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Suijker J, Pijpe A, Hoogerbrug D, Heymans MW, van Zuijlen PPM, Halm JA, Meij-de Vries A. IDENTIFICATION OF POTENTIALLY MODIFIABLE FACTORS TO IMPROVE RECOGNITION AND OUTCOME OF NECROTIZING SOFT-TISSUE INFECTIONS. Shock 2024; 61:585-591. [PMID: 38315508 DOI: 10.1097/shk.0000000000002325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
ABSTRACT Background : Necrotizing soft-tissue infections (NSTIs) present a surgical emergency of increasing incidence, which is often misdiagnosed and associated with substantial mortality and morbidity. A retrospective multicenter (11 hospitals) cohort study was initiated to identify the early predictors of misdiagnosis, mortality, and morbidity (skin defect size and amputation). Methods : Patients of all ages who presented with symptoms and were admitted for acute treatment of NSTIs between January 2013 and December 2017 were included. Generalized estimating equation analysis was used to identify early predictors (available before or during the first debridement surgery), with a significance level of P < 0.05. Results : The median age of the cohort (N = 216) was 59.5 (interquartile range = 23.6) years, of which 138 patients (63.9%) were male. Necrotizing soft-tissue infections most frequently originated in the legs (31.0%) and anogenital area (30.5%). More than half of the patients (n = 114, 54.3%) were initially misdiagnosed. Thirty-day mortality was 22.9%. Amputation of an extremity was performed in 26 patients (12.5%). Misdiagnosis was more likely in patients with a higher Charlson Comorbidity Index (β = 0.20, P = 0.001), and less likely when symptoms started in the anogenital area (β = -1.20, P = 0.003). Besides the established risk factors for mortality (septic shock and age), misdiagnosis was identified as an independent predictor of 30-day mortality (β = 1.03, P = 0.01). The strongest predictors of the final skin defect size were septic shock (β = 2.88, P < 0.001) and a skin-sparing approach to debridement (β = -1.79, P = 0.002). Conclusion : Recognition of the disease is essential for the survival of patients affected by NSTI, as is adequate treatment of septic shock. The application of a skin-sparing approach to surgical debridement may decrease morbidity.
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Affiliation(s)
| | | | | | - Martijn W Heymans
- Amsterdam, Department of Epidemiology and Data Science, Amsterdam, The Netherlands
| | | | - Jens A Halm
- Trauma Unit, Amsterdam UMC location AMC, Amsterdam, The Netherlands
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Nawijn F, Kerckhoffs MC, Hietbrink F. Quality of Life After Intensive Care Unit Admittance for Necrotizing Soft Tissue Infections Is Deemed Acceptable for Patients. Surg Infect (Larchmt) 2023; 24:924-929. [PMID: 38032595 DOI: 10.1089/sur.2023.184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
Background: Because mortality and amputation rates are declining for necrotizing soft tissue infections (NSTIs), this study aimed to assesses the self-reported one-year quality of life (QoL) of severely ill patients with NSTI who survived beyond the intensive care unit (ICU). Patients and Methods: A retrospective cohort study of patients with NSTI admitted to the ICU between 2010 and 2019 was conducted. A year after ICU discharge, QoL was assessed using the three-level EuroQol five-dimensions (EQ-5D-3L) questionnaire, Impact of Event Scale-Revised (IES-R) questionnaires, and pain scales. Furthermore, willingness to undergo ICU admission again if needed was reviewed. Results: Twenty-nine (of 38) patients with NSTI survived their hospitalization (76%). During the one-year follow-up, three patients died (8%; one-year survival 68%). Nineteen patients filled out the questionnaires (73%). The median EQ-5D-3L index score was 0.775 (interquartile range [IQR], 0.687-0.843). The domains reported most to cause impairment were "usual activity" and "pain/discomfort." Patients had a median pain score of five (of 10; IQR, 1-6) and two patients (15%; of 13) scored "clinical concern for PTSD.". Eighty-five percent of the patients would undergo the ICU treatment again if needed. Conclusions: The one-year QoL of ICU-admitted patients with NSTI varies widely, however, the overall QoL and one-year survival was similar to other ICU patients who underwent acute surgery and the QoL was slightly lower than the general ICU population. Most patients experience problems with daily activity and pain, but this does not mean that patients with NSTI automatically had poor self-reported quality of life or unwillingness to undergo ICU treatment again if needed.
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Affiliation(s)
- Femke Nawijn
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Monika C Kerckhoffs
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Kumar SS, Sun HH, Tay K, Sellke N, Bodner D, Gupta S, Mishra K, Scarberry K. Favorable Safety Outcomes of Delayed Primary Closure of Large Fournier's Gangrene Skin Defects. Urology 2023; 180:270-277. [PMID: 37544517 DOI: 10.1016/j.urology.2023.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/24/2023] [Accepted: 07/26/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVE To assess the feasibility and safety of delayed primary closure (DPC) in Fournier's gangrene (FG) patients with large genital defects. METHODS A single institution retrospective review was performed from October 2020 to December 2022 of adult males that underwent DPC for FG. All patients underwent standard medical management and were assessed for DPC eligibility by the urology service. Clinical data on patient factors and outcomes were collected, and descriptive statistics were assessed. RESULTS Of 16 patients that underwent DPC, the average age was 61.1years and body mass index was 34.6 kg/m2. Median Charlson Comorbidity Index was 3.5 (IQR 2-5.3) and Fournier's Gangrene Severity Index was 6.5 (IQR 4.8-8). Median number of debridements was 2.5 (IQR 2-3), with a time to closure of 6.5days (IQR 3-11) and length of stay of 13days (IQR 9-16.3). Mean genital defect size was 119 cm2 (range 44-346 cm2). Eight patients (50%) were closed using scrotal flaps alone while other patients had advancement flaps using the inner thigh, lower abdomen, and perineum. The majority of patients were discharged home directly (63%). There were four Clavien-Dindo III complications: two partial flap necrosis, one wound dehiscence, and one instance of bleeding. Of patients with follow-up, 6/15 (40.0%) had no known complications. CONCLUSION DPC is safe and effective for a range of patients presenting with FG. Patients with large defects may benefit from less complex wound management and direct discharge home.
