Necrotizing soft-tissue infections

Atraumatic Clostridial Myonecrosis in an Immunocompromised Host

BACKGROUND

Necrotizing fasciitis is usually associated with a surgical or traumatic wound. Clostridial myonecrosis is an uncommon but deadly infection that can develop in the absence of a wound and is often associated with occult gastrointestinal cancer or immunocompromise, or both.

CASE REPORT

We report a case of catastrophic atraumatic Clostridium septicum infection in an immunocompromised host. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians most commonly associate necrotizing fasciitis with superinfection of an open wound. This case reminds physicians that patients with acquired neutropenia can present with spontaneous gas gangrene due to C. septicum. Providers should consider this diagnosis in immunocompromised patients who present with acute onset of severe atraumatic limb pain.

A Retrospective Review of Patients with Necrotizing Fasciitis Presenting to an Emergency Department in Hong Kong

Background

Necrotizing fasciitis is a soft tissue gangrenous infection that require early diagnosis, radical debridement and broad-spectrum antibiotics.

Aim

To review the clinical spectrum and outcome of necrotizing fasciitis in Kwong Wah Hospital during a period of 18 months.

Method

Cases of necrotizing fasciitis were identified from discharge statistics for the period January 1999 to June 2000. Accident and Emergency Department (AED) notes and clinical records after admission were reviewed for clinical features, predisposing factors, microbiology, histology, treatment and outcome.

Results

Fifteen cases of necrotizing fasciitis were found but two of them had wrong diagnosis made. Of the thirteen cases, ten were male and three were female. The average age was 61.7 years old. Most of them presented with different combinations of swelling, pain, erythema and fever. They attended the emergency department with an interval of 3.5 days from the onset of symptoms. Risk factors were identified in 64% of patients, with diabetes mellitis (DM) and hypertension (HT) being the most common. Monomicrobial and polymicrobial infections were equally common in our study. Streptococcus pyogene was the most common pathogen. Only two NF (18%) were diagnosed in AED. Six patients were admitted to either surgical or orthopaedic wards and all of them underwent operations within 24 hours although two of them died. Other five patients were managed in medical ward and four of these patients underwent delayed operations but survived whilst one of them died despite of early surgical intervention. Overall mortality was 23%.

Conclusions

This condition affects a wide age group and have associated morbidities. It is often a fatal disease. Early recognition, high dose antibiotics and surgical debridement are important in its management.

Management and Novel Adjuncts of Necrotizing Soft Tissue Infections

Necrotizing soft tissue infections (NSTI) have been recognized for millennia and continue to impose considerable burden on both patient and society in terms of morbidity, death, and the allocation of resources. With improvements in the delivery of critical care, outcomes have improved, although disease-specific therapies are lacking. The basic principles of early diagnosis, of prompt and broad antimicrobial therapy, and of aggressive debridement have remained unchanged. Clearly novel and new therapeutics are needed to combat this persistently lethal disease. This review emphasizes the pillars of NSTI management and then summarizes the contemporary evidence supporting the incorporation of novel adjuncts to the pharmacologic and operative foundations of managing this disease.

Adjunctive hyperbaric oxygen for necrotizing fasciitis

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

We found no trials that met the inclusion criteria.

AUTHORS' CONCLUSIONS

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

The medical use of oxygen: a time for critical reappraisal

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

Necrotizing soft-tissue infections

NSTI is a life-threatening, surgical, and medical emergency. Clinical presentation, at least in the initial phase, can be misleading. Various studies have shown that delay in surgical debridement is associated with increased mortality. A high index of suspicion is important in early recognition and in instituting prompt therapy without delay. Early diagnosis, aggressive surgical debridement, aggressive supportive care, and optimal presumptive antibiotic therapy significantly improve morbidity and mortality associated with NSTIs.

Necrotizing fasciitis in a pediatric patient caused by lancefield group g streptococcus: case report and brief review of the literature

We report a case of necrotizing fasciitis with an accompanying toxic shock syndrome caused by Group G Streptococcus in a pediatric patient with a lymphatic malformation. Pediatricians need to be aware of the possibility of such infections, especially in those with vascular/lymphatic malformations, as early treatment is critical for survival.

