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Ferrada P, Cannon JW, Kozar RA, Bulger EM, Sugrue M, Napolitano LM, Tisherman SA, Coopersmith CM, Efron PA, Dries DJ, Dunn TB, Kaplan LJ. Surgical Science and the Evolution of Critical Care Medicine. Crit Care Med 2023; 51:182-211. [PMID: 36661448 DOI: 10.1097/ccm.0000000000005708] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Surgical science has driven innovation and inquiry across adult and pediatric disciplines that provide critical care regardless of location. Surgically originated but broadly applicable knowledge has been globally shared within the pages Critical Care Medicine over the last 50 years.
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Affiliation(s)
- Paula Ferrada
- Division of Trauma and Acute Care Surgery, Department of Surgery, Inova Fairfax Hospital, Falls Church, VA
| | - Jeremy W Cannon
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rosemary A Kozar
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Eileen M Bulger
- Division of Trauma, Burn and Critical Care Surgery, Department of Surgery, University of Washington at Seattle, Harborview, Seattle, WA
| | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital, County of Donegal, Ireland
| | - Lena M Napolitano
- Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Samuel A Tisherman
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Craig M Coopersmith
- Division of General Surgery, Department of Surgery, Emory University, Emory Critical Care Center, Atlanta, GA
| | - Phil A Efron
- Department of Surgery, Division of Critical Care, University of Florida, Gainesville, FL
| | - David J Dries
- Department of Surgery, University of Minnesota, Regions Healthcare, St. Paul, MN
| | - Ty B Dunn
- Division of Transplant Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lewis J Kaplan
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Corporal Michael J. Crescenz VA Medical Center, Section of Surgical Critical Care, Surgical Services, Philadelphia, PA
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Bekker MA, Rai S, Arbous MS, Georgousopoulou EN, Pilcher DV, van Haren FMP. Annual prevalence, characteristics, and outcomes of intensive care patients with skin or soft tissue infections in Australia and New Zealand: A retrospective cohort study between 2006-2017. Aust Crit Care 2021; 34:403-410. [PMID: 33663947 DOI: 10.1016/j.aucc.2020.10.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 09/23/2020] [Accepted: 10/31/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND There are limited published data on the epidemiology of skin and soft tissue infections (SSTIs) requiring intensive care unit (ICU) admission. This study intended to describe the annual prevalence, characteristics, and outcomes of critically ill adult patients admitted to the ICU for an SSTI. METHODS This was a registry-based retrospective cohort study, using data submitted to the Australian and New Zealand Intensive Care Society Adult Patient Database for all admissions with SSTI between 2006 and 2017. The inclusion criteria were as follows: primary diagnosis of SSTI and age ≥16 years. The exclusion criteria were as follows: ICU readmissions (during the same hospital admission) and transfers from ICUs from other hospitals. The primary outcome was in-hospital mortality, and the secondary outcomes were ICU mortality and length of stay (LOS) in the ICU and hospital with independent predictors of outcomes. RESULTS Admissions due to SSTI accounted for 10 962 (0.7%) of 1 470 197 ICU admissions between 2006 and 2017. Comorbidities were present in 25.2% of the study sample. The in-hospital mortality was 9% (991/10 962), and SSTI necessitating ICU admission accounted for 0.07% of in-hospital mortality of all ICU admissions between 2006 and 2017. Annual prevalence of ICU admissions for SSTI increased from 0.4% to 0.9% during the study period, but in-hospital mortality decreased from 16.1% to 6.8%. The median ICU LOS was 2.1 days (interquartile range = 3.4), and the median hospital LOS was 12.1 days (interquartile range = 20.6). ICU LOS remained stable between 2006 and 2017 (2.0-2.1 days), whereas hospital LOS decreased from 15.7 to 11.2 days. Predictors for in-hospital mortality included Australian and New Zealand Risk of Death scores [odds ratio (OR): 1.07; confidence interval (CI) (1.05, 1.09); p < 0.001], any comorbidity except diabetes [OR: 2.00; CI (1.05, 3.79); p = 0.035], and admission through an emergency response call [OR: 2.07; CI (1.03, 4.16); p = 0.041]. CONCLUSIONS SSTIs are uncommon as primary ICU admission diagnosis. Although the annual prevalence of ICU admissions for SSTI has increased, in-hospital mortality and hospital LOS have decreased over the last decade.