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Affiliation(s)
| | - Helen H Sun
- Case Western Reserve University School of Medicine, Cleveland, OH; Urology Institute, University Hospitals of Cleveland, Cleveland, OH.
| | - Kimberly Tay
- Case Western Reserve University School of Medicine, Cleveland, OH; Urology Institute, University Hospitals of Cleveland, Cleveland, OH
| | - Nicholas Sellke
- Case Western Reserve University School of Medicine, Cleveland, OH; Urology Institute, University Hospitals of Cleveland, Cleveland, OH
| | - Donald Bodner
- Case Western Reserve University School of Medicine, Cleveland, OH; Urology Institute, University Hospitals of Cleveland, Cleveland, OH
| | - Shubham Gupta
- Case Western Reserve University School of Medicine, Cleveland, OH; Urology Institute, University Hospitals of Cleveland, Cleveland, OH
| | - Kirtishri Mishra
- Case Western Reserve University School of Medicine, Cleveland, OH; Urology Institute, University Hospitals of Cleveland, Cleveland, OH
| | - Kyle Scarberry
- Case Western Reserve University School of Medicine, Cleveland, OH; Urology Institute, University Hospitals of Cleveland, Cleveland, OH
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The impact of necrotizing soft tissue infections on the lives of survivors: a qualitative study. Qual Life Res 2023:10.1007/s11136-023-03371-8. [PMID: 36840905 DOI: 10.1007/s11136-023-03371-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2023] [Indexed: 02/26/2023]
Abstract
PURPOSE Necrotizing soft tissue infections (NSTI) are potentially lethal infections marked by local tissue destruction and systemic sepsis, which require aggressive treatment. Survivors often face a long recovery trajectory. This study was initiated to increase understanding of the long-term impact of NSTI on health related quality of life (HRQoL), and how care may be improved. METHODS Thematic analysis was applied to qualitative data from 25 NSTI-survivors obtained through two focus groups (n = 14) and semi-structured interviews (n = 11). RESULTS The median age of the participants was 49 years, 14 were female. The median time since diagnosis was 5 years. Initial misdiagnosis was common, causing delay to treatment. Survivors experienced long-term physical consequences (scarring, cognitive impairment, fatigue, sleeping problems, recurrent infections), psychological consequences (traumatic stress symptoms, fear of relapse, adjusting to an altered appearance, sexual issues) and social and relational consequences (changes in social contacts, a lack of understanding). The disease also had a major psychological impact on family members, as well as major financial impact in some. There was a strong desire to reflect on 'mistakes' in case of initial misdiagnosis. To improve care, patient and family centered care, smooth transitions after discharge, and the availability of understandable information were deemed important. CONCLUSION This study reveals that NSTI have a large impact on physical and psychosocial wellbeing of survivors and their relatives. Except for a few differences (misdiagnosis, fear for re-infection and actual re-infection), the patient experience of patients with NSTI is largely similar to those of burn survivors. Thus, questionnaires to assess HRQoL in burn survivors may be used in future NSTI studies.
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Egerod I, Knudsen VE, Andersson AE, Fagerdahl A. Patient and family experience 2 years after necrotizing soft‐tissue infection: A longitudinal qualitative investigation. J Adv Nurs 2022. [DOI: 10.1111/jan.15535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 10/18/2022] [Accepted: 12/01/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Ingrid Egerod
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
- Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark
| | - Vibeke E. Knudsen
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Annette E. Andersson
- Institute of Health Care Sciences Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Department of Orthopedics Sahlgrenska University Hospital/Mölndal Gothenburg Sweden
| | - Ann‐Mari Fagerdahl
- Department of Clinical Science and Education Wound Centre, Södersjukhuset Stockholm Sweden
- Karolinska Institute Stockholm Sweden
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Decision support system and outcome prediction in a cohort of patients with necrotizing soft-tissue infections. Int J Med Inform 2022; 167:104878. [DOI: 10.1016/j.ijmedinf.2022.104878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 09/06/2022] [Accepted: 09/19/2022] [Indexed: 11/18/2022]
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Nawijn F, Verhiel SHWL, Nierich J, Eberlin KR, Hietbrink F, Chen NC. Survival and Health-Related Quality of Life after Hospitalization for Necrotizing Soft Tissue Infections of the Upper Extremity: A Long-Term Outcome Study. J Hand Microsurg 2022; 14:188-196. [PMID: 36016635 PMCID: PMC9398577 DOI: 10.1055/s-0040-1710200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Introduction The main aim of the study was to investigate the survival and health-related quality of life (HRQoL) after hospitalization for necrotizing soft tissue infections (NSTIs) of the upper extremity. Materials and Methods A retrospective study with long-term follow-up of patients surviving NSTIs of the upper extremity was performed. Survival and HRQoL after hospital discharge were the primary outcomes. The HRQoL was measured using the 36-item Short Form (SF-36), EuroQoL-5D-5L (EQ-5D), Quick Disability of Shoulder, Arm and Hand (QuickDASH), and numeric rating scales (NRS) for satisfaction with appearance and pain. Results A median of 6.5 years after hospitalization, 81% of the 108 patients survived. The response rate was 45% ( n = 38). The SF-36 score was 80 (interquartile range [IQR]: 58-91), the EQ-5D score 1.4 (IQR: 1.2-2.2), the EuroQoL-Visual Analog Scale score 77 (IQR: 67-90), the QuickDASH score 13.6 (IQR: 2.3-30.7), the NRS for satisfaction with appearance 8 (IQR: 7-9), and NRS for pain 1 (IQR: 0-5). Conclusion Six-and-a-half years after the NSTI, 81% of the patients were still alive. General health prior to the NSTI mainly influenced the risk at secondary mortality. In surviving patients, the HRQoL varied widely, but was adversely affected by female sex, intravenous drug use, NSTI type I or III, and longer length of hospital stay.
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Affiliation(s)
- Femke Nawijn
- Department of Surgery, University Medical Center Utrecht, CX Utrecht, The Netherlands
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, United States
| | - Svenna H. W. L. Verhiel
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, United States
| | - Juliette Nierich
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, United States
| | - Kyle R. Eberlin
- Division of Plastic and Reconstructive Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, United States
| | - Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, CX Utrecht, The Netherlands
| | - Neal C. Chen
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, United States
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Soft Tissue Reconstruction for Upper Extremity Necrotizing Soft Tissue Infections. Ann Plast Surg 2022; 89:631-636. [PMID: 35703211 DOI: 10.1097/sap.0000000000003237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION One of the main aspects of management for necrotizing soft tissue infection (NSTI) is surgical excision and debridement, which can result in large soft tissue defects. This study examined the reconstructive options and outcomes of patients with upper extremity NSTIs. METHODS A retrospective chart review was performed on patients from a single institution who were diagnosed with an upper extremity NSTI between 2014 and 2019. Patient characteristics, infectious etiology, surgical debridements, reconstructive procedures, and secondary procedures were analyzed. RESULTS There were 99 patients included in the study. The median size of the wound from the initial surgical debridement was 100 cm2 (interquartile range, 300 cm2). The mean number of debridements was 3.4. Seven patients underwent amputations, and 12 patients died. Most wounds were reconstructed via delayed primary closure (15 patients), skin grafting (16 patients), or a combination of the two (30 patients). Three patients underwent reverse radial forearm flaps, 1 patient underwent a groin flap, 3 patients underwent pedicled latissimus muscle flaps, and 2 patients underwent local flexor carpi ulnaris muscle flaps. Seven patients did not undergo any surgical reconstruction, and their wounds were managed with local wound care. Eight patients had complete or partial failure of their initial soft reconstruction requiring an additional operation, and 5 patients had secondary operations for neuromas and/or contractures. CONCLUSIONS Overall, patients with upper extremity NSTIs survive and undergo successful reconstruction of their wounds. Few patients required additional procedures for reconstructive failure or sequela of their wounds.