Simultaneous necrotizing soft tissue infection and colonic necrosis caused by Clostridium septicum

BACKGROUND

Clostridial myonecrosis is an uncommon, highly lethal necrotizing soft tissue infection. The source may be occult at the time of clinical presentation. In cases caused by Clostridium septicum, there is an association with colorectal malignant disease, suggesting that underlying colonic pathology frequently is the source of the infection.

METHODS

Case report and literature review.

CASE REPORT

A 37-year old man with acquired immunodeficiency syndrome, end-stage renal disease, and C. difficile colitis presented to the Emergency Department (ED) with a primary complaint of abdominal pain and incidental right forearm pain. While undergoing evaluation in the ED, he developed progressive erythema, edema, and emergence of bullae over his right forearm. After rapid imaging of his abdomen, he underwent guillotine amputation of his right upper extremity because of extensive myonecrosis and total abdominal colectomy secondary to right colonic necrosis and C. difficile colitis. Blood cultures were positive for C. septicum. Microscopic examination of both the necrotic colon and the right forearm musculature demonstrated invasion of gram-positive bacilli throughout.

CONCLUSIONS

Myonecrosis caused by C. septicum frequently occurs in the presence of colonic pathology, typically malignant disease. This case report illustrates the development of this pathological process in an immunosuppressed patient who did not have colon cancer, but rather colonic mucosal inflammation produced by C. difficile.

A case of gas gangrene in an immunosuppressed Crohn’s patient

Clostridium septicum (C. septicum) gas gangrene is well documented in the literature, typically in the setting of trauma or immunosuppression. In this paper, we report a unique case of spontaneous clostridial myonecrosis in a patient with Crohn’s disease and sulfasalazine-induced neutropenia. The patient presented with left thigh pain, vomiting and diarrhea. Blood tests demonstrated a profound neutropenia, and magnetic resonance imaging of the thigh confirmed extensive myonecrosis. The patient underwent emergency hip disarticulation, followed by hemicolectomy. C. septicum was cultured from the blood. Following completion of antibiotic therapy, the patient developed myonecrosis of the right pectoral muscle necessitating further debridement, and remains on lifelong prophylactic antibiotic therapy.

Necrotising fasciitis of the submandibular region

SummaryTwo cases of necrotizing fasciitis (NF) complicating different conditions of the maxillofacial region, treated at the Korle Bu Teaching Hospital are reported. These were managed by an early diagnosis, aggressive surgical exploration, fasciotomies and debridement of necrotic tissue. In addition, frequent irrigation within the fascial planes with eusol and saline solutions plus the administration of broad spectrum antibiotics ensured early containment of the spread of the infection. Our early recognition of the signs and symptoms of NF led to an early intervention resulting in minimal residual skin defects which even though were not skin-grafted healed satisfactorily.

Klebsiella pneumoniae Causing Necrotizing Fasciitis in a Patient with Thalassaemia Major

We present a case of Klebsiella pneumoniae necrotizing fasciitis in a patient with thalassaemia major. Klebsiella sp. is known to cause severe infections in patients with thalassaemia, with high mortality rates.

Fournier's gangrene in a patient receiving treatment for idiopathic thrombocytopenic purpura

We report the case of a 68-year-old man who was diagnosed with Fournier's gangrene (FG), which developed during immunosuppresive treatment for idiopathic thrombocytopenic purpura (ITP). The patient was administered steroids for ITP but on the 36th day, he developed FG and septic shock. We initiated antibiotic treatment and drained a periproctal abscess immediately. On day 53, extensive drainage to progressive FG and a splenectomy was performed, following which both FG and thrombocytopenia improved. This is the first case of FG has developing in a ITP patient. It appears that high-dose immunoglobulin therapy and splenectomy should be considered earlier especially for a patient complicated with FG.

