hours. Highly elevated admission respiratory rate (50 breaths/minute) was associated with increased mortality. CONCLUSIONS Necrotising fasciitis presents subtly and carries significant morbidity and mortality. A high index of suspicion allows early diagnosis and intervention. We believe that a pan-specialty approach is the cornerstone for good outcomes.
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Affiliation(s)
- DW Neilly
- Department of Trauma and Orthopaedics, Aberdeen Royal Infirmary, Aberdeen, UK
| | - M Smith
- Department of Trauma and Orthopaedics, Aberdeen Royal Infirmary, Aberdeen, UK
| | - A Woo
- Department of Trauma and Orthopaedics, Aberdeen Royal Infirmary, Aberdeen, UK
| | - V Bateman
- Department of Microbiology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - I Stevenson
- Department of Trauma and Orthopaedics, Aberdeen Royal Infirmary, Aberdeen, UK
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Predicting Morbidity and Mortality in Patients with Lower Extremity Necrotizing Fasciitis. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2019; 53:27-32. [PMID: 33536822 PMCID: PMC7847728 DOI: 10.14744/semb.2019.57778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 01/28/2019] [Indexed: 11/20/2022]
Abstract
Objectives: Necrotizing fasciitis (NF) is a rare but limb- and life-threatening soft-tissue infection. It is among the most challenging surgical infections faced by surgeons, and is often accompanied by severe systemic toxicity. The aim of this study was to evaluate the predictive power of serum lactate and creatinine levels for mortality and morbidity in lower extremity NF. Methods: A retrospective cohort analysis of 87 patients with lower extremity NF was performed to evaluate the management techniques and the amputation and survival rates according to serum lactate and creatinine levels as well as the time between the onset of symptoms and surgery. Results: The mean time between the onset of symptoms and surgery was 3.7 days. As the time between the onset of symptoms and surgery increased, the rate of amputation and mortality significantly increased (p<0.001). In all, 66% of the mortality in the group was seen among the 12 patients who had a serum creatinine level greater than 2 mg/dL at the time of presentation. In 12 of 14 patients (85.7%) who underwent amputation/disarticulation, the mean serum lactate level was 5.7 mmol/L (range: 5.1-8.7 mmol/L), and the mean serum creatinine level was 1.92 mg/dL (range: 1.4 to.3.3 mg/dL). The high levels of serum creatinine and lactate were found to be statistically significant in terms of predicting mortality and amputation (p<0.001). Conclusion: Based on the results of this study, it was determined that risk factors for mortality include age, late presentation, increased serum creatinine and lactate levels, and that these factors can predict the rate of death from NF at the time of presentation.
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A multiplex PCR assay for detection of Vibrio vulnificus, Aeromonas hydrophila, methicillin-resistant Staphylococcus aureus, Streptococcus pyogenes, and Streptococcus agalactiae from the isolates of patients with necrotizing fasciitis. Int J Infect Dis 2019; 81:73-80. [PMID: 30690211 DOI: 10.1016/j.ijid.2019.01.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 01/11/2019] [Accepted: 01/19/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Vibrio vulnificus, Aeromonas hydrophila, methicillin-resistant Staphylococcus aureus (MRSA), group A Streptococcus, and group B Streptococcus are commonly detected causative agents of necrotizing fasciitis (NF) in Chia-Yi Chang Gung Memorial Hospital. The aim of this study was to develop and evaluate a multiplex PCR method for the simultaneous detection of five of the most important human pathogens involved in NF by using a novel combination of species-specific genes. METHODS The samples used were collected from 99 patients with surgically confirmed NF of the extremities who were hospitalized consecutively between June 2015 and November 2017. Two sets of blood and tissue samples were collected from all patients; one set was sent to a microbiology laboratory for bacterial identification and the other set was sent to an immunohistochemistry laboratory for PCR amplification. RESULTS The multiplex PCR results for the blood samples showed negative findings. The multiplex PCR results for the tissue specimens showed 28 positive findings. Fourteen (87.5%) of the 16 V. vulnificus culture-positive tissue specimens, six (75%) of the eight A. hydrophila culture-positive tissue specimens, and four (100%) of the four MRSA culture-positive tissue specimens were positive by PCR. Similarly, two (100%) of the group A Streptococcus and two (100%) of the group B Streptococcus were PCR-positive. CONCLUSIONS The accuracy rate of the multiplex PCR presenting positive results in these culture-positive tissue samples was 87.5% (28/32). This suggests that multiplex PCR of tissue specimens may be a useful and rapid diagnostic tool for the detection of these lethal microorganisms in patients with NF.