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Horn DL, Roberts EA, Shen J, Chan JD, Bulger EM, Weiss NS, Lynch JB, Bryson-Cahn C, Robinson BRH. Outcomes of β-Hemolytic Streptococcal Necrotizing Skin and Soft-tissue Infections and the Impact of Clindamycin Resistance. Clin Infect Dis 2021; 73:e4592-e4598. [PMID: 33151283 PMCID: PMC8664434 DOI: 10.1093/cid/ciaa976] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/11/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND β-Hemolytic streptococci are frequently implicated in necrotizing soft-tissue infections (NSTIs). Clindamycin administration may improve outcomes in patients with serious streptococcal infections. However, clindamycin resistance is growing worldwide, and resistance patterns in NSTIs and their impact on outcomes are unknown. METHODS Between 2015 and 2018, patients with NSTI at a quaternary referral center were followed up for the outcomes of death, limb loss, and streptococcal toxic shock syndrome. Surgical wound cultures and resistance data were obtained within 48 hours of admission as part of routine care. Risk ratios for the association between these outcomes and the presence of β-hemolytic streptococci or clindamycin-resistant β-hemolytic streptococci were calculated using log-binomial regression, controlling for age, transfer status, and injection drug use-related etiology. RESULTS Of 445 NSTIs identified, 85% had surgical wound cultures within 48 hours of admission. β-Hemolytic streptococci grew in 31%, and clindamycin resistance was observed in 31% of cultures. The presence of β-hemolytic streptococci was associated with greater risk of amputation (risk ratio, 1.80; 95% confidence interval, 1.07-3.01), as was the presence of clindamycin resistance among β-hemolytic streptococci infections (1.86; 1.10-3.16). CONCLUSIONS β-Hemolytic streptococci are highly prevalent in NSTIs, and in our population clindamycin resistance was more common than previously described. Greater risk of limb loss among patients with β-hemolytic streptococci-particularly clindamycin-resistant strains-may portend a more locally aggressive disease process or may represent preexisting patient characteristics that predispose to both infection and limb loss. Regardless, these findings may inform antibiotic selection and surgical management to maximize the potential for limb salvage.
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Affiliation(s)
- Dara L Horn
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Emma A Roberts
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Jolie Shen
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Jeannie D Chan
- Department of Medicine, Divisions of Allergy & Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Eileen M Bulger
- Division of Trauma and Critical Care, Department of Surgery, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Noel S Weiss
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - John B Lynch
- Department of Medicine, Divisions of Allergy & Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Chloe Bryson-Cahn
- Department of Medicine, Divisions of Allergy & Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Bryce R H Robinson
- Division of Trauma and Critical Care, Department of Surgery, University of Washington, Harborview Medical Center, Seattle, Washington, USA
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Brakenridge SC, Wilfret DA, Maislin G, Andrade KE, Walker V, May AK, Dankner WM, Bulger EM. Resolution of organ dysfunction as a predictor of long-term survival in necrotizing soft tissue infections: Analysis of the AB103 Clinical Composite Endpoint Study in Necrotizing Soft Tissue Infections trial and a retrospective claims database-linked chart study. J Trauma Acute Care Surg 2021; 91:384-392. [PMID: 33797490 DOI: 10.1097/ta.0000000000003183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Necrotizing soft tissue infections (NSTIs) are an acute surgical condition with high morbidity and mortality. Timely identification, resuscitation, and aggressive surgical management have significantly decreased inpatient mortality. However, reduced inpatient mortality has shifted the burden of disease to long-term mortality associated with persistent organ dysfunction. METHODS We performed a combined analysis of NSTI patients from the AB103 Clinical Composite Endpoint Study in Necrotizing Soft Tissue Infections randomized-controlled interventional trial (ATB-202) and comprehensive administrative database (ATB-204) to determine the association of persistent organ dysfunction on inpatient and long-term outcomes. Persistent organ dysfunction was defined as a modified Sequential Organ Failure Assessment (mSOFA) score of 2 or greater at Day 14 (D14) after NSTI diagnosis, and resolution of organ dysfunction defined as mSOFA score of 1 or less. RESULTS The analysis included 506 hospitalized NSTI patients requiring surgical debridement, including 247 from ATB-202, and 259 from ATB-204. In both study cohorts, age and comorbidity burden were higher in the D14 mSOFA ≥2 group. Patients with D14 mSOFA score of 1 or less had significantly lower 90-day mortality than those with mSOFA score of 2 or higher in both ATB-202 (2.4% vs. 21.5%; p < 0.001) and ATB-204 (6% vs. 16%: p = 0.008) studies. In addition, in an adjusted covariate analysis of the combined study data sets D14 mSOFA score of 1 or lesss was an independent predictor of lower 90-day mortality (odds ratio, 0.26; 95% confidence interval, 0.13-0.53; p = 0.001). In both studies, D14 mSOFA score of 1 or less was associated with more favorable discharge status and decreased resource utilization. CONCLUSION For patients with NSTI undergoing surgical management, persistent organ dysfunction at 14 days, strongly predicts higher resource utilization, poor discharge disposition, and higher long-term mortality. Promoting the resolution of acute organ dysfunction after NSTI should be considered as a target for investigational therapies to improve long-term outcomes after NSTI. LEVEL OF EVIDENCE Prognostic/epidemiology study, level III.