Necrotizing soft tissue infections in the intensive care unit

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

Severe skin and soft tissue infections and associated critical illness

Skin and soft tissue infections (SSTIs) span a broad spectrum of clinical entities from limited cellulitis to rapidly progressive necrotizing fasciitis, which may be associated with septic shock or a toxic shock-like syndrome. These infections may be the primary instigators of critical illness requiring hospitalization and management in the intensive care unit. Alternatively, these infections may arise from metastatic spread of microorganisms from a distant focus. Regardless of the source, SSTIs may lead to critical illness. The complex interplay of environment, host, and pathogen are important to consider when evaluating SSTIs and planning therapy. This second of a two-part review focuses on severe SSTIs due to Clostridium spp, microorganisms associated with water sources, and polymicrobial/mixed infections. The key to a successful outcome is early identification of risk factors for specific pathogens and early initiation of empiric antimicrobial therapy. For some SSTIs, surgical intervention for diagnosis and/or therapy is also required.

Necrotizing fasciitis

Necrotizing fasciitis (NF) is a necrotizing soft tissue infection that can cause rapid local tissue destruction, necrosis and life-threatening severe sepsis. Predisposing conditions for NF include diabetes, malignancy, alcohol abuse, and chronic liver and kidney diseases. NF is classified into two categories (types 1 and 2) based on causative microorganisms. The initial clinical picture of NF mimics that of cellulitis or erysipelas, including fever, pain, tenderness, swelling and erythema. The cardinal manifestations of NF are severe pain at onset out of proportion to local findings, hemorrhagic bullae and/or vital sign abnormality. In such cases, NF should be strongly suspected and immediate surgical intervention should be considered, along with broad-spectrum antimicrobials and general supportive measures, regardless of the findings of imaging tests.

Postirradiation Klebsiella pneumoniae-associated necrotizing fasciitis in the western hemisphere: a rare but life-threatening clinical entity

Necrotizing fasciitis (NF) caused by Klebsiella spp. is a unique entity, particularly, in Asia, where virulent strains of Klebsiella predominate. It is now clear that Klebsiella spp. are capable of causing NF either isolated or in the context of disseminated disease. We present a unique case of NF caused by Klebsiella pneumoniae in the Western hemisphere after radiotherapy in a hospitalized patient with significant comorbidities. Physicians should be aware of nosocomially acquired K. pneumoniae fasciitis after radiotherapy in the setting of chronic comorbidities, such as diabetes and malignancy. Early diagnosis, surgical intervention, and appropriate empirical antibiotics are essential for a favorable outcome in such rare but life-threatening cases of NF.

Necrotizing fasciitis of the face: a life-threatening condition

Necrotizing fasciitis (NF) is a highly aggressive infectious process, polymicrobial in nature, involving soft tissues with a high risk of rapid spread through superficial and deep fascial planes and muscular layers. Cervical NF is quite rare, is mostly of odontogenic origin, and may be complicated by descendant mediastinitis with a very high mortality rate. Systemic conditions impairing the patient's immune competence, such as diabetes, may play a predisposing role. An effective treatment strategy includes prompt diagnosis (clinical findings, local microbiological tests, blood culture and, if deemed necessary, histopathology), broad-spectrum antibiotic therapy as early as possible which should be later adjusted according to antibiogram results, stabilization of vital functions and, if possible, elimination/ treatment of predisposing factors. This paper describes a complex and emblematic case.

Bacterial, fungal, parasitic, and viral myositis

Infectious myositis may be caused by a broad range of bacterial, fungal, parasitic, and viral agents. Infectious myositis is overall uncommon given the relative resistance of the musculature to infection. For example, inciting events, including trauma, surgery, or the presence of foreign bodies or devitalized tissue, are often present in cases of bacterial myositis. Bacterial causes are categorized by clinical presentation, anatomic location, and causative organisms into the categories of pyomyositis, psoas abscess, Staphylococcus aureus myositis, group A streptococcal necrotizing myositis, group B streptococcal myositis, clostridial gas gangrene, and nonclostridial myositis. Fungal myositis is rare and usually occurs among immunocompromised hosts. Parasitic myositis is most commonly a result of trichinosis or cystericercosis, but other protozoa or helminths may be involved. A parasitic cause of myositis is suggested by the travel history and presence of eosinophilia. Viruses may cause diffuse muscle involvement with clinical manifestations, such as benign acute myositis (most commonly due to influenza virus), pleurodynia (coxsackievirus B), acute rhabdomyolysis, or an immune-mediated polymyositis. The diagnosis of myositis is suggested by the clinical picture and radiologic imaging, and the etiologic agent is confirmed by microbiologic or serologic testing. Therapy is based on the clinical presentation and the underlying pathogen.

