Necrotizing Soft-Tissue Infections

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

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Is Prompt Hyperbaric Oxygen Adjunctive Therapy Able to Reduce Mortality and Amputation in Management of Necrotizing Soft-Tissue Infection?

Background: Necrotizing soft-tissue infection (NSTI) is a rare and serious disease with high morbidity and mortality. Standard therapeutic concepts have included urgent surgical intervention, broad-spectrum antibiotic treatment, and intensive care. Hyperbaric oxygen therapy (HBOT) is used as adjuvant therapy in some centers, but its benefits remain controversial. Methods: A retrospective analysis was conducted in which 98 patients with a clinical diagnosis of NSTI were treated with standard treatments plus HBOT. The clinical outcomes were wound healing, performance status, hospital length, complication rate, recurrence rate, morbidity (amputation rate), and mortality. Primary or secondary outcomes were compared between the time interval of HBOT and the clinical outcomes. Results: The average times from diagnosis of NSTI to initial HBO treatment and from initial surgery to initial HBO treatment were both significantly longer in dead patients than in surviving patients (P = 0.031; P = 0.020). These two time intervals were both significantly longer in amputated patients than in preserved patients (P = 0.031; P = 0.037). Conclusions: Using combined treatment with early surgical debridement combined with HBOT, it is possible to reduce hospital stay, intensive care unit stay, number of debridements, improve complete wound healing rate, and lower amputation and mortality rates among patients with NSTI. The early onset of HBOT soon after diagnosis, especially during critical conditions, is proved to be associated with higher survival and preservation rates.

First Case of Necrotizing Fasciitis and Septicemia Caused by Pigmentibacter ruber

We report the first case of necrotizing fasciitis caused by Pigmentibacter ruber. The isolated strain could not be identified by biochemical characterization or matrix-assisted laser desorption/ionization time-of-flight mass spectrometry but was identified as P. ruber by 16S ribosomal RNA and whole-genome sequencing. Although much remains unknown about the pathogenicity of this bacterial species in humans, it has been shown to cause life-threatening infections such as septicemia and necrotizing fasciitis. Because the isolate was highly resistant to β-lactams, it was difficult to treat with antimicrobial therapy. Thus, further documentation of cases and analyses are required.

Severe skin and soft tissue infection in cohort patients admitted in a teaching hospital in Belgium: identification of risk factors for surgery

BACKGROUND

Necrotizing soft tissue infections (NSTIs) are associated with significant mortality if not promptly diagnosed and surgically treated.

AIM

This study aims to compare patients with severe skin and soft tissue infection treated with or without a surgical intervention and to identify risk factors that can predict the need for early surgery.

METHODS

Demographics, clinical, laboratory, Risk Indicator for Necrotizing Fasciitis (LRINEC) and imaging results were retrospectively collected.

RESULTS

There were 91 non-NSTI (group 1), 26 NSTI who were operated (group 2) and eight suspected NSTI who were not operated (group 3). In the multivariate analysis, skin necrosis, tachycardia, CRP value and hyperglycemia were predictive for surgery. A performance analysis revealed AUC of 0.65 (95%CI: 0.52-0.78) as to the LRINEC score for the use of surgery. The AUC for a predictive model associating four variables (heart rate, skin necrosis, CRP and glycemia at admission) was 0.71 (95%CI: 0.59-0.84). In terms of outcome, the median length of stay (LOS) was statistically higher in group 2 vs. group 1 (seven days (5-15) vs. 34 days (20-42), p < .001) and in group 2 vs. group 3 (34 days (20-42) vs. 14 days (11-19), p = .005). The overall in-hospital mortality at 30 days was 3.2% and did not statistically differ between the three groups.

CONCLUSIONS

Although the LRINEC score performed well in predicting surgery, the AUC of a model combining four predictive variables (glycemia, skin necrosis, CRP and heart rate) was superior. Further research is needed to validate this model.

Necrotizing Soft Tissue Infection Following a Closed Distal Radius Fracture: A Case Report and Literature Review

Necrotizing soft tissue infections (NSTIs), characterized by extensive soft tissue destruction, are rare but life-threatening. We present a case of a NSTI in a healthy 65-year-old woman following a closed distal radius fracture. The patient presented with severe pain, fever, and lethargy 4 days after her index injury, with physical examination of the right upper limb revealing erythema and swelling to the mid-humeral level and blisters of the fingers and hand. Multiple surgical debridements were required to control the infection, which was caused by Streptococcus pyogenes. This case highlights the rapid progression and devastating consequences of NSTI, which can occur even in the setting of closed injuries in patients without comorbidities. Prompt diagnosis, early surgical intervention, and appropriate antimicrobial therapy are crucial in managing this pathology.Level of Evidence: Level 5.

Real-time identification of life-threatening necrotizing soft-tissue infections using indocyanine green fluorescence imaging

Significance

Necrotizing soft-tissue infections (NSTIs) are life-threatening infections with a cumulative case fatality rate of 21%. The initial presentation of an NSTI is non-specific, frequently leading to misdiagnosis and delays in care. No current strategies yield an accurate, real-time diagnosis of an NSTI.

Aim

A first-in-kind, observational, clinical pilot study tested the hypothesis that measurable fluorescence signal voids occur in NSTI-affected tissues following intravenous administration and imaging of perfusion-based indocyanine green (ICG) fluorescence. This hypothesis is based on the established knowledge that NSTI is associated with local microvascular thrombosis.

Approach

Adult patients presenting to the Emergency Department of a tertiary care medical center at high risk for NSTI were prospectively enrolled and imaged with a commercial fluorescence imager. Single-frame fluorescence snapshot and first-pass perfusion kinetic parameters-ingress slope (IS), time-to-peak (TTP) intensity, and maximum fluorescence intensity (IMAX)-were quantified using a dynamic contrast-enhanced fluorescence imaging technique. Clinical variables (comorbidities, blood laboratory values), fluorescence parameters, and fluorescence signal-to-background ratios (SBRs) were compared to final infection diagnosis.