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Affiliation(s)
- Scott C Brakenridge
- From the Department of Surgery (S.C.B.), University of Florida College of Medicine, Gainesville, Florida; Atox Bio, Ltd (D.A.W., W.M.D.), Durham, North Carolina; Biomedical Statistical Consulting (G.M.), Wynnewood, Pennsylvania; Health Economics and Outcomes Research, Optum (K.E.A., V.W.), Eden Prairie, Minnesota; Division of Acute Care Surgery (A.K.M.), Atrium Health, Charlotte, North Carolina; Department of Surgery (E.M.B.) University of Washington, Harborview Medical Center, Seattle, Washington
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Urbina T, Canoui-Poitrine F, Hua C, Layese R, Alves A, Ouedraogo R, Bosc R, Sbidian E, Chosidow O, Dessap AM, de Prost N. Long-term quality of life in necrotizing soft-tissue infection survivors: a monocentric prospective cohort study. Ann Intensive Care 2021; 11:102. [PMID: 34213694 PMCID: PMC8253876 DOI: 10.1186/s13613-021-00891-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 06/21/2021] [Indexed: 12/21/2022] Open
Abstract
Background Compared to other life-threatening infection survivors, long-term health-related quality of life (QOL) of patients surviving necrotizing soft-tissue infections (NSTI) and its determinants are little known. In this monocentric prospective cohort including NSTI survivors admitted between 2014 and 2017, QOL was assessed during a phone interview using the 36-Item Short-Form Health Survey (SF-36), the Hospital Anxiety and Depression (HAD), the activity of daily living (ADL), instrumental ADL (IADL) scales and the Impact of Event Scale-Revised (IES-R). The primary outcome measure was the SF-36 physical component summary (PCS). NSTI patients were compared according to intensive care unit (ICU) admission status. ICU survivors were matched on SAPS II with non-NSTI related septic shock survivors. Results Forty-nine NSTI survivors were phone-interviewed and included in the study. Median PCS was decreased compared to the reference population [− 0.97 (− 2.27; − 0.08) SD]. Previous cardiac disease was the only variable associated with PCS alteration [multivariate regression coefficient: − 8.86 (− 17.64; − 0.07), p = 0.048]. Of NSTI survivors, 15.2% had a HAD-D score ≥ 5 and 61.2% an IES-R score ≥ 33. ICU admission was not associated with lower PCS [35.21 (25.49–46.54) versus (vs) 41.82 (24.12–51.01), p = 0.516], but with higher IES-R score [14 (7.5–34) vs 7 (3–18), p = 0.035] and a higher proportion of HAD-D score ≥ 5 (28.6 vs 4.0%, p = 0.036). Compared to non-NSTI septic shock-matched controls, NSTI patients had similar PCS [33.81 (24.58; − 44.39) vs 44.87 (26.71; − 56.01), p = 0.706] but higher HAD-D [3.5 (1–7) vs 3 (1.5–6), p = 0.048] and IES-R scores [18 (8–35) vs 8 (3–19), p = 0.049]. Conclusions Long-term QOL in NSTI survivors is severely impaired, similarly to that of non-NSTI septic shock patients for physical compartments, but with more frequent depressive and/or post-traumatic stress disorders. Only ICU admission and previous cardiac disease were predictive of QOL impairment. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00891-9.
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Affiliation(s)
- Tomas Urbina
- Médecine Intensive Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 75571, Paris Cedex 12, France.,Sorbonne Université, Université Pierre-Et-Marie Curie, Paris 6, France.,Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil, France
| | - Florence Canoui-Poitrine
- Université Paris-Est Créteil Val de Marne (UPEC), Créteil, France.,Service de Santé Publique, Hôpitaux Universitaires Henri Mondor, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France
| | - Camille Hua
- Université Paris-Est Créteil Val de Marne (UPEC), Créteil, France.,Service de Dermatologie, Hôpitaux Universitaires Henri Mondor, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France
| | - Richard Layese
- Service de Santé Publique, Hôpitaux Universitaires Henri Mondor, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France
| | - Aline Alves
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil, France
| | - Rachida Ouedraogo
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil, France
| | - Romain Bosc
- Plastic, Reconstructive, Aesthetic and Maxillofacial Surgery Department, Henri Mondor Hospital, 51 Avenue du Marechal de Lattre de Tassigny, 94000, Créteil, France.,Henri Mondor Breast Center, Henri Mondor Hospital, 51 Avenue du Marechal de Lattre de Tassigny, 94000, Créteil, France.,Biology of the NeuroMuscular System, INSERM Team U955-E10, Paris East University, 94000, Créteil, France
| | - Emilie Sbidian
- Université Paris-Est Créteil Val de Marne (UPEC), Créteil, France.,Service de Dermatologie, Hôpitaux Universitaires Henri Mondor, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France.,Centre D'Investigation Clinique 1430, Inserm, 94010, Créteil, France
| | - Olivier Chosidow
- Université Paris-Est Créteil Val de Marne (UPEC), Créteil, France.,Service de Dermatologie, Hôpitaux Universitaires Henri Mondor, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France
| | - Armand Mekontso Dessap
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil, France.,Université Paris-Est Créteil Val de Marne (UPEC), Créteil, France.,Groupe de Recherche Clinique CARMAS, Université Paris Est-Créteil, Créteil, France
| | - Nicolas de Prost
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil, France. .,Université Paris-Est Créteil Val de Marne (UPEC), Créteil, France. .,Groupe de Recherche Clinique CARMAS, Université Paris Est-Créteil, Créteil, France.
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The Skin-Sparing Debridement Technique in Necrotizing Soft-Tissue Infections: A Systematic Review. J Surg Res 2021; 264:296-308. [PMID: 33845413 DOI: 10.1016/j.jss.2021.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 02/18/2021] [Accepted: 03/03/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Skin-sparing debridement (SSd) was introduced as an alternative to en bloc debridement (EBd) to decrease morbidity caused by scars in patients surviving Necrotizing soft-tissue infections (NSTI). An overview of potential advantages and disadvantages is needed. The aim of this review was to assess (1) whether SSd is noninferior to EBd regarding general outcomes, that is, mortality, length of stay (LOS), complications, and (2) if SSd does indeed result in decreased skin defects. METHODS A systematic literature search was performed according to the PRISMA guidelines. All human studies describing patients treated with SSd were included, when at least of evidence level consecutive case series. Studies describing up to 20 patients were pooled to improve readability and prevent overemphasis of findings from single small studies. RESULTS Ten studies, one cohort study and nine case series, all classified as poor based on Chambers criteria for case series, were included. Compared to patients treated with EBd, patients treated with SSd had no increased mortality rate, LOS or complication rate. SSd-treated patients had a high rate (75%) of total delayed primary closure (DPC) in the pooled case series. CONCLUSION The current available evidence is of insufficient quality to conclude whether SSd is noninferior to EBd for all assessed outcomes. There are suggestions that SSd may result in a decreased need for skin transplants, which could potentially improve the (health related) quality of life in survivors. Experienced surgical teams could cautiously implement SSd under close monitoring, ideally with uniform outcome registry.
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13
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Necrotizing Soft-Tissue Infections: Clinical Features and Diagnostic Aspects. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021. [PMID: 33079362 DOI: 10.1007/978-3-030-57616-5_4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2023]
Abstract
The term necrotizing soft-tissue infection (NSTI) encompasses a heterogenous group of patients with necrotizing infections, involving any body part. NSTI is diagnosed by surgical exploration, where necrosis of the subcutaneous tissue and/or muscle tissue, undermining of the skin, thrombosis of the superficial veins, and deliquescent tissue can be seen. Patients can present with vague symptoms, and approximately half of patients experience severe pain. The clinical presentation and microbiological etiology vary according to affected body site, with NSTI located to the extremities being dominated by monomicrobial group A streptococcal infections, and NSTI located to the anogenital area dominated by polymicrobial infections. No set of diagnostic criteria exists, and suspicion of the diagnosis should come from careful clinical examination and signs of local or systemic severity. Laboratory blood values show no distinct pattern but resemble those of sepsis. Imaging can aid the diagnostic process but must not delay surgical intervention.