Aggressive management of necrotizing fasciitis through a multidisciplinary approach using minimal surgical procedures: a case report

Necrotizing fasciitis is an aggressive, destructive infection of the soft tissue and fascia and is a life-threatening surgical emergency. A case study is presented of necrotizing fasciitis in the right lower extremity of a 53-year-old male resident of a long-term skilled nursing facility. Limb salvage was achieved through a multidisciplinary approach with early surgical management and aggressive postoperative management. Through 3 surgical procedures, the combined efforts of podiatric surgery, orthopaedic surgery, general/trauma surgery, and infectious disease provided early wound closure and limb salvage. An aggressive multidisciplinary approach to the management of necrotizing fasciitis in the lower extremity is necessary for limb salvage. Use of this multidisciplinary approach will minimize the number of surgical procedures and decrease the potential morbidity and mortality seen in patients with this infection.

Analysis of protection afforded by a Clostridium perfringens α-toxoid against heterologous clostridial phospholipases C

The major virulence determinant in clostridial myonecrosis caused by Clostridium perfringens is a phospholipase C (PLC), the alpha-toxin. Previously, mice have been protected against challenge with heterologous alpha-toxin or Clostridium perfringens spores by immunisation with the C-domain (known as Cpa(247-370) or alpha-toxoid) of the alpha-toxin. In this study, we have determined the ability of the alpha-toxoid to protect against the lethal effects of a divergent C. perfringens alpha-toxin and against the PLCs of C. absonum or C. bifermentans, species which have been isolated from cases of clostridial myonecrosis. Protection against the C. perfringens alpha-toxin variant, the C. absonum alpha-toxin or the C. bifermentans PLC was elicited by immunisation with the alpha-toxoid in vivo.

Chirurgisches Konzept und Ergebnisse bei nekrotisierender Fasziitis

BACKGROUND

Necrotizing fasciitis (NF) is still a source of high morbidity and mortality. These difficult cases are increasingly referred to burn centers due to special wound and critical care issues. Here we examine our institution's recent experience with a large series of NF.

METHOD

We performed a retrospective chart review of 32 consecutive patients over a 10-year period with NF who required radical surgical debridement and surface reconstruction.

RESULTS

Overall survival was 85%, with average length of stay of 74.0+/-7.5 days for survivors (S) and 68.8+/-6.3 days for nonsurvivors (NS) (P>0.05). Time until first operation was 5.2 days in S and 3.4 days in NS (P<0.05). Patient age averaged 51.1+/-11.2 years for S and 57.0+/-12.0 years for NS (P<0.05). Survivors averaged 1.6 relevant comorbidities and NS averaged 3.6 (P<0.05). Affected total body surface (TBS) per patient averaged 6.8+/-3.3% for S and 10.2+/-5.1% for NS (P<0.05). All NS had affection of the trunk, and none of the patients with exclusive affection of extremities died.

CONCLUSIONS

There were frequent delays in diagnosis and referrals to our institution, and progress can be made in educating the medical community to identify these patients. Not only the affected TBS and location but also comorbidities, age, and immediate surgical treatment are important prognostic factors. Referral to a specialized facility such as a burn center is urgently recommended for optimal surgical intervention, wound care, and critical care management.

Necrotizing fasciitis: reviewing the causes and treatment strategies

PURPOSE

To update the practitioner with causes, diagnosis, and treatment options for necrotizing fasciitis.

TARGET AUDIENCE

This continuing education activity is intended for physicians and nurses with an interest in better understanding the pathophysiology, diagnosis, and treatment of necrotizing fasciitis.

OBJECTIVES

After reading this article and taking this test, the reader should be able to: 1. Identify the risk factors and causes of necrotizing fasciitis (NF). 2. Describe the clinical presentation and diagnosis of NF. 3. Explain the treatment options for NF.