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Minini A, Galli S, Salvi AG, Zarattini G. Necrotizing fasciitis of the hand: a case report. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 90:162-168. [PMID: 30715018 PMCID: PMC6503417 DOI: 10.23750/abm.v90i1-s.7992] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 12/14/2018] [Indexed: 01/17/2023]
Abstract
Necrotizing Fasciitis is a rare life-threatening infection, usually polymicrobial, that frequently affects the extremities in as many as two thirds of the cases. It typically involves primarily the muscular fascia, and then spreads through muscular and subcutaneous tissues. The early diagnosis may be challenging, and appears to be crucial in the management of this condition. We report a case of a 45-year-old man, former drug abuser, diabetic, HCV+, who developed a necrotizing fasciitis of the hand following a minor trauma. Early diagnosis based on clinical, laboratory (LRINEC score) and radiological findings, together with an accurate debridement of the affected site, allowed us to limitate the amputation to the third ray only. The reconstruction with the capitate osteotomy and the coverage with the posterior interosseous flap helped us in further reduction of the functional impairment of the hand. (www.actabiomedica.it)
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Affiliation(s)
- Andrea Minini
- Clinica Ortopedica dell'Università degli Studi di Brescia.
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Kim YH, Ha JH, Kim JT, Kim SW. Managing necrotising fasciitis to reduce mortality and increase limb salvage. J Wound Care 2018; 27:S20-S27. [DOI: 10.12968/jowc.2018.27.sup9a.s20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Youn Hwan Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, Korea
| | - Jeong Hyun Ha
- Department of Plastic and Reconstructive Surgery, College of Medicine, Seoul National University, Seoul National University Hospital, Seoul, Korea
| | - Jeong Tae Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, Korea
| | - Sang Wha Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine, Seoul National University, Seoul National University Hospital, Seoul, Korea
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Agarwal L, Yasin A. Necrotising fasciitis: a fatal case of sepsis and a diagnostic challenge - case report and review of literature. Int J Emerg Med 2018; 11:23. [PMID: 29626314 PMCID: PMC5889371 DOI: 10.1186/s12245-018-0183-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 03/28/2018] [Indexed: 12/04/2022] Open
Abstract
Background Necrotising fasciitis (NF) is a severe, devastating soft tissue infection characterised by rapidly progressing tissue necrosis. This rare condition has a high mortality rate and poses diagnostic and management challenges to the clinician. There is usually a history of trauma, which maybe trivial. Some of the premorbid conditions associated with NF are diabetes and or immunocompromised state. It requires prompt recognition and early treatment with intravenous antibiotics and extensive surgical debridement. Case presentation We describe a 74-year-old lady who presented to our emergency department following 3 days’ history of watery diarrhoea and feeling generally unwell. She had signs of severe sepsis and was started on broad-spectrum intravenous antibiotics and fluids for sepsis with unknown source. She was found to have an area of blackish discolouration on her thigh which was suspected as necrotising fasciitis (NF) and referred to the surgeons. She had no history of trauma or significant comorbidity. She underwent surgical exploration and debridement within few hours of arrival into the emergency department and subsequent further debridement with above-knee amputation of the affected limb. She eventually died after about 48 h of hospital stay despite an early diagnosis and prompt surgical debridement and a multidisciplinary approach. Conclusions Necrotising fasciitis has been previously reported in literature but we would like to highlight through this case the importance of looking for the source of sepsis by thorough clinical examination and the need to have a high threshold of suspicion for this rare condition and urgent involvement of a surgical team for debridement.