Results

Fourteen patients were enrolled and imaged (six NSTI, six cellulitis, one diabetes mellitus-associated gangrene, and one osteomyelitis). Clinical variables demonstrated no statistically significant differences between NSTI and non-NSTI patient groups (p -value ≥ 0.22 ). All NSTI cases exhibited prominent fluorescence signal voids in affected tissues, including tissue features not visible to the naked eye. All cellulitis cases exhibited a hyperemic response with increased fluorescence and no distinct signal voids. Median lesion-to-background tissue SBRs based on snapshot, IS, TTP, and IMAX parameter maps ranged from 3.2 to 9.1, 2.2 to 33.8, 1.0 to 7.5, and 1.5 to 12.7, respectively, for the NSTI patient group. All fluorescence parameters except TTP demonstrated statistically significant differences between NSTI and cellulitis patient groups (p -value < 0.05 ).

Conclusions

Real-time, accurate discrimination of NSTIs compared with non-necrotizing infections may be possible with perfusion-based ICG fluorescence imaging.

Treatment strategies for orbital gas-producing necrotizing fasciitis secondary to odontogenic maxillary sinusitis: Technical notes

This paper presents treatment strategies for orbital necrotizing fasciitis (NF) in a case of a 33-year-old male diagnosed with orbital NF, which developed after dental root canal treatment. Although orbital NF is rare, it is rapidly progressive and can easily lead to the loss of tissue and visual function, sometimes to a life-threatening extent. Prompt and adequate treatment has been a challenge yet remains quite essential. In addition to the conventional approach to NF, such as immediate antibiotic administration and drainage, orbital NF patients like this case were often treated by incorporating additional steps, which include: 1) performing minimally invasive but adequate removal of necrotic tissue through intraoperative use of ultrasound equipment and postoperative use of proteolytic enzyme-containing ointment for chemical debridement; 2) managing intraorbital pressure by lateral cantholysis and orbital floor removal (decompression); and 3) maintaining the aerobic conditions of the wound after surgical drainage via orbital wall removal. Thus far, satisfactory results in patients with extensive NF of the orbit, including the presented case, were achieved with regards to preserving periorbital tissues, vision, and ocular motility through a multidisciplinary approach. These should be considered as optional means of preserving the orbital tissue and visual function.

Squirrel bite-a rare cause of necrotizing soft tissue infection: Case report

Although squirrel bites are uncommon and generally benign, they have been implicated in the transmission of certain diseases in humans, some of which can be life-threatening. This report discusses the case of a 27-year-old hunter who developed a necrotizing soft tissue infection with vesiculo-bullous skin lesions after a ground squirrel bite.

Identifying necrotizing soft tissue infection using infectious fluid analysis and clinical parameters based on machine learning algorithms

Background

Determining the presence of necrotizing soft tissue infection (NSTI) poses a significant hurdle. As of late, there has been a notable increase in the application of artificial intelligence (AI) machine learning techniques in identifying diseases, a shift that can be attributed to their exceptional efficiency, unbiased nature, and high precision.

Methods

Information was gathered from a cohort of 13 patients suffering from NSTI, alongside 12 patients with cellulitis. The construction of NSTI diagnostic machine learning models utilized four different algorithms, specifically random forest, k-nearest neighbors (KNN), support vector machine (SVM), and logistic regression. These models were constructed based on 28 distinctive attributes identified through statistical examination. Following this, the diagnostic efficiency of each algorithms was evaluated. A novel random forest model, streamlined for clinical use, was later developed by focusing on 6 attributes that had the most pronounced influence on the accuracy of our initial random forest model.

Results

The following data was noted regarding the sensitivity and specificity of the four NSTI diagnostic models:logistic regression displayed 78.2 % and 83.7 %, KNN presented 79.1 % and 87.1 %, SVM showed 83.5 % and 86.3 %, and random forest exhibited 89.6 % and 92.9 %, respectively. In comparison, lactate levels in fluid demonstrated 100 % sensitivity and 76.9 % specificity at an optimal cut-off point of 69.6 mg/dL. Among all four machine learning models, random forest outperformed the others and also showed better results than fluid lactate. A newly constructed random forest model, created using 6 of the 13 identified features, displayed promising results in diagnosing NSTI, having a sensitivity and specificity of 90.2 % and 92.2 %, respectively.

Conclusions

Developing a diagnostic model for NSTI employing the random forest algorithm has resulted in a diagnostic technique that is more efficient, cost-effective, and expedient. This approach could provide healthcare practitioners with the tools to identify and manage NSTI with greater efficacy.

Imaging features of soft-tissue infections

Skin and soft tissues are among the most common sites of infections. Infections can involve the superficial epidermis to deep muscles and bones. Most infections spread through contiguous structures, although hematogenous spread can occur in the setting of an immunocompromised state and with atypical infections. While clinical diagnosis of infections is possible, it often lacks specificity, necessitating the use of imaging for confirmation. Cross-sectional imaging with US, CT, and MRI is frequently performed not just for diagnosis, but to delineate the extent of infection and to aid in management. Nonetheless, the imaging features have considerable overlap, and as such, it is essential to integrate imaging features with clinical features for managing soft tissue infections. Radiologists must be aware of the imaging features of different infections and their mimics, as well as the pros and cons of each imaging technique to properly use them for appropriate clinical situations. In this review, we summarize the most recent evidence-based features of key soft tissue infections.

Clostridium perfringens Empyema: Anaerobic Invasion in an Uncommon Location

Clostridium perfringens bacteremia arises due to skin inoculation from the external environment or translocation from the gastrointestinal tract. In the event of bacteremia, it tends to colonize in anaerobic environments due to its obligatory anaerobic nature. Its inoculation in the lung, albeit rare, can occur if an anaerobic nidus is created. In the presented case, the patient developed C. perfringens bacteremia andempyema in the area of lung necrosis caused by acute pulmonary embolism. He did not have any history of chest trauma, and the source of bacteremia was deemed to be via gut translocation. The patient was noted to have multiple gastric ulcers on endoscopy and jejunal wall thickening, which likely led to the bacterial translocation into the bloodstream. He underwent video-assisted thoracoscopic surgery-assisted decortication and intravenous antibiotics, eventually leading to clinical improvement. To identify the source of Clostridium in the absence of penetrating trauma, a thorough gastrointestinal evaluation, including a colonoscopy, is warranted to identify the pathology leading to the gastrointestinal translocation.