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14
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Lu P, Angliss M, Paul E, Bruscino-Raiola F. Health-related quality of life in necrotising soft tissue infection survivors: perspective from an Australian tertiary referral centre. ANZ J Surg 2021; 91:1733-1738. [PMID: 33438334 DOI: 10.1111/ans.16540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 12/04/2020] [Accepted: 12/06/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Necrotising soft tissue infection (NSTI) is a life-threatening disease with widespread tissue destruction. Immediate and aggressive surgical debridement remains the main focus of treatment. This results in disfiguring scars, functional limitation and psychological sequelae for survivors. As mortality rate declines with improvements in care, a greater focus should be placed upon the psychological and functional outcomes of survivors. This study aims to assess the health-related quality of life (HRQoL) of patients following NSTI using the Short Form-36 (SF-36) and Derriford Appearance Scale-24 (DAS-24). METHODS All NSTI patients admitted at our tertiary referral centre between 1 January 2013 and 31 December 2019 were invited to complete the DAS-24 and SF-36 surveys. A retrospective chart review was also performed. RESULTS A total of 30 participants responded to the surveys. On comparison against the general Australian population, the NSTI cohort demonstrated significantly reduced physical and mental HRQoL as measured by the SF-36 (P < 0.001). Increased age was significantly associated with a reduced physical HRQoL (P = 0.002), while dysfunction with appearance as measured by the DAS-24 form correlated with both reduced physical and mental HRQoL (P = 0.020). A total of 79.3% of patients expressed concern regarding their appearance with a significantly higher level of distress at their appearance compared to a non-clinical population (P = 0.120). CONCLUSION Despite the rarity of NSTI, this study demonstrates that this disease has a large and persistent burden for survivors, who report significantly reduced HRQoL and distress with appearance. Further research into comprehensive physical and psychosocial services for NSTI survivors is required.
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Affiliation(s)
- Patrick Lu
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,John Anstee Research Group, Department of Plastic, Hand and Faciomaxillary Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Margaret Angliss
- John Anstee Research Group, Department of Plastic, Hand and Faciomaxillary Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Eldho Paul
- Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Frank Bruscino-Raiola
- John Anstee Research Group, Department of Plastic, Hand and Faciomaxillary Surgery, Alfred Health, Melbourne, Victoria, Australia
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May AK, Talisa VB, Wilfret DA, Bulger E, Dankner W, Bernard A, Yende S. Estimating the Impact of Necrotizing Soft Tissue Infections in the United States: Incidence and Re-Admissions. Surg Infect (Larchmt) 2020; 22:509-515. [PMID: 32833599 DOI: 10.1089/sur.2020.099] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: Previous estimates of the incidence of necrotizing soft tissue infections (NSTI) in the United States have substantial limitations and underestimate its occurrence. Improvements in hospital mortality after NSTI have increased the number of survivors at risk for long-term sequelae. This study estimates the incidence of NSTI and the burden of re-admission and associated healthcare spending in patients who survived admission for NSTI. Methods: Index admissions for NSTI were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes combined with either Current Procedural Technology (CPT) or diagnosis-related group codes to increase specificity. Two separate datasets were used to provide primary and secondary estimates of the annual incidence of NSTIs in the United States: the National Inpatient Sample (NIS) for the years 2012-2016 and the Watson Health dataset for 2009-2013, respectively, and extrapolated to estimate the incidence for 2018. The Nationwide Readmissions Database (NRD) from 2013-2015 was used to estimate of the risk for re-admission, cost of re-admissions, and to compare 90-day re-admission rates for NSTI to common medical conditions. Results: National Inpatient Sample and Watson Health datasets demonstrated an increasing annual incidence and estimated 33,600 and 28,500 cases in 2018, respectively. The estimated annual incidences in the United States in 2018 were 10.3 and 8.7 per 100,000 persons, respectively. Risk of 90-day re-admission ranged from 24%-29% over the 3 years, 89% of which were unplanned. Of those re-admitted, 90% had one or more comorbidities, the most common diagnoses associated with re-admission were infection in 65%, acute kidney injury in 22%, and shock in 10%. The median re-admission length of stay was seven days (interquartile range [IQR]: 4-13 days) with a median cost of re-admission of $13,590 (IQR: $7186-$27440). Conclusion: The incidence of NSTI is more common than generally reported. Re-admission within 90 days is common, occurring in more than one in four survivors resulting in high healthcare costs.
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Affiliation(s)
- Addison K May
- Carolinas Medical Center, Atrium Health, Charlotte, North Carolina, USA
| | - Victor B Talisa
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center and Department of Critical Care Medicine, University of Pittsburgh, Pennsylvania, USA
| | | | - Eileen Bulger
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | | | - Andrew Bernard
- Department of Surgery, University of Kentucky, Lexington, Kentucky, USA
| | - Sachin Yende
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center and Department of Critical Care Medicine, University of Pittsburgh, Pennsylvania, USA
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16
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Comparison of Traditional and Skin-Sparing Approaches for Surgical Treatment of Necrotizing Soft-Tissue Infections. Surg Infect (Larchmt) 2020; 21:363-369. [DOI: 10.1089/sur.2019.263] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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17
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Suijker J, de Vries A, de Jong VM, Schepers T, Ponsen KJ, Halm JA. Health-Related Quality of Life Is Decreased After Necrotizing Soft-Tissue Infections. J Surg Res 2019; 245:516-522. [PMID: 31450039 DOI: 10.1016/j.jss.2019.07.097] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 06/26/2019] [Accepted: 07/24/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND A necrotizing soft-tissue infection (NSTI) is a rare but severe infection with a high mortality rate of 12%-20%. Diagnosing is challenging and often delayed. Treatment consists of surgical debridement of all necrotic tissue and administration of antibiotics. Despite adequate treatment, survivors are often left with extensive wounds, resulting in mutilating scars and functional deficits. Both the disease and the subsequent scars can negatively influence the health-related quality of life (HRQoL). The present study was performed to contribute to the knowledge about HRQoL in patients after NSTI. METHODS We retrospectively identified patients treated for NSTI in a tertiary center in the Netherlands. Patient and treatment characteristics were collected and patients were asked to fill in a Short Form 36 questionnaire. RESULTS Forty-six patients with a diagnosis of NSTI were identified. Twenty-eight (61%) were male and mean age was 57 y. Thirty-nine patients (80%) survived. Thirty-one (84%) of the survivors returned the questionnaire after a median follow-up of 4.1 y (interquartile range [IQR], 2.4-5.9 y). Statistically significantly decreased scores when compared to the Dutch reference values were observed for the Short Form 36 domains, physical functioning, role-physical functioning, general health, and the combined Physical Component Score. No differences were observed for the other five domains or for the Mental Component Score. CONCLUSIONS This study confirms that NSTI negatively affects HRQoL as reported by the patient, especially on the physical domains. To learn more about HRQoL in patients after NSTI, studies in larger groups with a more disease-specific questionnaire should be performed. LEVEL OF EVIDENCE Level 3, prognostic and epidemiological.