Continuous renal replacement therapy in patients following traumatic injury

In critically injured patients, the incidence of acute renal failure has been reported to occur in as many as 31% of patients. The use of CRRT modalities for patients following traumatic injuries is becoming more common, albeit slowly, and this therapy may impact upon long-term recovery of renal function and mortality. Historical studies investigating the early use of intermittent dialysis reported significant improvement in survival in patients who were dialyzed earlier and more vigorously than in control subjects. Early trauma patients also showed improved survival following war injuries when dialyzed prophylactically. Although there is a growing acceptance in favor of earlier renal replacement therapy, the published consensus and the practice in many centers has been to dialyze/filter relatively ill rather than relatively healthy patients. The R Adams Cowley Shock Trauma Center (STC) in Baltimore, Maryland, USA, admits over 8,000 trauma patients each year. Within the STC, a program of continuous renal replacement therapy was established in the early 1980's. We review both historical and current literature on the use of renal replacement therapies after traumatic injury, and suggest some future areas of investigation and indications for these modalities.

Multiple dimensions of caring for a patient with acute necrotizing fasciitis

Critical care nurses within acute care settings are responsible for providing healthcare to a wide variety of patients and, consequently, knowledge regarding how to care for a patient with acute necrotizing fasciitis is imperative. A case study is presented to evidence the need for a multidisciplinary approach. Necrotizing fasciitis is defined and treatment options are presented. Caring for this patient is very challenging and demands a multidisciplinary team to coordinate all aspects of care to promote better patient outcomes.

Rapidly progressive soft tissue infections

Skin and soft tissue infections are among the most common reasons for people to seek medical advice. They also represent one of the most common indications for antimicrobial therapy and account for approximately 7-10% of hospitalisations in North America. Although non-limb and non-life threatening infections may be treated on an out-patient basis with oral antibiotics, patients with more serious acute skin and soft tissue infections may require admission to hospital for management; this decision is especially true if the infection is rapidly progressive. We provide a concise overview of the differential diagnosis and approach to management of community-acquired rapidly progressive skin and soft tissue infections.

Caloric requirements in patients with necrotizing fasciitis

Patients with necrotizing fasciitis (NF) and other soft tissue infections are often treated in burn centers due to the extent of wound care and surgical intervention needed. Sepsis and surgery increase metabolic needs and may limit oral intake and necessitate enteral (TEN) or parenteral (TPN) nutrition. We reviewed the records of patients admitted with necrotizing fasciitis or surgical soft tissue infections from January 1993 to June 1998 who had indirect calorimetry (IC) measurements performed. Records were also reviewed for surgical/medical management and nutritional intervention. Twenty-six patients were admitted with 17 of these having IC measurements (133 total IC measurements). The IC group had more surgeries (mean 4.9 versus 2.7) and 82% required mechanical ventilation (mean 17.9 days). Energy expenditure showed a moderate but significant increase in energy needs (mean 23.8 kcal/kg/day, 124% BEE) with large variations (10.7-42.4 kcal/kg/day, 60%-199% BEE) in individual energy requirements. Caloric intake averaged 73% of needs based on IC (range 53%-104%). Nearly all patients (94%) required TEN (82%) and/or TPN (41%) nutrition for a mean of 24 days (range 1-68 days). NF presents a broad range of metabolic and surgical needs. Our data indicates patients with NF have increased energy requirements and suggests provision of calories at 124% basal or 25 kcal/kg actual wt/d; but due to the large individual variation, routine assessment using IC is recommended. Clinicians need to recognize the likely need for nutritional support and possibly lengthy clinical course for these patients.

A Fatal Case of Necrotizing Fasciitis Caused by Serratia marcescens

A patient with a history of type II diabetes mellitus (DM), end stage renal disease (ESRD), and congestive heart failure (CHF) developed necrotizing fasciitis caused by Serratia marcescens after scraping his leg on rocks in a river while fishing. Aggressive management with surgical debridement, antibiotics, and pressure support was unsuccessful.

The evolving characteristics and care of necrotizing soft-tissue infections

BACKGROUND

Necrotizing soft-tissue infections such as necrotizing fasciitis and Fournier's gangrene are a source of high morbidity and mortality. These difficult cases are increasingly being referred to burn centers for specialized wound and critical care issues. In this study, we examine our institution's recent experience with a large series of necrotizing soft-tissue infections.

STUDY DESIGN

A retrospective chart review was performed of 65 consecutive patients over a 5-year period with necrotizing soft-tissue infections that required radical surgical debridement.