Rare Insights: Temporoparietal Necrotizing Fasciitis Stemming From a Dental Source

Necrotizing fasciitis (NF) of the face is a rare yet serious condition requiring prompt and comprehensive management. This approach typically involves input from various medical specialties such as infectious disease specialists, critical care physicians, and surgeons. The primary goals are early recognition, aggressive surgical debridement, appropriate antibiotic therapy, and supportive care. Prompt diagnosis is crucial, based on symptoms like severe pain, rapidly spreading erythema, and systemic signs of infection. Broad-spectrum antibiotics are initiated empirically, and adjusted based on culture results. Urgent surgical debridement is crucial, removing all necrotic tissue. Careful consideration must be given to preserve vital structures. Close monitoring and intensive care may be necessary, especially for severe cases. Soft tissue reconstruction may follow once the infection is controlled, aiming to restore function and aesthetics. Long-term follow-up is essential to observe for complications and recurrence.

Group A Streptococcal Infections in Pediatric Age: Updates about a Re-Emerging Pathogen

Group A Streptococcus (GAS) presents a significant global health burden due to its diverse clinical manifestations ranging from mild infections to life-threatening invasive diseases. While historically stable, the incidence of GAS infections declined during the COVID-19 pandemic but resurged following the relaxation of preventive measures. Despite general responsiveness to β-lactam antibiotics, there remains an urgent need for a GAS vaccine due to its substantial global disease burden, particularly in low-resource settings. Vaccine development faces numerous challenges, including the extensive strain diversity, the lack of suitable animal models for testing, potential autoimmune complications, and the need for global distribution, while addressing socioeconomic disparities in vaccine access. Several vaccine candidates are in various stages of development, offering hope for effective prevention strategies in the future.

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

BACKGROUND

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

CASE PRESENTATION

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

CONCLUSIONS

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

Understanding limb necrotizing infections: A comprehensive approach

INTRODUCTION

Necrotizing soft tissue infections (NSTI) are increasing, posing a significant risk of morbidity and mortality. Due to nonspecific symptoms, a high index of suspicion is crucial. Treatment involves a multidisciplinary approach, with broad-spectrum antibiotics, early surgical debridement, and life support. This study analyzes the characteristics, demographics, complications, and treatment of NSTI in a hospital in Madrid, Spain.

METHODS

A retrospective observational study was conducted, including all surgically treated NSTI patients at our center from January 2016 to December 2022, examining epidemiological and clinical data. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) was prospectively calculated for all patients.

RESULTS

Twenty-two patients (16 men, 6 women, mean age 54.8) were included. Median time from symptom onset to emergency room visit was 3.5 days. All reported severe treatment-resistant pain; sixteen had fever exceeding 37.8°C (72.7%). Skin lesions occurred in twelve (54.5%), and thirteen had hypotension and tachycardia (59.1%). Treatment involved resuscitative support, antibiotherapy, and radical debridement. Median time to surgery was 8.25h. Intraoperative cultures were positive in twenty patients: twelve Streptococcus pyogenes, four Staphylococcus aureus, one Escherichia coli, and four polymicrobial infection. In-hospital mortality rate was 22.73%.

CONCLUSIONS

We examined the correlation between our results, amputation rates and mortality with LRINEC score and time to surgery. However, we found no significant relationship unlike some other studies. Nevertheless, a multidisciplinary approach with radical debridement and antibiotic therapy remains the treatment cornerstone. Our hospital stays, outcomes and mortality rates align with our literature review, confirming high morbimortality despite early and appropriate intervention.

Chaotropic Effect-Induced Sol-Gel Transition and Radical Stabilization for Bacterially Sensitive Near-Infrared Photothermal Therapy

Deep-seated bacterial infections (DBIs) are stubborn and deeply penetrate tissues. Eliminating deep-seated bacteria and promoting tissue regeneration remain great challenges. Here, a novel radical-containing hydrogel (SFT-B Gel) cross-linked by a chaotropic effect was designed for the sensing of DBIs and near-infrared photothermal therapy (NIR-II PTT). A silk fibroin solution stained with 4,4',4″-(1,3,5-triazine-2,4,6-triyl)tris(1-methylpyridin-1-ium) (TPT3+) was employed as the backbone, which could be cross-linked by a closo-dodecaborate cluster (B12H122-) through a chaotropic effect to form the SFT-B Gel. More interestingly, the SFT-B Gel exhibited the ability to sense DBIs, which could generate a TPT2+• radical with obvious color changes in the presence of bacteria. The radical-containing SFT-B Gel (SFT-B★ Gel) possessed strong NIR-II absorption and a remarkable photothermal effect, thus demonstrating excellent NIR-II PTT antibacterial activity for the treatment of DBIs. This work provides a new approach for the construction of intelligent hydrogels with unique properties using a chaotropic effect.

Truncating NFKB1 variants cause combined NLRP3 inflammasome activation and type I interferon signaling and predispose to necrotizing fasciitis

In monogenic autoinflammatory diseases, mutations in genes regulating innate immune responses often lead to uncontrolled activation of inflammasome pathways or the type I interferon (IFN-I) response. We describe a mechanism of autoinflammation potentially predisposing patients to life-threatening necrotizing soft tissue inflammation. Six unrelated families are identified in which affected members present with necrotizing fasciitis or severe soft tissue inflammations. Exome sequencing reveals truncating monoallelic loss-of-function variants of nuclear factor κ light-chain enhancer of activated B cells (NFKB1) in affected patients. In patients' macrophages and in NFKB1-variant-bearing THP-1 cells, activation increases both interleukin (IL)-1β secretion and IFN-I signaling. Truncation of NF-κB1 impairs autophagy, accompanied by the accumulation of reactive oxygen species and reduced degradation of inflammasome receptor nucleotide-binding oligomerization domain, leucine-rich repeat-containing protein 3 (NLRP3), and Toll/IL-1 receptor domain-containing adaptor protein inducing IFN-β (TRIF), thus leading to combined excessive inflammasome and IFN-I activity. Many of the patients respond to anti-inflammatory treatment, and targeting IL-1β and/or IFN-I signaling could represent a therapeutic approach for these patients.