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Affiliation(s)
- Lekha Agarwal
- Emergency Medicine Department, Peterborough City Hospital, North West Anglia NHS Foundation Trust, Peterborough, UK.
| | - Athar Yasin
- Emergency Medicine Department, Peterborough City Hospital, North West Anglia NHS Foundation Trust, Peterborough, UK
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44
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Solomon IH, Borscheid R, Laga AC, Askari R, Granter SR. Frozen sections are unreliable for the diagnosis of necrotizing soft tissue infections. Mod Pathol 2018; 31:546-552. [PMID: 29243739 DOI: 10.1038/modpathol.2017.173] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 10/14/2017] [Accepted: 10/15/2017] [Indexed: 11/09/2022]
Abstract
Necrotizing soft tissue infections are rare but are associated with high rates of morbidity and mortality. The use of bedside or intraoperative frozen sections has been reported to be associated with faster diagnosis and better outcomes; however, to date no large studies have been published to determine the sensitivity and specificity of frozen sections in this setting. Twenty years of cases suspicious for necrotizing soft tissue infection at a large academic referral center were reviewed, blinded to the final clinical diagnosis (gold standard). Cases were assessed for the number of neutrophils, extent of necrosis, presence of thrombi, bacteria, karyorrhexis, and fibrin, and concordance with permanent sections. A total of 166 cases suspicious for necrotizing soft tissue infection had frozen section slides available for review. Sixty-three cases were clinically determined to be positive and 103 negative. Neutrophils, necrosis, thrombi, bacteria, karyorrhexis, and fibrin were present in both positive and negative cases; however, no histological feature or combination of features was found to be both sensitive and specific for necrotizing soft tissue infection. The combined presence of necrosis and frequent neutrophils was 73% sensitive and 68% specific, with a 58% positive predictive value and 80% negative predictive value. The additional observation of bacteria decreased sensitivity to 32%, whereas raising specificity to 91%, with 69% positive predictive value and 68% negative predictive value. Thirty-two cases (19%) contained findings identified on permanent sections (eg, bacteria) not observed on frozen section slides, highlighting the risk of false negatives owing to technical limitations or sampling errors. Frozen sections in necrotizing soft tissue infections and negative cases may show similar histological findings. Combined with the risk of false negatives, these results suggest that frozen sections are likely to be of limited clinical utility due to lack of sensitivity and specificity, and risk for delayed diagnosis and treatment.
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Affiliation(s)
- Isaac H Solomon
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rene Borscheid
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alvaro C Laga
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Reza Askari
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Scott R Granter
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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45
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Sartelli M, Guirao X, Hardcastle TC, Kluger Y, Boermeester MA, Raşa K, Ansaloni L, Coccolini F, Montravers P, Abu-Zidan FM, Bartoletti M, Bassetti M, Ben-Ishay O, Biffl WL, Chiara O, Chiarugi M, Coimbra R, De Rosa FG, De Simone B, Di Saverio S, Giannella M, Gkiokas G, Khokha V, Labricciosa FM, Leppäniemi A, Litvin A, Moore EE, Negoi I, Pagani L, Peghin M, Picetti E, Pintar T, Pupelis G, Rubio-Perez I, Sakakushev B, Segovia-Lohse H, Sganga G, Shelat V, Sugrue M, Tarasconi A, Tranà C, Ulrych J, Viale P, Catena F. 2018 WSES/SIS-E consensus conference: recommendations for the management of skin and soft-tissue infections. World J Emerg Surg 2018; 13:58. [PMID: 30564282 PMCID: PMC6295010 DOI: 10.1186/s13017-018-0219-9] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 11/22/2018] [Indexed: 02/08/2023] Open
Abstract
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. SSTIs are a frequent clinical problem in surgical departments. In order to clarify key issues in the management of SSTIs, a task force of experts met in Bertinoro, Italy, on June 28, 2018, for a specialist multidisciplinary consensus conference under the auspices of the World Society of Emergency Surgery (WSES) and the Surgical Infection Society Europe (SIS-E). The multifaceted nature of these infections has led to a collaboration among general and emergency surgeons, intensivists, and infectious disease specialists, who have shared these clinical practice recommendations.