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Affiliation(s)
- Jaco Suijker
- Burn Centre, Red Cross Hospital, Beverwijk, the Netherlands.
| | - Annebeth de Vries
- Burn Centre, Red Cross Hospital, Beverwijk, the Netherlands; Department of Surgery, Red Cross Hospital, Beverwijk, the Netherlands.
| | | | - Tim Schepers
- Trauma Unit, Amsterdam UMC location AMC, Amsterdam, the Netherlands
| | - Kees J Ponsen
- Department of Surgery, Medical Center Alkmaar, Alkmaar, the Netherlands
| | - Jens A Halm
- Trauma Unit, Amsterdam UMC location AMC, Amsterdam, the Netherlands
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18
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Madsen MB, Skrede S, Perner A, Arnell P, Nekludov M, Bruun T, Karlsson Y, Hansen MB, Polzik P, Hedetoft M, Rosén A, Saccenti E, Bergey F, Martins dos Santos VAP, Norrby-Teglund A, Hyldegaard O. Patient’s characteristics and outcomes in necrotising soft-tissue infections: results from a Scandinavian, multicentre, prospective cohort study. Intensive Care Med 2019; 45:1241-1251. [DOI: 10.1007/s00134-019-05730-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 08/02/2019] [Indexed: 12/19/2022]
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19
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Nawijn F, Houwert RM, van Wessem KPJ, Simmermacher RKJ, Govaert GAM, van Dijk MR, de Jong MB, de Bruin IGJ, Leenen LPH, Hietbrink F. A 5-Year Evaluation of the Implementation of Triple Diagnostics for Early Detection of Severe Necrotizing Soft Tissue Disease: A Single-Center Cohort Study. World J Surg 2019; 43:1898-1905. [PMID: 30953197 DOI: 10.1007/s00268-019-04999-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND The standardized approach with triple diagnostics (surgical exploration with visual inspection, microbiological and histological examination) has been proposed as the golden standard for early diagnosis of severe necrotizing soft tissue disease (SNSTD, or necrotizing fasciitis) in ambivalent cases. This study's primary aim was to evaluate the protocolized approach after implementation for diagnosing (early) SNSTD and relate this to clinical outcome. METHODS A cohort study analyzing a 5-year period was performed. All patients undergoing surgical exploration (with triple diagnostics) for suspected SNSTD since implementation were prospectively identified. Demographics, laboratory results and clinical outcomes were collected and analyzed. RESULT Thirty-six patients underwent surgical exploration with eight (22%) negative explorations. The overall 30-day mortality rate was 25%, with an early, SNSTD-related mortality rate of 11% (n = 3). Of these, one patient (4%) underwent primary amputation, but died during surgery. No significant differences between baseline characteristics were found between patients diagnosed with SNSTD in early/indistinctive or late/obvious stage. Patient diagnosed at an early stage had a significantly shorter ICU stay (2 vs. 6 days, p = 0.031). Mortality did not differ between groups; patients who died were all ASA IV patients. CONCLUSION Diagnosing SNSTD using the approach with triple diagnostics resulted in a low mortality rate and only a single amputation in a pre-terminal patient in the first 5 years after implementation. All deceased patients had multiple preexisting comorbidities consisting of severe systemic diseases, such as end-stage heart failure. Early detection proved to facilitate faster recovery with shorter ICU stay.
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Affiliation(s)
- Femke Nawijn
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Roderick M Houwert
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Karlijn P J van Wessem
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Rogier K J Simmermacher
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Geertje A M Govaert
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Marijke R van Dijk
- Department of Pathology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
| | - Mirjam B de Jong
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Ivar G J de Bruin
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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20
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Kruppa C, Hutter DJ, Königshausen M, Gessmann J, Schildhauer TA, Coulibaly MO. Necrotizing fasciitis and the midterm outcomes after survival. SAGE Open Med 2019; 7:2050312119842433. [PMID: 31057795 PMCID: PMC6452519 DOI: 10.1177/2050312119842433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 03/15/2019] [Indexed: 12/17/2022] Open
Abstract
Background and Aims: Radical surgical intervention is necessary to save patients’ lives in cases
of necrotizing fasciitis. This leads to persistent disabilities and most
likely to a deteriorated quality of life. The purpose of this study was to
evaluate the midterm outcomes after survival of necrotizing fasciitis. Materials and Methods: A retrospective analysis of 69 patients, treated for necrotizing fasciitis
between 2003 and 2012. The patients were identified using the International
Classification of Diseases (10th Revision) code M 72.6. Of the 50 survivors,
22 patients completed the Short Form 36 and Short Musculoskeletal Function
Assessment questionnaires as a postal survey. The follow-up averaged
59 months (range: 6–128 months). Results: The average age at the time of necrotizing fasciitis was 60.0 years. The body
mass index average was 29.7. The patients had a significantly decreased
physical component summary score of 33.3 compared to a normative group
(p < 0.001) (Short Form 36). They further showed a significantly
decreased dysfunction and bother indices (Short Musculoskeletal Function
Assessment) (p < 0.001). An increased age (⩾70 years) was associated with
an inferior role emotional (p = 0.048) and physical functioning (p = 0.011)
as well as social functioning (p = 0.038) (Short Form 36). The majority of
patients (16, 72.7%) complained of pain at the final follow-up and 50% of
patients required an assistive device on a regular basis. Conclusion: Patients who survived necrotizing fasciitis suffer from functional impairment
and changed body appearance. Assistive devices or pain medication are often
required, and the patients present with significantly decreased physical,
social, and emotional functioning at the midterm follow-up. The patient’s
age is a critical factor regarding functional or mental outcome parameters.
Further research on the post-hospital course and long-term multidisciplinary
care is required to improve the outcomes of these patients.
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Affiliation(s)
- Christiane Kruppa
- Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Danial J Hutter
- Research School, Faculty of Medicine, Ruhr-University Bochum, Bochum, Germany
| | - Matthias Königshausen
- Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Jan Gessmann
- Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Thomas A Schildhauer
- Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Marlon O Coulibaly
- Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Bochum, Germany
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Patient experience of necrotising soft-tissue infection from diagnosis to six months after intensive care unit stay: A qualitative content analysis. Aust Crit Care 2019; 33:187-192. [PMID: 30871854 DOI: 10.1016/j.aucc.2019.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 12/21/2018] [Accepted: 02/03/2019] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Necrotizing soft tissue infection (NSTI) is a severe, life-threatening condition requiring immediate diagnosis and treatment to avoid widespread tissue destruction and death. Current research seeks to explain the complex interaction between patient and disease agent, whereas only few studies have addressed the patient perspective. OBJECTIVE The present study aimed to describe the patient experience of NSTI in the first six months after diagnosis. METHODS The study had a qualitative design with patient involvement. We interviewed 27 NSTI survivors at six months after diagnosis and applied content analysis to capture their experiences. Patients were recruited from two referral centers in Sweden and one in Denmark. FINDINGS We identified three categories representing chronological stages of the illness trajectory depicting pivotal patient experiences: regaining awareness in the intensive care unit, transitioning to the ward, and returning home to normal life. Fear of infection or reinfection permeated all stages of the trajectory. Each stage was characterized by ambivalence: at first the relief of being alive and distress of serious illness, then the relief of independence and distress of abandonment, and finally the relief of being home and distress of still being dependent on others. CONCLUSION Fear of infection and reinfection during and after hospitalization characterized lives of NSTI survivors and their family. This fear was potentially debilitating in daily life, working life and social life. Healthcare professionals need to be aware of these modifiable factors to help alleviate the concerns of patient and family throughout the illness trajectory.