Pyoderma Gangrenosum: Diagnostic Criteria, Subtypes, Systemic Associations, and Workup

Pyoderma gangrenosum (PG) is an inflammatory neutrophilic dermatosis with variable clinical features. The classic presentation is an ulceration with an erythematous to violaceous undermined border. Extracutaneous manifestations may occur. Associated systemic diseases include inflammatory bowel disease, inflammatory arthritides, and hematologic disorders. The pathophysiologic mechanism of disease is not completely known but likely related to the cumulative impact of inflammation, immune-mediated neutrophilic dysfunction, and genetic predisposition. Incidence is between 3 and 10 people per million but may be greater due to under recognition. In this article, we will discuss the diagnostic criteria, disease subtypes, systemic associations, and workup.

Assessing Second Debridement Timing and Mortality in Necrotizing Soft Tissue Infections

BACKGROUND

Patients with necrotizing soft tissue infection undergo an average of 4-5 debridements per hospital admission. Optimal timing for initial debridement is emergent. Second debridement is universally recommended to occur within 24 hours of the first, but no studies have successfully evaluated this time frame. Prior work has suggested that delays in second debridement are associated with increased mortality, and that few patients receive second debridement within 24 hours.

METHODS

We performed a retrospective cohort study at a single center from 01/01/08 to 09/01/2021. The explanatory variable was whether the subject received second debridement within 24 hours of initial debridement. The primary outcome was in-hospital mortality. Baseline characteristics were collected. Subjects were stratified into 2 groups by time between first and second debridement: <24 and ≥24 hours. Variables were compared using Fisher's exact and Wilcoxon rank-sum tests.

RESULTS

77 patients met inclusion criteria. The median overall time to second debridement was 40 hours. 12 subjects received second debridement within 24 hours (15.6%). There was no difference in in-hospital mortality between the <24 (n = 3, 25.0%) and ≥24-hour second debridement groups (n = 4, 6.2%; P = .07). The 2 groups did not differ by secondary outcomes, including total number of debridements, ICU LOS, or wound closure.

CONCLUSION

No difference in mortality was observed between subjects undergoing second debridement within 24 vs after 24 hours. Only 16% of subjects received second debridement within the recommended 24-hour time interval. Further study is required to identify the optimal timing of second debridement.

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

ABSTRACT

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

Reported outcome measures in necrotising soft tissue infections: a systematic review

Introduction

There are inconsistencies in outcome reporting for patients with necrotising soft tissue infections (NSTI). The aim of this study was to evaluate reported outcome measures in NSTI literature that could inform a core outcome set (COS) such as could be used in a study of hyperbaric oxygen in this indication.

Methods

A systematic review of all NSTI literature identified from Cochrane, Ovid MEDLINE and Scopus databases as well as grey literature sources OpenGrey and the New York Academy of Medicine databases which met inclusion criteria and were published between 2010 and 2020 was performed. Studies were included if they reported on > 5 cases and presented clinical endpoints, patient related outcomes, or resource utilisation in NSTI patients. Studies did not have to include intervention. Two independent researchers then extracted reported outcome measures. Similar outcomes were grouped and classified into domains to produce a structured inventory. An attempt was made to identify trends in outcome measures over time and by study design.

Results

Three hundred and seventy-five studies were identified and included a total of 311 outcome measures. Forty eight percent (150/311) of outcome measures were reported by two or more studies. The four most frequently reported outcome measures were mortality without time specified, length of hospital stay, amputation performed, and number of debridements, reported in 298 (79.5%), 260 (69.3%), 156 (41.6%) and 151 (40.3%) studies respectively. Mortality outcomes were reported in 23 different ways. Randomised controlled trials (RCTs) were more likely to report 28-day mortality or 90-day mortality. The second most frequent amputation related outcome was level of amputation, reported in 7.5% (28/375) of studies. The most commonly reported patient-centred outcome was the SF-36 which was reported in 1.6% (6/375) of all studies and in 2/10 RCTs.

Conclusions

There was wide variance in outcome measures in NSTI studies, further highlighting the need for a COS.

Contemporary national outcomes of hyperbaric oxygen therapy in necrotizing soft tissue infections

BACKGROUND

The role of hyperbaric oxygen therapy (HBOT) in necrotizing soft tissue infections (NSTI) is mainly based on small retrospective studies. A previous study using the 1998-2009 National Inpatient Sample (NIS) found HBOT to be associated with decreased mortality in NSTI. Given the argument of advancements in critical care, we aimed to investigate the continued role of HBOT in NSTI.

METHODS

The 2012-2020 National Inpatient Sample (NIS) was queried for NSTI admissions who received surgery. 60,481 patients between 2012-2020 were included, 600 (<1%) underwent HBOT. Primary outcome was in-hospital mortality. Secondary outcomes included amputation, hospital length of stay, and costs. A multivariate model was constructed to account for baseline differences in groups.

RESULTS

Age, gender, and comorbidities were similar between the two groups. On bivariate comparison, the HBOT group had lower mortality rate (<2% vs 5.9%, p<0.001) and lower amputation rate (11.8% vs 18.3%, p<0.001) however, longer lengths of stay (16.9 days vs 14.6 days, p<0.001) and higher costs ($54,000 vs $46,000, p<0.001). After multivariate analysis, HBOT was associated with decreased mortality (Adjusted Odds Ratio (AOR) 0.22, 95% CI 0.09-0.53, P<0.001) and lower risk of amputation (AOR 0.73, 95% CI 0.55-0.96, P = 0.03). HBO was associated with longer stays by 1.6 days (95% CI 0.4-2.7 days) and increased costs by $7,800 (95% CI $2,200-$13,300), they also had significantly lower risks of non-home discharges (AOR 0.79, 95%CI 0.65-0.96).

CONCLUSIONS

After correction for differences, HBOT was associated with decreased mortality, amputations, and non-home discharges in NSTI with the tradeoff of increase to costs and length of stay.

Fournier's gangrene with Streptococcus Anginosus in the setting of hidrandenitis suppurativa perineal abscess: A case report

INTRODUCTION

Fournier's gangrene is a rare but life-threatening form of necrotizing soft tissue infection involving the perineal, genital, or perianal region, commonly caused by a mix of aerobic and anaerobic organisms. Initially discovered in dental abscesses, Streptococcus anginosus have been increasingly reported in pyogenic and systemic infections with abscess formation. We present a rare case of perineal abscess that developed into Fournier's gangrene in which the causative pathogen isolated was S. anginosus.