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Affiliation(s)
| | - Xavier Guirao
- 0000 0000 9238 6887grid.428313.fUnit of Endocrine, Head, and Neck Surgery and Unit of Surgical Infections Support, Department of General Surgery, Parc Taulí Hospital Universitari, Sabadell, Spain
| | - Timothy C. Hardcastle
- Trauma Service, Inkosi Albert Luthuli Central Hospital and Department of Surgery, Nelson R Mandela School of Clinical Medicine, Durban, South Africa
| | - Yoram Kluger
- 0000 0000 9950 8111grid.413731.3Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Marja. A. Boermeester
- 0000000404654431grid.5650.6Department of Surgery, Academic Medical Centre, Amsterdam, Netherlands
| | - Kemal Raşa
- Department of Surgery, Anadolu Medical Center, Kocaali, Turkey
| | - Luca Ansaloni
- 0000 0004 1758 8744grid.414682.dGeneral Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Federico Coccolini
- 0000 0004 1758 8744grid.414682.dGeneral Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Philippe Montravers
- 0000 0000 8588 831Xgrid.411119.dAnesthesiology and Critical Care Medicine, Paris Diderot Sorbonne Cite University, Bichat-Claude Bernard University Hospital, HUPNSV, Paris, France
| | - Fikri M. Abu-Zidan
- 0000 0001 2193 6666grid.43519.3aDepartment of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Michele Bartoletti
- 0000 0004 1757 1758grid.6292.fInfectious Diseases Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Matteo Bassetti
- 0000 0001 2113 062Xgrid.5390.fInfectious Diseases Division, Department of Medicine University of Udine and Azienda Sanitaria Universitaria Intergrata di Udine, Udine, Italy
| | - Offir Ben-Ishay
- 0000 0000 9950 8111grid.413731.3Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Walter L. Biffl
- Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, CA USA
| | - Osvaldo Chiara
- General Surgery-Trauma Team, State University of Milano, Niguarda Hospital Milano, Milan, Italy
| | - Massimo Chiarugi
- grid.414498.4Emergency Surgery Unit, State University of Pisa, Cisanello Hospital, Pisa, Italy
| | - Raul Coimbra
- 0000 0000 9852 649Xgrid.43582.38Riverside University Health System Medical Center and Loma Linda University School of Medicine, Moreno Valley, CA USA
| | - Francesco Giuseppe De Rosa
- 0000 0001 2336 6580grid.7605.4Department of Medical Sciences, Infectious Diseases, University of Turin, Turin, Italy
| | - Belinda De Simone
- Unit of General, Emergency and Trauma Surgery, Regional Hospital of Perpignan, Perpignan, France
| | - Salomone Di Saverio
- 0000 0004 0383 8386grid.24029.3dDepartment of Surgery, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Maddalena Giannella
- 0000 0004 1757 1758grid.6292.fInfectious Diseases Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - George Gkiokas
- 0000 0001 2155 0800grid.5216.0Second Department of Surgery, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Vladimir Khokha
- Department of Emergency Surgery, City Hospital, Mozyr, Belarus
| | | | - Ari Leppäniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Andrey Litvin
- 0000 0001 1018 9204grid.410686.dDepartment of Surgical Disciplines, Immanuel Kant Baltic Federal University, Regional Clinical Hospital, Kaliningrad, Russian Federation
| | - Ernest E. Moore
- Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, CO USA
| | - Ionut Negoi
- Department of Surgery, Emergency Hospital of Bucharest, Bucharest, Romania
| | - Leonardo Pagani
- Infectious Diseases Unit, Bolzano Central Hospital, Bolzano, Italy
| | - Maddalena Peghin
- 0000 0001 2113 062Xgrid.5390.fInfectious Diseases Division, Department of Medicine University of Udine and Azienda Sanitaria Universitaria Intergrata di Udine, Udine, Italy
| | - Edoardo Picetti
- grid.411482.aDepartment of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
| | - Tadeja Pintar
- 0000 0004 0571 7705grid.29524.38Department of Surgery, UMC Ljubljana, Ljubljana, Slovenia
| | - Guntars Pupelis
- 0000 0004 0375 2558grid.488518.8Department of General and Emergency Surgery, Riga East University Hospital ‘Gailezers’, Riga, Latvia
| | - Ines Rubio-Perez
- 0000 0000 8970 9163grid.81821.32General Surgery Department, Colorectal Surgery Unit, La Paz University Hospital, Madrid, Spain
| | - Boris Sakakushev
- 0000 0001 0726 0380grid.35371.33General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Helmut Segovia-Lohse