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Affiliation(s)
- Marjolein A Bekker
- Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands.
| | - Sumeet Rai
- Intensive Care Unit, Canberra Hospital, Yamba Dr, Garran, Australian Capital Territory, 2605, Australia; Medical School, Australian National University, Building 4, The Canberra Hospital, Hospital Rd, Garran, Australian Capital Territory, 2605, Australia.
| | - M Sesmu Arbous
- Department of Intensive Care, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands.
| | - Ekavi N Georgousopoulou
- Medical School, Australian National University, Building 4, The Canberra Hospital, Hospital Rd, Garran, Australian Capital Territory, 2605, Australia.
| | - David V Pilcher
- Intensive Care Unit, Alfred Hospital, 55 Commercial Rd, Melbourne, Victoria, 3004, Australia; The Australian and New Zealand - Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Prahran, Melbourne, Victoria, Australia; The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation (CORE), 277 Camberwell Road, Camberwell, Melbourne, Victoria, 3124, Australia.
| | - Frank M P van Haren
- Intensive Care Unit, Canberra Hospital, Yamba Dr, Garran, Australian Capital Territory, 2605, Australia; Medical School, Australian National University, Building 4, The Canberra Hospital, Hospital Rd, Garran, Australian Capital Territory, 2605, Australia; Faculty of Health, University of Canberra, 11 Kirninari Street, Bruce, Australian Capital Territory, 2617, Australia.
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Abstract
Necrotizing fasciitis is a fulminant and potentially life-threatening infection of the skin and soft tissue. It is usually caused by a combination of different bacteria and is often due to assumed minor trauma. Clinically, only relatively insignificant skin changes are initially present, such as blistering or erythema. They are often accompanied by excessive pain. In the further course, the massive systemic reaction becomes predominant. The diagnosis of necrotizing fasciitis is primarily clinical, which can be supported by laboratory parameters (LRINEC score) and computed tomography imaging. Decisive for the prognosis is the immediate initiation of surgical treatment by radical debridement. Additionally, the calculated administration of a combination of different antibiotics should be initiated. As part of the further complex intensive care treatment, a regular reevaluation of the wounds is carried out. Multiple débridements are always necessary until plastic surgery for defect coverage can be carried out.
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Affiliation(s)
- V M Hösl
- Hochschulzentrum für Plastische‑, Ästhetische, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland.
| | - A Kehrer
- Hochschulzentrum für Plastische‑, Ästhetische, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - L Prantl
- Hochschulzentrum für Plastische‑, Ästhetische, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
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Cen H, Zhang L. Management of carbapenem-resistant Klebsiella pneumoniae infection in a patient with diabetic foot ulcer and necrotizing soft tissue infection, bacteremia and lung infection: A case report. Asian J Surg 2020; 43:930-931. [PMID: 32527579 DOI: 10.1016/j.asjsur.2020.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 04/16/2020] [Indexed: 10/24/2022] Open
Affiliation(s)
- Hanghui Cen
- Department of Burn Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China.
| | - Liping Zhang
- Department of Burn Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China
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5
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Abstract
Necrotizing fasciitis is a fulminant and potentially life-threatening infection of the skin and soft tissue. It is usually caused by a combination of different bacteria and is often due to assumed minor trauma. Clinically, only relatively insignificant skin changes are initially present, such as blistering or erythema. They are often accompanied by excessive pain. In the further course, the massive systemic reaction becomes predominant. The diagnosis of necrotizing fasciitis is primarily clinical, which can be supported by laboratory parameters (LRINEC score) and computed tomography imaging. Decisive for the prognosis is the immediate initiation of surgical treatment by radical debridement. Additionally, the calculated administration of a combination of different antibiotics should be initiated. As part of the further complex intensive care treatment, a regular reevaluation of the wounds is carried out. Multiple débridements are always necessary until plastic surgery for defect coverage can be carried out.
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Affiliation(s)
- V M Hösl
- Hochschulzentrum für Plastische‑, Ästhetische, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland.
| | - A Kehrer
- Hochschulzentrum für Plastische‑, Ästhetische, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - L Prantl
- Hochschulzentrum für Plastische‑, Ästhetische, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
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Abstract
Severe infections frequently cause large soft tissue defects which require early defect coverage by plastic surgeons. A number of reconstructive treatment options are available, ranging from local flaps to microvascular free flap reconstructions. In this respect it is important that the selection of the optimal reconstructive technique is made based on individual patient characteristics and in a timely manner. Weeks of inpatient treatment with vacuum dressings often delay defect coverage and should be avoided as they burden both the patient and the healthcare system. Therefore, it is in the best interest of patients to receive early treatment by plastic surgeons. This manuscript presents the essential reconstructive treatment approaches based on highly informative case reports of patients from the plastic surgical practice at a university hospital.