PRESENTATION OF CASE

A 58-year-old male with uncontrolled type 2 diabetes, hypertension and hidradenitis suppurativa of the groin, presented with worsening testicular pain. He was found to have a necrotizing soft tissue infection of the perineum, consistent with Fournier's gangrene. He was successfully treated with multiple surgical debridement and broad-spectrum intravenous antibiotics. He was transitioned to oral antibiotics before transferring to a tertiary care facility for reconstruction.

DISCUSSION

The setting of uncontrolled diabetes and hidradenitis suppurativa may be the likely etiology for this peculiar case of Fournier's gangrene secondary to S. anginosus. Compromised tissue integrity and impaired local immune defenses from these etiologies predisposes to the development of Fournier's gangrene. Historically, these abscesses typically resolve after intravenous antibiotics and incision and drainage. However, the abscess in this case did not resolve but rather progressed to Fournier's gangrene. Perineal abscesses that grow S. anginosus should raise a high index of suspicion for worse outcomes.

CONCLUSION

In conclusion, we recommend a multidisciplinary approach and rapid diagnosis for the management of S. anginosus in the setting of a perineal abscess, with early aggressive surgical debridement and broad-spectrum antibiotics.

Necrotizing Fasciitis Associated With Toxic Shock Syndrome

Necrotizing fasciitis is a rapidly progressing bacterial infection that affects the deep fascia and subcutaneous tissues, often resulting in tissue necrosis and systemic toxicity. This case involves a male in his late forties who initially sought emergency care for a minor rash on his right lower extremity and symptoms of a viral illness. Despite an initial diagnosis of hematoma, his symptoms rapidly escalated within 24 hours, prompting his return to the emergency room. During this subsequent visit, signs of septic shock emerged, accompanied by a worsening rash and blister formation. Admitted to the intensive care unit, our patient received urgent treatment, including broad-spectrum antibiotics and surgical debridement based on the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score for assessing necrotizing fasciitis severity. Further debridement and a fasciotomy were performed, leading to improved clinical conditions, stabilized vitals, and normalized laboratory results. This case underscores the critical importance of early clinical suspicion, prompt diagnosis, and a collaborative, team-based approach in successfully managing necrotizing fasciitis.

Chemotherapy Extravasation Causing Soft-Tissue Necrosis Mimicking Infection: A Longitudinal Case Study

Extravasation injuries are uncommon, underreported, and often misdiagnosed in patients. The signs and symptoms of extravasation injuries vary from simple pain and tenderness to tissue necrosis and potentially fatal secondary infections. Extravasation may progress to more severe conditions such as necrotizing fasciitis (NF) or cellulitis, so special care is needed by physicians to identify and treat these injuries correctly. Here, we explore a case study on extravasation injuries mimicking NF leading to infectious complications and discuss the proper diagnosis and treatment of extravasation injuries as well as other NF-mimicking diseases. We present a case of a 44-year-old Hispanic male with a history of B-cell acute lymphoblastic leukemia who underwent inpatient chemotherapy treatment via a chest port.

Increase in Streptococcal Necrotizing Fasciitis During and After the Coronavirus Disease 2019 Pandemic

Background: Necrotizing fasciitis (NF) is a life-threatening and rare condition. However, we report and analyze a remarkably high number of NF cases during the coronavirus disease 2019 (COVID-19) pandemic and especially in the first months after the COVID-19 pandemic. Patients and Methods: We conducted a retrospective analysis of 17 cases of NF treated in our clinic between January and May 2023. Data were collected on demographics, comorbidities, risk factors, laboratory findings, and clinical outcomes. For each individual case two risk indicating scores, the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) and Laboratory and Anamnestic Risk Indicator for Necrotizing Fasciitis (LARINF) were calculated. Results: In the pandemic years 2021 and 2022 there were 21 and 30 patients with NF, respectively, treated in our clinic. Of the 17 included NF cases in this study from January until May 2023, 16 cases required intensive care unit (ICU) admission, six cases required limb amputation, and four cases resulted in death. The microbiologic examination revealed seven cases of polymicrobial infections, eight cases of monomicrobial infections primarily caused by Streptococcus pyogenes, and two cases without microbial growth. The LRINEC score showed a sensitivity of 82%, whereas the LARINF score demonstrated a sensitivity of 100% for identifying cases of NF. Conclusions: This study highlights a notable increase in NF during and after the COVID-19 pandemic, predominantly associated with Streptococcus pyogenes-induced infections. These cases demonstrate a highly aggressive nature, leading to limb amputation or death in more than half of the cases.

Mucocutaneous Manifestations of Recreational Drug Use

Recreational drug use is increasingly common in the dermatology patient population and is often associated with both general and specific mucocutaneous manifestations. Signs of substance use disorder may include changes to general appearance, skin, and mucosal findings associated with particular routes of drug administration (injection, insufflation, or inhalation) or findings specific to a particular drug. In this review article, we provide an overview of the mucocutaneous manifestations of illicit drug use including cocaine, methamphetamine, heroin, hallucinogens, marijuana, and common adulterants to facilitate the identification and improved care of these patients with the goal being to connect this patient population with appropriate resources for treatment.

Reduced interleukin-18 secretion by human monocytic cells in response to infections with hyper-virulent Streptococcus pyogenes

BACKGROUND

Streptococcus pyogenes (group A streptococcus, GAS) causes a variety of diseases ranging from mild superficial infections of the throat and skin to severe invasive infections, such as necrotizing soft tissue infections (NSTIs). Tissue passage of GAS often results in mutations within the genes encoding for control of virulence (Cov)R/S two component system leading to a hyper-virulent phenotype. Dendritic cells (DCs) are innate immune sentinels specialized in antigen uptake and subsequent T cell priming. This study aimed to analyze cytokine release by DCs and other cells of monocytic origin in response to wild-type and natural covR/S mutant infections.

METHODS

Human primary monocyte-derived (mo)DCs were used. DC maturation and release of pro-inflammatory cytokines in response to infections with wild-type and covR/S mutants were assessed via flow cytometry. Global proteome changes were assessed via mass spectrometry. As a proof-of-principle, cytokine release by human primary monocytes and macrophages was determined.