- 0000 0001 2289 5077grid.412213.7Second Department of Surgery, Hospital de Clínicas, Universidad Nacional de Asuncion, San Lorenzo, Paraguay
| | - Gabriele Sganga
- 0000 0001 0941 3192grid.8142.fEmergency Surgery (or Division of Emergency Surgery), Fondazione Policlinico Universitario A. Gemelli IRCCS – Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vishal Shelat
- grid.240988.fGeneral Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Michael Sugrue
- 0000 0004 0617 6488grid.415900.9Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, Ireland
| | - Antonio Tarasconi
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
| | - Cristian Tranà
- Department of Surgery, Macerata Hospital, Macerata, Italy
| | - Jan Ulrych
- 0000 0000 9100 9940grid.411798.2First Department of Surgery, Department of Abdominal, Thoracic Surgery and Traumatology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Pierluigi Viale
- 0000 0004 1757 1758grid.6292.fInfectious Diseases Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Fausto Catena
- 0000 0001 0941 3192grid.8142.fEmergency Surgery (or Division of Emergency Surgery), Fondazione Policlinico Universitario A. Gemelli IRCCS – Università Cattolica del Sacro Cuore, Rome, Italy
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van Sambeek CHL, van Stigt SF, Brouwers L, Bemelman M. Necrotising fasciitis: a ticking time bomb? BMJ Case Rep 2017; 2017:bcr-2017-221770. [PMID: 28978607 DOI: 10.1136/bcr-2017-221770] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Necrotising fasciitis (NF) is a destructive bacterial infection and has often been described in media reports as a 'flesh-eating disease', which if diagnosed late is associated with worse outcome. Unfortunately, diagnosing NF is difficult due to the similar presentation of NF compared with other types of skin and soft tissue infections. The early presentation of NF only shows tenderness, swelling, erythema and warm skin. Moreover, NF is normally accompanied with aberrant laboratory findings, mainly elevated C reactive protein (CRP) levels. In this case report we evaluate the diagnostic process of a patient with NF without aberrant infection parameters; both normal levels of CRP and white blood cell count were seen.
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Affiliation(s)
| | - Sander F van Stigt
- Department of Trauma Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Lars Brouwers
- Department of Trauma Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Mike Bemelman
- Department of Trauma Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
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Yii YC, Hsieh VCR, Lin CL, Wang YC, Chen WK. Alcohol use disorder increases the risk of necrotizing fasciitis: A nationwide retrospective cohort study. Medicine (Baltimore) 2017; 96:e7509. [PMID: 28796035 PMCID: PMC5556201 DOI: 10.1097/md.0000000000007509] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This nationwide retrospective cohort study determined the association between alcohol use disorder (AUD) and the risk of necrotizing fasciitis (NF).This study used health insurance claims data of 52,212 in-patients with AUD and 208,848 controls randomly frequency-matched by age and sex at a 1:4 ratio. The AUD cohort included patients newly diagnosed with AUD between January 1, 2000 and December 31, 2008. The NF event occurrence was observed until December 31, 2011. We used the Kaplan-Meier method to present the cumulative incidence curve and Cox proportional hazard models to depict the risk of NF in patients with AUD.The incidence of NF was 19.4 per 10,000 person-years in the AUD cohort, which was nearly 7.73-fold higher than that in the comparison cohort (2.54 per 10,000 person-years). After adjustment for age, sex, and comorbidities, the patients with AUD exhibited a 3.55-fold higher risk of NF than did the controls (hazard ratio [HR] = 3.55, 95% confidence interval [CI] = 3.00-4.20). Nevertheless, in the AUD groups without any comorbidity, patients with AUD exhibited a significant 15.2-fold higher risk of NF than did the comparison cohort (HR = 15.2, 95% CI = 10.9-21.3). Moreover, the adjusted HRs of NF risk with respect to the severity of AUD were 2.15 (95% CI = 1.76-2.62), 4.54 (95% CI = 3.67-5.62), and 10.7 (95% CI = 8.66-13.2) for mild, moderate, and severe AUD, respectively.This study indicated that AUD should be considered an independent and significant risk factor for NF.