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Faunø Thrane J, Ovesen T. Scarce evidence of efficacy of hyperbaric oxygen therapy in necrotizing soft tissue infection: a systematic review. Infect Dis (Lond) 2019; 51:485-492. [PMID: 30985236 DOI: 10.1080/23744235.2019.1597983] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Background: Necrotizing soft tissue infection (NSTI) is a rare and potentially life-threatening disease. Rapid surgical intervention, antibiotics and intensive care are the mainstay of treatment. Hyperbaric oxygen therapy (HBOT) is used as adjuvant therapy in some centres but there is a lack of research-based evidence of efficacy. Methods: Following the PRISMA guideline we conducted a systematic review on the efficacy of HBOT on NSTI with mortality as primary outcome. Through January 2019 major databases were searched and relevant literature assessed. The criteria for study inclusion were research of any design and any period of time comparing HBOT vs. non-HBOT in a population of NSTI-patients. Studies were analysed using the modified Delphi method and risk of bias in non-randomized studies - of interventions tool. Relative risk (RR) on mortality was calculated for each study individually. Results: A number of 1733 studies were identified through database search. Ultimately, 21 studies were included of which 19 were case series with a control group. The majority of the studies performed poor in quality assessment and all featured a high to critical risk of bias. The association of HBOT on mortality was generally reported as positive, however, the results should be considered with great scepticism. Conclusions: The evidence of HBOT in NSTI is poor and biased. There is a strong need for randomized controlled trials (RCTs) to shed light on a potential life-saving treatment.
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Affiliation(s)
- Jens Faunø Thrane
- a Department of Otorhinolaryngology, Head & Neck Surgery , Aarhus University Hospital , Aarhus , Denmark.,b Department of Otorhinolaryngology, Head & Neck Surgery , Aalborg University Hospital , Aalborg , Denmark
| | - Therese Ovesen
- c Department of Clinical Medicine , Aarhus University , Aarhus , Denmark.,d Department of Otorhinolaryngology, Head & Neck Surgery , Region Hospital Holstebro , Holstebro , Denmark
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Hua C, Bosc R, Sbidian E, De Prost N, Hughes C, Jabre P, Chosidow O, Le Cleach L. Interventions for necrotizing soft tissue infections in adults. Cochrane Database Syst Rev 2018; 5:CD011680. [PMID: 29851032 PMCID: PMC6494525 DOI: 10.1002/14651858.cd011680.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Necrotizing soft tissue infections (NSTIs) are severe and rapidly spreading soft tissue infections of the subcutaneous tissue, fascia, or muscle, which are mostly caused by bacteria. Associated rates of mortality and morbidity are high, with the former estimated at around 23%, and disability, sequelae, and limb loss occurring in 15% of patients. Standard management includes intravenous empiric antimicrobial therapy, early surgical debridement of necrotic tissues, intensive care support, and adjuvant therapies such as intravenous immunoglobulin (IVIG). OBJECTIVES To assess the effects of medical and surgical treatments for necrotizing soft tissue infections (NSTIs) in adults in hospital settings. SEARCH METHODS We searched the following databases up to April 2018: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers, pharmaceutical company trial results databases, and the US Food and Drug Administration and the European Medicines Agency websites. We checked the reference lists of included studies and reviews for further references to relevant randomised controlled trials (RCTs). SELECTION CRITERIA RCTs conducted in hospital settings, that evaluated any medical or surgical treatment for adults with NSTI were eligible for inclusion. Eligible medical treatments included 1) comparisons between different antimicrobials or with placebo; 2) adjuvant therapies such as intravenous immunoglobulin (IGIV) therapy compared with placebo; no treatment; or other adjuvant therapies. Eligible surgical treatments included surgical debridement compared with amputation, immediate versus delayed intervention, or comparisons of number of interventions.RCTs of hyperbaric oxygen (HBO) therapy for NSTI were ineligible because HBO is the focus of another Cochrane Review. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. The primary outcome measures were 1) mortality within 30 days, and 2) proportion of participants who experience a serious adverse event. Secondary outcomes were 1) survival time, and 2) assessment of long-term morbidity. We used GRADE to assess the quality of the evidence for each outcome. MAIN RESULTS We included three trials randomising 197 participants (62% men) who had a mean age of 55 years. One trial compared two antibiotic treatments, and two trials compared adjuvant therapies with placebo. In all trials, participants concomitantly received standard interventions, such as intravenous empiric antimicrobial therapy, surgical debridement of necrotic tissues, intensive care support, and adjuvant therapies. All trials were at risk of attrition bias and one trial was not blinded.Moxifloxacin versus