RESULTS

In vitro infections of moDCs and other monocytic cells with natural GAS covR/S mutants resulted in reduced secretion of IL-8 and IL-18 as compared to wild-type infections. In contrast, moDC maturation remained unaffected. Inhibition of caspase-8 restored secretion of both molecules. Knock-out of streptolysin O in GAS strain with unaffected CovR/S even further elevated the IL-18 secretion by moDCs. Of 67 fully sequenced NSTI GAS isolates, 28 harbored mutations resulting in dysfunctional CovR/S. However, analyses of plasma IL-8 and IL-18 levels did not correlate with presence or absence of such mutations.

CONCLUSIONS

Our data demonstrate that strains, which harbor covR/S mutations, interfere with IL-18 and IL-8 responses in monocytic cells by utilizing the caspase-8 axis. Future experiments aim to identify the underlying mechanism and consequences for NSTI patients.

Labial Necrotizing Fasciitis Caused by Pelvic Eggerthia catenaformis Infection

A patient with comorbid diabetes mellitus, obesity, and hypertension acutely presented to the ED due to labial cellulitis with rapidly progressing symptoms of systemic inflammation. Clinical examination revealed fever and groin pain that was tender to palpation. Initial contrast-enhanced CT scans showed labial cellulitis extending to the inguinal canal, with later CT imaging findings of subcutaneous air indicative of necrotizing fasciitis (NF). Antimicrobial therapy was initiated empirically and later tailored to culture antibiogram. The patient underwent acute surgical abscess drainage and tissue debridement but was transferred to the surgical intensive care unit (SICU) due to postoperative blood loss and hypotension. Two additional surgical procedures were needed before sufficient drainage was achieved, and Eggerthia catenaformis (E. catenaformis) was isolated from all samples. Due to the extent of the infection, the patient was admitted for a total of 16 days, with five days spent in the SICU. They recovered completely due to adequate surgery and antimicrobial therapy for a total of 24 days. Here, we present the third reported case of NF due to E. catenaformiswhile emphasizing timely treatment with empiric antibiotics and surgical intervention.

Characterization of patients with odontogenic necrotizing soft tissue infections in the head and neck area. A retrospective analysis

OBJECTIVE

Necrotizing soft-tissue infection (NSTI) in the head and neck area may develop from odontogenic infections. The aim of this study was to characterize patients with NSTI in the head and neck with odontogenic origin in a well-defined prospectively collected cohort.

MATERIAL AND METHODS

Patients with NSTI in the head and neck, hospitalized between 2013 and 2017 at Copenhagen University Hospital and registered in the Scandinavian INFECT database were included. Medical records of identified patients and from the INFECT database were screened for a defined set of data including the primary focus of infection, comorbidities, predisposing factors, clinical and radiographic diagnostics, course of treatment, and treatment outcome.

RESULTS

Thirty-five patients with NSTI in the head and neck area were included in the study. A total of 54% had odontogenic origin, primarily from mandibular molars, and 94% had radiographic signs of infectious oral conditions. Overall, comorbidities were reported in 51% with cardiovascular disease being the most prevalent. In 20%, no comorbidities or predisposing conditions could be identified. The overall 30-day mortality rate was 9%.

CONCLUSIONS

More than half of NSTI cases in the head and neck region had an odontogenic origin, and special attention should be paid to infections related to mandibular molars.

Unbridled Threat of Gas Gangrene in a Patient With Uncontrolled Diabetes Mellitus: A Compelling Case Report of Clostridium perfringens Infection

Clostridium perfringens, a Gram-positive anaerobic bacterium, is well-known for its association with gas gangrene, a severe and rapidly progressing infection characterized by tissue gas production and necrosis. In this case report, we present the instance of a 64-year-old male with poorly controlled diabetes mellitus who developed a C. perfringens-related infection following a traumatic foot wound. The report emphasizes the critical significance of early diagnosis and aggressive treatment in C. perfringens infections, particularly in patients with underlying risk factors. Detailed accounts of clinical findings, laboratory results, computed tomography, and surgical interventions are provided. A multidisciplinary approach proved essential for successful management. The inherent scholarly value of this case is substantiated by its meticulous documentation of the clinical trajectory, diagnostic modalities, and treatment modalities employed. The intricate collaboration across diverse medical disciplines, the uncommon manifestation of the infection following a traumatic foot wound, and the favorable outcome achieved through prompt and multidisciplinary intervention collectively contribute to the exceptional nature and didactic significance of this case. The dissemination of such clinical experiences assumes paramount importance in advancing medical scholarship, cultivating awareness, and engendering a profound comprehension of the complexities associated with C. perfringens infections, thereby enriching the wider scientific and medical community.

Machine Learning Prediction Algorithm for In-Hospital Mortality following Body Contouring

BACKGROUND

Body contouring is a common procedure, but it is worth attention because of concern for a variety of complications, and even the potential for death. As a result, the purpose of this study was to determine the key predictors following body contouring and create models for the risk of mortality using diverse machine learning (ML) models.

METHODS

The National Inpatient Sample database from 2015 to 2017 was queried to identify patients undergoing body contouring. Candidate predictors, such as demographics, comorbidities, personal history, postoperative complications, and operative features, were included. The outcome was in-hospital mortality. Models were compared by area under the curve, accuracy, sensitivity, specificity, positive and negative predictive values, and decision curve analysis.

RESULTS

Overall, 8214 patients undergoing body contouring were identified, among whom 141 (1.72%) died in the hospital. Variable importance plot demonstrated that sepsis was the variable with greatest importance across all ML algorithms, followed by Elixhauser Comorbidity Index, cardiac arrest, and so forth. The naive Bayes model had a higher predictive performance (area under the curve, 0.898; 95% CI, 0.884 to 0.911) among these eight ML models. Similarly, in the decision curve analysis, the naive Bayes model also demonstrated a higher net benefit (ie, the correct classification of in-hospital deaths considering a tradeoff between false-negatives and false-positives) compared with the other seven models across a range of threshold probability values.

CONCLUSION

The ML models, as indicated by this study, can be used to predict in-hospital death for patients at risk who undergo body contouring.

A Case of Fatal Non-Clostridial Gas Gangrene Following Intramuscular Injection: A Diagnostic Challenge and Dilemma at Autopsy

Introduction

Gas Gangrene following intramuscular injection is a rare but serious condition that can lead to morbidity and mortality. This case conveys a severe and fatal complication following intramuscular injections of diclofenac and vitamin B12 in a diabetic patient.