RESULTS

Overall survival was 83%, with an average length of stay of 32.4+/-3.32 days for survivors and for the entire group of 29.5+/-3 days. Time from onset of symptoms to initial presentation to our institution averaged 6.9+/-1.19 days. Patients averaged 2.9+/-0.22 surgical procedures, and 46% of patients required skin grafting with an average graft area of 1554+/-248 cm(2). Of the survivors, only 54% were able to return home, with 46% needing further hospitalization or transfer to an inpatient rehabilitation facility.

CONCLUSIONS

There were frequent delays in diagnosis and referrals to and from within our institution, and progress can be made in educating the medical community to identify these patients. Advancements in wound care and critical care have made inroads into the treatment of patients with necrotizing soft-tissue infections. However, these infections continue to be a source of high morbidity and mortality and significant healthcare resource consumption. These challenging patients are best served with prompt diagnosis, immediate radical surgical debridement, and aggressive critical care management. Referral to a major burn center may help provide optimal surgical intervention, wound care, and critical care management.

Rapid infectious killers

Central to the practice of emergency medicine is the ability to identify patients in whom immediate intervention is needed to prevent long-term morbidity and mortality. This article has highlighted some of the characteristics of several infectious diseases that may become fatal quickly if not treated quickly and appropriately by physicians. Bacterial meningitis,necrotizing soft tissue infections, invasive gram-negative disease, pneumo-coccal pneumonia, and West Nile encephalitis all require prompt recognition and treatment by emergency care providers.

Role of Clostridium perfringens phospholipase C in the pathogenesis of gas gangrene

Gas gangrene is an acute and devastating infection most frequently caused by Clostridium perfringens and characterized by severe myonecrosis, intravascular leukocyte accumulation, and significant thrombosis. Several lines of evidence indicate that C. perfringens phospholipase C (Cp-PLC), also called alpha-toxin, is the major virulence factor in this disease. This toxin is a Zn2+ metalloenzyme with lecithinase and sphingomyelinase activities. Its three dimensional structure shows two domains, an N-terminal domain which contains the active site, and a C-terminal domain required for the Ca2+dependent interaction with membranes. Cp-PLC displays several biological activities: it increases capillary permeability, induces platelet aggregation, hemolysis, myonecrosis, decreases cardiac contractility, and is lethal. Experiments with genetically engineered Cp-PLC variants have revealed that the sphingomyelinase activity and the C-terminal domain are required for toxicity. The myotoxicity of Cp-PLC is largely dependent on its membrane damaging effect. In addition, it has been suggested that the alterations in the blood flow induced by this toxin also contribute to muscle damage. In gas gangrene, Cp-PLC dysregulates transduction pathways in endothelial cells, platelets and neutrophils leading to the uncontrolled production of several intercellular mediators and adhesion molecules. Thus, Cp-PLC alters the traffic of neutrophils to the infected tissue and promotes thrombotic events, enhancing the conditions for anaerobic growth.

Necrotizing Soft Tissue Infections: A Guide to Early Diagnosis and Initial Therapy

Necrotizing skin and soft tissue infections are caused by many different bacteria, are frequently polymicrobial, and may have a deceptively innocent early clinical presentation. Clostridial and nonclostridial necrotizing infections are frequently similar in their early presentation. The initial presentation of these infections can be insidious, which results in delay in diagnosis and the start of therapy. The clinician must use sound medical principles of clinical history and meticulous examination in each patient, combined with constant suspicion, to establish a timely diagnosis. This group of infectious diseases is associated with frequent morbidity and significant mortality rates, which increase with any delay in the diagnosis and the initiation of medical and surgical therapy. Also associated with these necrotizing infections is an excessive index of litigation. This review is intended as a guide for the clinician in making an early diagnosis of any necrotizing skin and soft tissue infection and initiating effective medical and surgical therapy.

Atraumatic Clostridial myonecrosis: case report and literature review

Clostridial myonecrosis (CM) is a rare, life-threatening infection that is most often associated with recent surgery or skeletal muscle trauma. It usually affects patients with some degree of underlying immunocompromise or vascular insufficiency. Occasionally, CM can occur at remote sites, with seeding from a gastrointestinal source in the setting of malignancy. We report a case of a 75-year-old man who developed rapidly progressive myonecrosis in the right shoulder, without prior trauma, caused by Clostridium septicum. On autopsy, this patient was found to have previously undiagnosed radiation colitis with ulcerations and abscess formation, secondary to recent prostate cancer radiation therapy. Although several case reports discuss CM in the setting of bowel malignancy, our case illustrates that non-malignant bowel inflammation may be a sufficient source for the infection. Clinical features of this uncommon disease are discussed, and the relevant literature is reviewed with regard to Clostridium septicum as an etiologic agent.