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Affiliation(s)
- Yong-Cheng Yii
- Department of Emergency Medicine, China Medical University Hospital
- School of Medicine, College of Medicine, China Medical University
| | | | - Cheng-Li Lin
- College of Medicine, China Medical University
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - Yu-Chiao Wang
- College of Medicine, China Medical University
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - Wei-Kung Chen
- Department of Emergency Medicine, China Medical University Hospital
- School of Medicine, College of Medicine, China Medical University
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Shang S, Zhang R, Hou Z. Necrotizing fasciitis-A catastrophic complication following routine tibia fracture surgery: A case report and literature review. Medicine (Baltimore) 2017; 96:e6908. [PMID: 28591027 PMCID: PMC5466205 DOI: 10.1097/md.0000000000006908] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Necrotizing fasciitis (NF) is defined as a rare, life-threatening, rapidly spreading soft tissue infection resulting from a polymicrobial origin, with a predominance of anaerobic organisms that presents with necrosis of the muscle, fascia, and surrounding soft tissue. PATIENT CONCERNS AND DIAGNOSES A 64-year-old male who sustained tibia fracture caused by falling from a height underwent a tibia surgery with minimally invasive plate osteosynthesis technique in another institution. Postoperatively, the patient had development of a very uncommon NF at the site of the tibia procedure. When the patient was transferred to our unit, he rapidly processed to toxic shock and coagulopathy. INTERVENTIONS AND OUTCOMES Although the patient underwent antibiotics treatment in the emergency room and was transferred to the operating room for surgery promptly, the patient's condition deteriorated rapidly and he died of septic shock and multiple organ failure unfortunately. LESSONS Our study aims to highlight the risk of NF in the elderly with diabetes during the perioperative period even if the injury is a simple closed fracture. Physicians must be vigilant to early inflammatory signs and pain in immunosuppressed patients.
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Meekul J, Chotirosniramit A, Himakalasa W, Orrapin S, Wongthanee A, Pongtam O, Kulprachakarn K, Rerkasem K. A Randomized Controlled Trial on the Outcome in Comparing an Alginate Silver Dressing With a Conventional Treatment of a Necrotizing Fasciitis Wound. INT J LOW EXTR WOUND 2017; 16:108-113. [PMID: 28682725 DOI: 10.1177/1534734617701051] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Necrotizing fasciitis (NF) is a high morbidity and mortality disease and also demands high economic resources. The standard treatment of NF is surgical debridement and proper dressing for wound bed preparation. The efficacy of silver alginate dressing can inhibit the growth of microorganisms and keep the environment clean for wound bed preparation. However an optimal dressing to manage such wounds has yet to emerge. NF patients who were admitted between April 2013 and May 2016 were randomized to have wound dressing using either silver dressing (Ag group) or normal saline solution gauze (NSS group). The 4 main outcomes for comparison between the 2 groups were the duration of wound bed preparation, total cost during hospital stay, the duration of hospital stay, and the pain score. Thirty-nine patients were included in the study: 19 patients in the NSS group and 20 patients in the Ag group. The mean duration of wound bed preparation in the NSS group was 31.87 days, and in Ag group it was 21.39 days, but this trend was not statistically significant ( P = .057). The mean cost of treatment in the NSS and Ag groups was not significantly different ( P = .434; US$3308.83 and US$2647.82, respectively). The duration of hospital days in the 2 groups was not significantly different either (29.19 days [NSS group] and 20.99 days [Ag group]; P = .222). The pain score was significantly lower in the Ag group than those in the NSS group. Although silver dressing seems to be expensive, the cost of total treatment during hospital stay and the duration of hospital stay were not significantly different between groups. However, the mean duration of wound bed preparation seems to trend favoring toward the silver dressing group.