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22
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Rosén A, Arnell P, Madsen MB, Nedrebø BG, Norrby-Teglund A, Hyldegaard O, Dos Santos VM, Bergey F, Saccenti E, Skrede S. Diabetes and necrotizing soft tissue infections-A prospective observational cohort study: Statistical analysis plan. Acta Anaesthesiol Scand 2018; 62:1171-1177. [PMID: 29671865 DOI: 10.1111/aas.13130] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 03/09/2018] [Accepted: 03/21/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Necrotizing soft tissue infections (NSTIs) are rare but carry a high morbidity and mortality. The multicenter INFECT project aims to improve the understanding of the pathogenesis, clinical characteristics, diagnosis, and prognosis of NSTIs. This article describes the study outline and statistical analyses that will be used. METHODS Within the framework of INFECT project, patients with NSTI at 5 Scandinavian hospitals are enrolled in a prospective observational cohort study. The goal is to evaluate outcome and characteristics for patients with NSTI and diabetes compared to patients with NSTI without diabetes. The primary outcome is mortality at 90 days after inclusion. Secondary outcomes include days alive and out of ICU and hospital, SAPS II, SOFA score, infectious etiology, amputation, affected body area, and renal replacement therapy. Comparison in mortality between patients with diabetes type 1 and 2 as well as between insulin-treated and non-insulin-treated diabetes patients will be made. Clinical data for diabetic patients with NSTI will be reported. CONCLUSION The study will provide important data on patients with NSTI and diabetes.
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Affiliation(s)
- A Rosén
- Department of Anaesthesia and Intensive Care Medicine, Sahlgrenska University Hospital/Ostra, Gothenburg, Sweden
| | - P Arnell
- Department of Anaesthesia and Intensive Care Medicine, Sahlgrenska University Hospital/Ostra, Gothenburg, Sweden
| | - M B Madsen
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - B G Nedrebø
- Department of Medicine, Haugesund County Hospital, Haugesund, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - A Norrby-Teglund
- Centre for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - O Hyldegaard
- Department of Anaesthesia, Center of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - V M Dos Santos
- LifeGlimmer GmbH, Berlin, Germany
- Laboratory of Systems and Synthetic Biology, Wageningen University & Research, Wageningen, The Netherlands
| | - F Bergey
- LifeGlimmer GmbH, Berlin, Germany
| | - E Saccenti
- Laboratory of Systems and Synthetic Biology, Wageningen University & Research, Wageningen, The Netherlands
| | - S Skrede
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
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23
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Experiences of family caregivers the first six months after patient diagnosis of necrotising soft tissue infection: A thematic analysis. Intensive Crit Care Nurs 2018; 49:28-36. [PMID: 29937074 DOI: 10.1016/j.iccn.2018.05.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 05/07/2018] [Accepted: 05/07/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Necrotising soft tissue infection, or necrotising fasciitis, is a rapidly progressing disease requiring immediate diagnosis and treatment consisting of antimicrobial therapy, hyperbaric oxygen, debridement surgery and treatment in the intensive care unit. The harrowing illness trajectory affects the family caregivers potentially producing long-term psychological issues. OBJECTIVES We aimed to explore the experiences and coping strategies of family caregivers during the first six months after patient diagnosis of necrotising soft tissue infection. METHODS Our study had a prospective, explorative, qualitative design using semi-structured interviews and thematic analysis to understand necrotising soft tissue infection as an intrinsic and instrumental case. Family caregivers (n = 25) were recruited at three university hospitals in Denmark and Sweden. FINDINGS We identified three chronological themes describing issues of importance to the family caregivers. In the intensive care unit: Coping with illness and intensive care; In the ward: Coping with injury and post-intensive care and At home: Coping with recovery and new home life. CONCLUSION Challenges facing family caregivers of necrotising soft tissue infections survivors are still under-recognised. Healthcare professionals need to ensure that families and stakeholders throughout the patient trajectory have access to and co-create timely information and care plans to bridge the knowledge gap across care environments and to relieve family responsibility.
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24
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Factors predicting health-related quality of life following necrotizing fasciitis. J Plast Reconstr Aesthet Surg 2018; 71:857-862. [PMID: 29503165 DOI: 10.1016/j.bjps.2018.01.035] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 11/15/2017] [Accepted: 01/21/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Necrotizing fasciitis (NF) is a debilitating soft tissue infection that results in disfiguring scars and often amputations. While mortality rates have improved, long-term outcomes in survivors of NF are poorly understood. OBJECTIVES The objective of this study is to analyze the impact of NF on survivors' health-related quality of life (HRQoL) influenced by age, sex, comorbidities, %TBSA, and confidence with appearance. METHODS We surveyed 56 adult patients with NF treated at either of two regional referral centers in Manitoba, Canada, between January 1, 2004, and December 31, 2014. Necrotizing soft tissue infections involving the fascial planes were identified during surgical debridement. HRQoL was measured by the Medical Outcomes Short Form-36. Derriford Appearance Scale-24, age, sex, comorbidities, and %TBSA were recorded, and group comparisons and stepwise regression models were developed for the mental and physical component scores separately. RESULTS Mean Mental Component Score (MCS) was 44.5 ± 14.3 and mean Physical Component Score (PCS) was 36.5 ± 11.5; both means were lower than the Canadian population norm of 50. Although stepwise linear regression analyses with block entry indicated influence from age, sex, and comorbid conditions for the MCS and PCS, the only factors that were statistically significant in the final models were confidence with appearance for the MCS and %TBSA for the PCS. CONCLUSIONS NF has long-term impact on mental and physical health-related quality of life. Distress regarding confidence with appearance affects mental quality of life, whereas the size of the injured area impacted physical quality of life. These findings can help guide targeted interventions that could potentially improve recovery from NF.