Burn center management of necrotizing fasciitis

Necrotizing fasciitis is a rapidly progressive soft-tissue infection associated with significant morbidity and mortality. Necrotizing fasciitis is similar to invasive burn wound infection in that diagnosis requires histologic examination of affected tissue and treatment requires aggressive surgical debridement followed by skin autograft. Transfer to a burn center facilitates the management of necrotizing fasciitis, where requisite surgical and nursing expertise is available. We reviewed the experience of one burn center in the management of necrotizing fasciitis over a 5-year period. Ten patients were transferred to the burn center from other medical facilities for care, arriving a mean of 8.9 days after initial hospital admission. The diagnosis was made by a surgical service or consultation before transfer in all cases; initial admission to a medical rather than a surgical service delayed surgery in five cases. All patients had surgical debridement before transfer but required a mean of 5.1 additional operations at the burn center. Although the mean extent of involvement was 14.8% body surface area, the mean length of burn center stay was 34.9 days. Complications were frequent, including pulmonary failure requiring mechanical ventilation (n = 6), renal insufficiency or failure (n = 5), hypotension requiring pressers (n = 4), deep venous thrombosis (n = 3), and pulmonary emboli (n = 1). Overall mortality was 2 of 10 patients (20%). Both fatalities were associated with delay in initial surgical procedure and in transfer to the burn center. The similarity of necrotizing fasciitis and invasive burn wound infection makes the burn center the ideal setting for the treatment of this disease. We advocate the addition of necrotizing fasciitis to the list of conditions currently recognized by the American Burn Association as appropriate for burn center transfer and care.

Aggressiveness - The key to a Successful Outcome in Necrotizing Soft Tissue Infection

16 patients with necrotizing soft tissue infections were managed during last three years in various service hospitals. The experience indicates that there is considerable overlap in clinical findings and bacteriology. The infections seem to be variations of the same disease process, a spreading necrotizing infection. The number of these patients suggests that there is an increasing incidence of this entity. Staphylococcus and coliforms were the commonest organisms cultured in most of these patients. Because of the high mortality rate upto 50% as reported, we advocate aggressive and early treatment of this condition. Urgent radical exploration, excision of all necrotic tissue and adequate drainage of the deep fascial planes was done in all patients until healthy tissue planes were reached. A strong index of suspicion aids early diagnosis which ensures a favourable outcome. Our study indicates that the lower gastrointestinal tract should be considered as a possible cause of infection in all patients with synergistic gangrene. The involvement of the perineum and scrotum was most common. All these patients were treated with a common approach of resuscitation, broad spectrum antibiotics, immediate surgical excision of all necrotic tissue, aggressive nutritional therapy and early skin coverage with 20% mortality. The infection was primary in 8, postsurgical in 4 and following trauma in 4 cases. In majority of patients, Staphylococcus with beta haemolytic streptococci and E coli were the organisms isolated initially. Mortality was highest in intensive infections extending the abdomen and chest. Aggressive, effective and early treatment of necrotizing soft tissue infections is imperative to prevent a fatal outcome. Urgent radical exploration by the most experienced surgeon available is essential and includes wide excision of all necrotic tissue and adequate drainage of the deep fascial planes until indubitably healthy tissue is experienced. The surgeon must be prepared to proceed to a laparotomy, diverting colostomy or a suprapubic cystotomy where there exists any element of doubt. Aggression is also of significance in resuscitation, early institution of empirical broad spectrum antibiotic therapy, elaborate repeated daily dressings with hydrogen peroxide and to allow further debridement till the process is controlled.