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Affiliation(s)
- Jarernchon Meekul
- 1 Department of Surgery, Faculty of Medicine, Chiang Mai University, Thailand
| | | | | | - Saritphat Orrapin
- 3 Department of Surgery, Faculty of Medicine, Thammasat University (Rangsit Campus), Thailand
| | - Antika Wongthanee
- 4 NCD Center of Excellence, Research Institute of Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Orapin Pongtam
- 5 NCD Center, Faculty of Medicine, Chiang Mai University, Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand
| | - Kanokwan Kulprachakarn
- 5 NCD Center, Faculty of Medicine, Chiang Mai University, Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand
| | - Kittipan Rerkasem
- 1 Department of Surgery, Faculty of Medicine, Chiang Mai University, Thailand.,4 NCD Center of Excellence, Research Institute of Health Sciences, Chiang Mai University, Chiang Mai, Thailand.,5 NCD Center, Faculty of Medicine, Chiang Mai University, Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand
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Rudkjøbing VB, Thomsen TR, Xu Y, Melton-Kreft R, Ahmed A, Eickhardt S, Bjarnsholt T, Poulsen SS, Nielsen PH, Earl JP, Ehrlich GD, Moser C. Comparing culture and molecular methods for the identification of microorganisms involved in necrotizing soft tissue infections. BMC Infect Dis 2016; 16:652. [PMID: 27821087 PMCID: PMC5100109 DOI: 10.1186/s12879-016-1976-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 10/26/2016] [Indexed: 12/26/2022] Open
Abstract
Background Necrotizing soft tissue infections (NSTIs) are a group of infections affecting all soft tissues. NSTI involves necrosis of the afflicted tissue and is potentially life threatening due to major and rapid destruction of tissue, which often leads to septic shock and organ failure. The gold standard for identification of pathogens is culture; however molecular methods for identification of microorganisms may provide a more rapid result and may be able to identify additional microorganisms that are not detected by culture. Methods In this study, tissue samples (n = 20) obtained after debridement of 10 patients with NSTI were analyzed by standard culture, fluorescence in situ hybridization (FISH) and multiple molecular methods. The molecular methods included analysis of microbial diversity by 1) direct 16S and D2LSU rRNA gene Microseq 2) construction of near full-length 16S rRNA gene clone libraries with subsequent Sanger sequencing for most samples, 3) the Ibis T5000 biosensor and 4) 454-based pyrosequencing. Furthermore, quantitative PCR (qPCR) was used to verify and determine the relative abundance of Streptococcus pyogenes in samples. Results For 70 % of the surgical samples it was possible to identify microorganisms by culture. Some samples did not result in growth (presumably due to administration of antimicrobial therapy prior to sampling). The molecular methods identified microorganisms in 90 % of the samples, and frequently detected additional microorganisms when compared to culture. Although the molecular methods generally gave concordant results, our results indicate that Microseq may misidentify or overlook microorganisms that can be detected by other molecular methods. Half of the patients were found to be infected with S. pyogenes, but several atypical findings were also made including infection by a) Acinetobacter baumannii, b) Streptococcus pneumoniae, and c) fungi, mycoplasma and Fusobacterium necrophorum. Conclusion The study emphasizes that many pathogens can be involved in NSTIs, and that no specific “NSTI causing” combination of species exists. This means that clinicians should be prepared to diagnose and treat any combination of microbial pathogens. Some of the tested molecular methods offer a faster turnaround time combined with a high specificity, which makes supplemental use of such methods attractive for identification of microorganisms, especially for fulminant life-threatening infections such as NSTI.
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Affiliation(s)
- Vibeke Børsholt Rudkjøbing
- Center for Microbial Communities, Department of Chemistry and Bioscience, Aalborg University, Aalborg, Denmark
| | - Trine Rolighed Thomsen
- Center for Microbial Communities, Department of Chemistry and Bioscience, Aalborg University, Aalborg, Denmark.,Life Science Division, The Danish Technological Institute, Taastrup, Denmark
| | - Yijuan Xu
- Center for Microbial Communities, Department of Chemistry and Bioscience, Aalborg University, Aalborg, Denmark.,Life Science Division, The Danish Technological Institute, Taastrup, Denmark
| | - Rachael Melton-Kreft
- Center for Genomic Sciences, Allegheny-Singer Research Institute, Pittsburgh, USA
| | - Azad Ahmed
- Center for Genomic Sciences, Allegheny-Singer Research Institute, Pittsburgh, USA
| | - Steffen Eickhardt
- Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Bjarnsholt
- Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Steen Seier Poulsen
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Per Halkjær Nielsen
- Center for Microbial Communities, Department of Chemistry and Bioscience, Aalborg University, Aalborg, Denmark
| | - Joshua P Earl
- Center for Genomic Sciences, Philadelphia, PA, USA.,Departments of Microbiology and Immunology, Center for Advanced Microbial Processing, Institute for Molecular Medicine and Infectious Disease, Philadelphia, PA, USA.,Departments of Microbiology and Immunology, Philadelphia, PA, USA
| | - Garth D Ehrlich
- Center for Genomic Sciences, Philadelphia, PA, USA.,Departments of Microbiology and Immunology, Center for Advanced Microbial Processing, Institute for Molecular Medicine and Infectious Disease, Philadelphia, PA, USA.,Departments of Microbiology and Immunology, Philadelphia, PA, USA.,Otolaryngology-Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Claus Moser
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Denmark.
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