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25
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Madsen MB, Skrede S, Bruun T, Arnell P, Rosén A, Nekludov M, Karlsson Y, Bergey F, Saccenti E, Martins dos Santos VAP, Perner A, Norrby-Teglund A, Hyldegaard O. Necrotizing soft tissue infections - a multicentre, prospective observational study (INFECT): protocol and statistical analysis plan. Acta Anaesthesiol Scand 2018; 62:272-279. [PMID: 29082520 DOI: 10.1111/aas.13024] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 10/08/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND The INFECT project aims to advance our understanding of the pathophysiological mechanisms in necrotizing soft tissue infections (NSTIs). The INFECT observational study is part of the INFECT project with the aim of studying the clinical profile of patients with NSTIs and correlating these to patient-important outcomes. With this protocol and statistical analysis plan we describe the methods used to obtain data and the details of the planned analyses. METHODS The INFECT study is a multicentre, prospective observational cohort study. Patients with NSTIs are enrolled in five Scandinavian hospitals, which are all referral centres for NSTIs. The primary outcomes are the descriptive variables of the patients. Secondary outcomes include identification of factors associated with 90-day mortality and amputation; associations between affected body part, maximum skin defect and Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score and 90-day mortality; 90-day mortality in patients with and without acute kidney injury (AKI) and LRINEC score of six and above or below six; and association between affected body part at arrival and microbiological findings. Exploratory outcomes include univariate analyses of baseline characteristics associations with 90-day mortality. The statistical analyses will be conducted in accordance with the predefined statistical analysis plan. CONCLUSION Necrotizing soft tissue infections result in severe morbidity and mortality. The INFECT study will be the largest prospective study in patients with NSTIs to date and will provide important data for clinicians, researchers and policy makers on the characteristics and outcomes of these patients.
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Affiliation(s)
- M. B. Madsen
- Department of Intensive Care; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
| | - S. Skrede
- Department of Medicine; Haukeland University Hospital; Bergen Norway
- Department of Clinical Science; University of Bergen; Bergen Norway
| | - T. Bruun
- Department of Medicine; Haukeland University Hospital; Bergen Norway
| | - P. Arnell
- Department of Anaesthesia and Intensive Care; Sahlgrenska University Hospital; Gothenburg Sweden
| | - A. Rosén
- Department of Anaesthesia and Intensive Care; Sahlgrenska University Hospital; Gothenburg Sweden
| | - M. Nekludov
- Department of Anaesthesia; Surgical Services and Intensive Care; Karolinska Institutet; Karolinska University Hospital; Stockholm Sweden
| | - Y. Karlsson
- Department of Anaesthesiology and Intensive Care; Blekinge County Hospital; Karlskrona Sweden
| | | | - E. Saccenti
- Laboratory of Systems and Synthetic Biology; Wageningen University & Research; Wageningen the Netherlands
| | - V. A. P. Martins dos Santos
- LifeGlimmer GmBH; Berlin Germany
- Laboratory of Systems and Synthetic Biology; Wageningen University & Research; Wageningen the Netherlands
| | - A. Perner
- Department of Intensive Care; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
| | - A. Norrby-Teglund
- Centre for Infectious Medicine; Karolinska Institutet; Karolinska University Hospital; Huddinge Sweden
| | - O. Hyldegaard
- Department of Anaesthesia; Centre of Head and Orthopaedics; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
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Immunoglobulin G for patients with necrotising soft tissue infection (INSTINCT): a randomised, blinded, placebo-controlled trial. Intensive Care Med 2017; 43:1585-1593. [DOI: 10.1007/s00134-017-4786-0] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 03/30/2017] [Indexed: 01/23/2023]
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Egerod I, Andersson AE, Fagerdahl AM, Knudsen VE. Images of suffering depicted in diaries of family caregivers in the acute stage of necrotising soft tissue infection: A content analysis. Intensive Crit Care Nurs 2017; 41:57-62. [PMID: 28292567 DOI: 10.1016/j.iccn.2017.02.004] [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] [Received: 12/18/2016] [Revised: 02/08/2017] [Accepted: 02/11/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Severe necrotising soft tissue infections (NSTI) are rare life threatening rapidly progressing bacterial infections requiring immediate diagnosis and treatment. The aim of the study was to explore the experience of family caregivers of patients with necrotising soft tissue infection during the acute stage of disease. METHODS Our study had a qualitative descriptive binational design using qualitative content analysis to explore diaries written by close family members (n=15). Participants were recruited from university hospitals in Denmark and Sweden. FINDINGS Three main categories emerged: Trajectory, Treatment, and Patient & Family. The first helped us construct an overview of the NSTI trajectory showing issues of importance to patient and family caregivers. The following categories were analysed further to describe four themes central to the family caregiver experience: craving information, needing to be near, suffering separation and network taking over. CONCLUSIONS Necrotising soft tissue infections are uncommon causing shock and concern. Centralised treatment might involve physical separation of patient and family during the acute stage of illness. Family accommodations near the patient and accessibility to adequate communication devices at the bedside are recommended. Health professionals need to keep in mind the importance of information and reassurance on the wellbeing of the family and ultimately of the patient.
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Affiliation(s)
- Ingrid Egerod
- University of Copenhagen, Rigshospitalet, Intensive Care Unit 4131, Blegdamsvej 9, Copenhagen, Denmark,.
| | - Annette E Andersson
- Institute of Health and care science, University of Gothenburg, Sweden; Department of Orthopedic Surgery, Sahlgrenska University Hospital, Mölndal, Sweden.
| | - Ann-Mari Fagerdahl
- Ann-Mari Fagerdahl: Department of Clinical Science and Education, Södersjukhuset, Karolinska Institute, Stockholm, Sweden.
| | - Vibeke E Knudsen
- University of Copenhagen, Rigshospitalet, Intensive Care Unit 4131, Blegdamsvej 9, Copenhagen, Denmark,.
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Triple diagnostics for early detection of ambivalent necrotizing fasciitis. World J Emerg Surg 2016; 11:51. [PMID: 27766113 PMCID: PMC5057419 DOI: 10.1186/s13017-016-0108-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 09/29/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Necrotizing fasciitis is an uncommon, rapidly progressive and potential lethal condition. Over the last decade time to surgery decreased and outcome improved, most likely due to increased awareness and more timely referral. Early recognition is key to improve mortality and morbidity. However, early referral frequently makes it a challenge to recognize this heterogeneous disease in its initial stages. Signs and symptoms might be misleading or absent, while the most prominent skin marks might be in discrepancy with the position of the fascial necrosis. Gram staining and especially fresh frozen section histology might be a useful adjunct. METHODS Retrospective analysis of 3 year period. Non-transferred patients who presented with suspected necrotizing fasciitis are included. ASA classification was determined. Mortality was documented. RESULTS In total, 21 patients are included. Most patients suffered from severe comorbidities. In 11 patients, diagnoses was confirmed based on intra-operative macroscopic findings. Histology and/or microbiotic findings resulted in 6/10 remaining patients in a change in treatment strategy. In total, 17 patients proved to suffer necrotizing fasciitis. In the cohort series 2 patients died due to necrotizing fasciitis. CONCLUSION In the early phases of necrotizing fasciitis, clinical presentation can be ambivalent. In the present cohort, triple diagnostics consisting of an incisional biopsy with macroscopic, histologic and microbiotic findings was helpful in timely identification of necrotizing fasciitis.
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Hakkarainen TW, Kopari NM, Pham TN, Evans HL. Necrotizing soft tissue infections: review and current concepts in treatment, systems of care, and outcomes. Curr Probl Surg 2014; 51:344-62. [PMID: 25069713 DOI: 10.1067/j.cpsurg.2014.06.001] [Citation(s) in RCA: 223] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 06/05/2014] [Indexed: 01/17/2023]
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