Necrotizing fasciitis due to penicillin-resistant Streptococcus pneumoniae: case report and review of the literature

Necrotizing fasciitis (NF) is a life-threatening infection involving rapid necrosis of subcutaneous and fascial tissues. Streptococcus pneumoniae (SPN) soft tissue infection is exceedingly uncommon, reported primarily in patients with immunosuppression or other underlying conditions. We report a case of NF and septic shock in a healthy 32-year-old man, whose only predisposing factor was antecedent blunt trauma. Pathological examination and culture of the extensive tissue debridement were positive only for SPN. The serotype 9V isolate was penicillin (PCN)-resistant (MIC=2.0), and closely-related by pulse field gel electrophoresis and multilocus fingerprinting to clone France 9V-3, an important genetic reservoir for increasing PCN-resistance worldwide. This unique case has implications for our pathogenic under-standing and empiric management of NF.

Massive infectious soft-tissue injury: diagnosis and management of necrotizing fasciitis and purpura fulminans

LEARNING OBJECTIVES

After studying the article, the participant should be able to: 1. Describe the most common bacteriology of necrotizing fasciitis and purpura fulminans. 2. Describe the "finger test" in the diagnosis of necrotizing fasciitis. 3. Discuss the three presentation patterns of necrotizing fasciitis. 4. Discuss the pathophysiology of acute infectious purpura fulminans. 5. Discuss the treatment strategies for necrotizing fasciitis and purpura fulminans, including the use of artificial skin substitutes. Necrotizing fasciitis and purpura fulminans are two destructive processes that involve skin and soft tissues. The plastic and reconstructive surgeon may frequently be called on for assistance in the diagnosis, treatment, and/or reconstruction of patients with these conditions. Understanding the natural history and unique characteristics of these processes is essential for effective surgical management and favorable patient outcome. A comprehensive review of the literature pertaining to these two conditions is presented, outlining the different pathophysiologies, the patterns of presentation, and the treatment strategies necessary for successful management of these massive infectious soft-tissue diseases.

Identification of residues critical for toxicity in Clostridium perfringens phospholipase C, the key toxin in gas gangrene

Clostridium perfringens phospholipase C (PLC), also called alpha-toxin, is the major virulence factor in the pathogenesis of gas gangrene. The toxic activities of genetically engineered alpha-toxin variants harboring single amino-acid substitutions in three loops of its C-terminal domain were studied. The substitutions were made in aspartic acid residues which bind calcium, and tyrosine residues of the putative membrane-interacting region. The variants D269N and D336N had less than 20% of the hemolytic activity and displayed a cytotoxic potency 103-fold lower than that of the wild-type toxin. The variants in which Tyr275, Tyr307, and Tyr331 were substituted by Asn, Phe, or Leu had 11-73% of the hemolytic activity and exhibited a cytotoxic potency 102- to 105-fold lower than that of the wild-type toxin. The results demonstrated that the sphingomyelinase activity and the C-terminal domain are required for myotoxicity in vivo and that the variants D269N, D336N, Y275N, Y307F, and Y331L had less than 12% of the myotoxic activity displayed by the wild-type toxin. This work therefore identifies residues critical for the toxic activities of C. perfringens PLC and provides new insights toward understanding the mechanism of action of this toxin at a molecular level.

Necrotizing fasciitis caused by Aeromonas hydrophila

Aeromonas Hydrophila is a gram-negative bacillus commonly found in soil, sewage, and fresh or brackish water in many parts of the United States. In healthy people, the most common clinical manifestations attributed to Aeromonas are diarrhea and soft tissue infections. In people with suppressed immune systems or liver disease, A hydrophila can cause meningitis, endocarditis, peritonitis, hemolytic-uremic syndrome, or septicemia. We present the first known case of fulminant necrotizing fasciitis from A hydrophila that is not associated with trauma, liver disease, or immunosuppression.

Cutaneous (non-HIV) infections

Cutaneous infections continue to represent a large proportion of inpatient dermatology. Though most infectious skin diseases do not warrant hospitalization, some do and can rapidly become fatal if not treated promptly. A selected group of infections are reviewed--primary cutaneous infections, exotoxin-mediated syndromes, and systemic infections--that warrant hospitalization. Dermatologists play a critical role in the synthesis of patient history and appreciation of morphologic skin disease, which, when coupled with appropriate lab tests, may help to establish a diagnosis allowing for the timely implementation of effective and targeted therapy.