Case Report

The patient developed pain and swelling in the left buttock after the injection of vitamin B12 and Diclofenac one on each buttock which worsened over time. He was diagnosed with gas gangrene when he presented to the emergency department. The blood culture identified Klebsiella pneumonia. The patient's condition rapidly deteriorated, leading to sepsis and acute kidney injury. Despite intensive care management, the patient succumbed five days after admission. At autopsy, gas gangrene of the left lower limb was evident on external examination. Histopathological examination confirmed the acute tubular damage in the kidney and the postmortem blood culture also grew Klebsiella pneumonia and Enterobacter cloacae. The cause of death was determined to be acute tubular necrosis as a result of sepsis due to non-clostridial gas gangrene.

Conclusion

This instance of gas gangrene following trivial trauma poses a challenge for the forensic pathologist in establishing the causal association and in determining the causative organism. These are important when medical/surgical intervention is in question to be the cause of a fatal infection like gas gangrene. Ante-mortem/postmortem blood culture can aid in defining the causative organism of gas gangrene but the causal association with the alleged trauma/insult is still a challenge at autopsy. This case report addresses and tries to overcome the diagnostic challenges and dilemmas at autopsy in a case of gas gangrene.

Necrotizing Fasciitis in a Patient With Signet-Ring Cell Gastric Adenocarcinoma

Necrotizing fasciitis is an aggressive infection of the skin and soft tissues that requires prompt recognition and management. Immediate source control and adjunctive antibiotic therapy are the cornerstones of management. There are limited reported cases of necrotizing fasciitis related to gastrointestinal malignancy, including gastric cancer. This report describes the case of a 36-year-old male who developed left abdominal wall necrotizing fasciitis related to perforated gastric adenocarcinoma with signet-ring features. Signet-ring adenocarcinoma is associated with a more aggressive malignancy. The rapid progression of the infection leading to refractory shock and acute respiratory distress rendered the patient a poor candidate for surgical source control because of high surgical risk. Patient eventually expired. Immediate recognition of necrotizing fasciitis and perforated gastric cancer can prompt early surgical referral for definitive source control and gastric resection or repair.

Necrotizing fasciitis - two case reports and literature review

<b><br>Introduction:</b> Necrotizing fasciitis (NF) is a rare, rapidly progressing infection of the skin and subcutaneous tissue. NF can lead to massive tissue necrosis, resulting in sepsis, septic shock and death. In this disease, it is important to quickly diagnose and implement appropriate treatment.</br> <b><br>Aim:</b> Analysis of the diagnostic and therapeutic process in two clinical cases and a review of the literature on the methods of diagnosis and treatment of necrotizing fasciitis.</br> <b><br>Material and methods:</b> The medical data of two patients hospitalized in the St Alexander Hospital in Kielce from December 2022 to June 2023 due to necrotizing fasciitis were analyzed. Also literature search across PubMed, Medline and Research Gate databases from 2000 up to 2023 was performed. We reviewed English literature according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. The following keywords were used: necrotizing fasciitis, etiopathogenesis, pathophysiology, management.</br> <b><br>Results:</b> The research group consisted of two male patients with NF after trauma, in different parts of the body. Based on the clinical examination, the results of laboratory and imaging tests, a diagnosis was made and appropriate treatment was initiated. Despite the applied treatment, one patient died as a result of progressive multiple organ failure.</br> <b><br>Conclusions:</b> Despite advances in diagnosis and treatment, including universal access to antibiotics, necrotizing fasciitis still cause high mortality. The microbiological complexity of the majority of cases and non-specific symptoms make the diagnostic and therapeutic process difficult. Taking into account necrotizing fasciitis each time in the differential diagnosis of inflammation of the skin and subcutaneous tissue, especially based on trauma, will allow to reduce morbidity and mortality in this disease.</br>.

Risk Factors for Predicting Mortality and Amputation of Patients with Necrotizing Soft-Tissue Infections: Retrospective Analysis of 111 Cases from a Single Medical Center

Objective

Necrotizing soft-tissue infections (NSTIs) are rare clinical infections with surgical emergencies having a high mortality rate. This study aimed to investigate risk factors for mortality and amputation of patients with NSTI.

Methods

We retrospectively analyzed critical factors for outcomes of 111 patients with NSTI hospitalized in our department from 1 January 1999 to 31 December 2018. NSTI diagnosis was based on the patient's clinical characteristics, laboratory risk indicator for necrotizing fasciitis (LRINEC) score, laboratory test data, and microbiological findings in blood and wound culture. The risk factors for mortality and amputation of NSTI were determined using univariate or multivariate logistic regression analysis, receiver operating characteristics (ROC), and the area under the ROC curve (AUC) at 90 days after admission.

Results

Diagnosis of 111 patients with NSTI was confirmed according to clinical features, LRINEC score, image data, laboratory findings, and microorganism culture in blood and wounds. The mortality rate was 9.91% (11/111) at day 90 follow-up. High white blood cell (WBC), low hematocrit (HCT), and multiple surgeries were identified to be critical risk factors for NSTI mortality in univariate and multivariate logistic analyses. AUCs, 95% confidence intervals (CI), and P values of risk factors were 0.699, 0.54-0.95, and P = 0.0117 for high WBC; 0.788, 0.63-0.97, and P = 0.0006 for low HCT; and 0.745, 0.59-0.90, and P = 0.0018 for multiple surgeries, respectively. These patients also had high LRINEC scores. Amputation occurred in 34.23% (38/111) of patients. Risk factors for amputation were higher age, low hemoglobin (Hb), and multiple wounds. AUCs, 95% confidence intervals (CI), and P values were 0.713, 0.11-0.32, and P < 0.0001 for higher age; 0.798, 0.08-0.29, and P=0.0007 for low Hb; and 0.757, 0.17-0.34, and P  < 0.0001 for multiple lesion sites, respectively.

Conclusions

High LRINEC scores, high WBC, low HCT, and multiple surgeries were relevant to increased mortality. Higher age, low Hb, and multiple wounds were associated with amputation risk. These clinical features must be paid attention to when patients are diagnosed with NSTI.

The Role of Burn Centers in the Treatment of Necrotizing Soft-Tissue Infections: A Nationwide Dutch Study

Patients with extensive and complex wounds due to Necrotizing Soft-Tissue Infections (NSTI) may be referred to a burn center. This study describes the characteristics, outcomes, as well as diagnostic challenges of these patients. Patients admitted to three hospitals with a burn center for the treatment of NSTI in a 5-year period were included. Eighty patients (median age 54 years, 60% male) were identified, of whom 30 (38%) were referred by other centers, usually after survival of the initial septic phase. Those referred from other centers, compared to those primarily admitted to the study hospitals, were more likely to have group A streptococcal involvement (62% vs 35%, p = .02), larger wounds (median 7% vs 2% total body surface area, p < .001), and a longer length of stay (median 49 vs 22 days, p < .001). Despite a high incidence of septic shock (50%), the mortality rate was low (12%) for those primarily admitted. Approximately half (53%) of the patients were initially misdiagnosed upon presentation, which was associated with delay to first surgery (16 hours vs 4 hours, p < .001). Those initially misdiagnosed had more (severe) comorbidities, and less frequently reported pain or blue livid discoloration of the skin. This study underlines the burn centers' function as referral centers for extensively affected patients with NSTI. Besides the unique wound and reconstructive expertise, the low mortality rate indicates these centers provide adequate acute care as well. A major remaining challenge remains recognition of the disease upon presentation. Future studies in which factors associated with misdiagnosis are explored are needed.

Necrotizing Soft-Tissue Infections: A Case-Based Review

GENERAL PURPOSE

To review the assessment and management of necrotizing fasciitis.

TARGET AUDIENCE

This continuing-education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will:1. Identify the etiologic pathogens for necrotizing fasciitis.2. Summarize assessment guidelines for patients who present with signs of necrotizing fasciitis.3. Explain recommended treatment protocols for patients who have necrotizing fasciitis.

Serologic Evaluations in the Distinction Between Sinusitis-Related Orbital Cellulitis and Periorbital Necrotizing Fasciitis

PURPOSE

While sinusitis-related orbital cellulitis (SROC) and periorbital necrotizing fasciitis (PNF) share similar clinical presentations, they are managed differently, making rapid recognition of the appropriate clinical entity critical to optimal outcomes. This study was performed to assess whether serologic testing might help clinicians to distinguish between SROC and PNF.

METHODS

A retrospective review analysis was used to compare initial complete blood counts and comprehensive metabolic panels among adult patients with SROC and PNF. Statistical evaluations were used to determine the significance of differences between the groups.

RESULTS

Thirteen patients with PNF and 14 patients with SROC were identified. The 2 groups were similar in age, gender, and likelihood of immunosuppression ( p > 0.05 for each metric). Mean leukocyte counts were 18.52 (standard deviation = 7.02) and 10.31 (standard deviation = 5.77) for PNF and SROC, respectively ( p = 0.0057). White blood cell levels were above normal limits for 12 patients with PNF (92.3%) and 7 patients with SROC (50%) ( p = 0.017). No other laboratory test was significantly different between the 2 groups.

CONCLUSIONS

While the majority of serologic testing was quite similar in patients with either SROC or PNF, leukocyte levels may represent an important clue to distinguish between the two diseases. Clinical evaluation remains the gold standard to make the proper diagnosis, but markedly elevated white blood cell counts should prompt clinicians to at least consider a diagnosis of PNF.

Clostridium perfringens phospholipase C, an archetypal bacterial virulence factor, induces the formation of extracellular traps by human neutrophils

Neutrophil extracellular traps (NETs) are networks of DNA and various microbicidal proteins released to kill invading microorganisms and prevent their dissemination. However, a NETs excess is detrimental to the host and involved in the pathogenesis of various inflammatory and immunothrombotic diseases. Clostridium perfringens is a widely distributed pathogen associated with several animal and human diseases, that produces many exotoxins, including the phospholipase C (CpPLC), the main virulence factor in gas gangrene. During this disease, CpPLC generates the formation of neutrophil/platelet aggregates within the vasculature, favoring an anaerobic environment for C. perfringens growth. This work demonstrates that CpPLC induces NETosis in human neutrophils. Antibodies against CpPLC completely abrogate the NETosis-inducing activity of recombinant CpPLC and C. perfringens secretome. CpPLC induces suicidal NETosis through a mechanism that requires calcium release from inositol trisphosphate receptor (IP3) sensitive stores, activation of protein kinase C (PKC), and the mitogen-activated protein kinase/extracellular signal-regulated kinase (MEK/ERK) pathways, as well as the production of reactive oxygen species (ROS) by the metabolism of arachidonic acid. Proteomic analysis of the C. perfringens secretome identified 40 proteins, including a DNAse and two 5´-nucleotidases homologous to virulence factors that could be relevant in evading NETs. We suggested that in gas gangrene this pathogen benefits from having access to the metabolic resources of the tissue injured by a dysregulated intravascular NETosis and then escapes and spreads to deeper tissues. Understanding the role of NETs in gas gangrene could help develop novel therapeutic strategies to reduce mortality, improve muscle regeneration, and prevent deleterious patient outcomes.

A fatal case of Aeromonas jandaei necrotizing fasciitis

Introduction

Necrotizing soft tissue infections (NSTIs) are associated with a fulminating course because of their rapid destruction of tissue planes underlying the skin. Aeromonas -associated monomicrobial NSTIs are usually associated with exposure to fresh water, particularly among agricultural workers and fish handlers. Albeit uncommon in incidence, urgent medical and surgical intervention are required once a diagnosis has been made.

Case report

A 40-year-old male patient, a known case of alcoholic liver disease, presented to the emergency department with pain and diffuse swelling of bilateral lower limbs, which quickly progressed to form blackish discolouration and blebs. Blood for preliminary haematological and biochemical investigations, as well as fluid draining from blebs, were sent for microbiological investigation. The Gram stain revealed occasional neutrophils and Gram-negative bacilli, and pure growth in aerobic culture was identified as Aeromonas jandaei by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS). The patient was started on empirical antimicrobials, although lesions continued to progress and he ultimately succumbed within 12 h of hospital admission.

Conclusion

As appropriate antimicrobial therapy and early surgical intervention are required for management of the same, occupational exposure and the fulminant course should raise suspicion of Aeromonas -associated infections.

Favorable Safety Outcomes of Delayed Primary Closure of Large Fournier's Gangrene Skin Defects

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.