amoxicillin-clavulanate One trial included 54 participants who had a NSTI; it compared a third-generation quinolone, moxifloxacin, at a dose of 400 mg given once daily, against a penicillin, amoxicillin-clavulanate, at a dose of 3 g given three times daily for at least three days, followed by 1.5 g three times daily. Duration of treatment varied from 7 to 21 days. We are uncertain of the effects of these treatments on mortality within 30 days (risk ratio (RR) 3.00, 95% confidence interval (CI) 0.39 to 23.07) and serious adverse events at 28 days (RR 0.63, 95% CI 0.30 to 1.31) because the quality of the evidence is very low.AB103 versus placebo One trial of 43 randomised participants compared two doses, 0.5 mg/kg and 0.25 mg/kg, of an adjuvant drug, a CD28 antagonist receptor (AB103), with placebo. Treatment was given via infusion pump for 10 minutes before, after, or during surgery within six hours after the diagnosis of NSTI. We are uncertain of the effects of AB103 on mortality rate within 30 days (RR of 0.34, 95% CI 0.05 to 2.16) and serious adverse events measured at 28 days (RR 1.49, 95% CI 0.52 to 4.27) because the quality of the evidence is very low.Intravenous immunoglobulin (IVIG) versus placebo One trial of 100 randomised participants assessed IVIG as an adjuvant drug, given at a dose of 25 g/day, compared with placebo, given for three consecutive days. There may be no clear difference between IVIG and placebo in terms of mortality within 30 days (RR 1.17, 95% CI 0.42 to 3.23) (low-certainty evidence), nor serious adverse events experienced in the intensive care unit (ICU) (RR 0.73 CI 95% 0.32 to 1.65) (low-certainty evidence).Serious adverse events were only described in one RCT (the IVIG versus placebo trial) and included acute kidney injury, allergic reactions, aseptic meningitis syndrome, haemolytic anaemia, thrombi, and transmissible agents.Only one trial reported assessment of long-term morbidity, but the outcome was not defined in the way we prespecified in our protocol. The trial used the Short Form Health Survey (SF36). Data on survival time were provided upon request for the trials comparing amoxicillin-clavulanate versus moxifloxacin and IVIG versus placebo. However, even with data provided, it was not possible to perform survival analysis. AUTHORS' CONCLUSIONS We found very little evidence on the effects of medical and surgical treatments for NSTI. We cannot draw conclusions regarding the relative effects of any of the interventions on 30-day mortality or serious adverse events due to the very low quality of the evidence.The quality of the evidence is limited by the very small number of trials, the small sample sizes, and the risks of bias in the included trials. It is important for future trials to clearly define their inclusion criteria, which will help with the applicability of future trial results to a real-life population.Management of NSTI participants (critically-ill participants) is complex, involving multiple interventions; thus, observational studies and prospective registries might be a better foundation for future research, which should assess empiric antimicrobial therapy, as well as surgical debridement, along with the placebo-controlled comparison of adjuvant therapy. Key outcomes to assess include mortality (in the acute phase of the condition) and long-term functional outcomes, e.g. quality of life (in the chronic phase).
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Affiliation(s)
- Camille Hua
- Hôpital Henri MondorDepartment of Dermatology51 Avenue du Maréchal de Lattre de TassignyCréteilFrance94000
| | - Romain Bosc
- Hôpital Henri MondorDepartment of Plastic, Reconstructive and Aesthetic Surgery51 Avenue du Maréchal de Lattre de TassignyCréteilFrance94000
| | - Emilie Sbidian
- Hôpital Henri MondorDepartment of Dermatology51 Avenue du Maréchal de Lattre de TassignyCréteilFrance94000
| | - Nicolas De Prost
- Hôpital Henri MondorMedical Intensive Care Unit51 Avenue du Maréchal de Lattre de TassignyCréteilFrance94000
| | - Carolyn Hughes
- The University of Nottinghamc/o Cochrane Skin GroupA103, King's Meadow CampusLenton LaneNottinghamUKNG7 2NR
| | - Patricia Jabre
- Hôpital Universitaire Necker‐Enfants MaladesAssistance Publique‐Hôpitaux de Paris (AP‐HP), SAMU (Service d'Aide Médicale Urgente) de Paris149 Rue de SèvresParisFrance75015
- Institut national de la santé et de la recherche médicale (Inserm) U970, Paris‐Centre de recherche Cardiovasculaire (PARCC), Université Paris DescartesParisFrance
| | - Olivier Chosidow
- Hôpital Henri MondorDepartment of Dermatology51 Avenue du Maréchal de Lattre de TassignyCréteilFrance94000
| | - Laurence Le Cleach
- Hôpital Henri MondorDepartment of Dermatology51 Avenue du Maréchal de Lattre de TassignyCréteilFrance94000
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Investigation of multiple mortality events in eastern box turtles (Terrapene carolina carolina). PLoS One 2018; 13:e0195617. [PMID: 29621347 PMCID: PMC5886585 DOI: 10.1371/journal.pone.0195617] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Accepted: 03/26/2018] [Indexed: 11/19/2022] Open
Abstract
Wildlife mortality investigations are important for conservation, food safety, and public health; but they are infrequently reported for cryptic chelonian species. Eastern box turtles (Terrapene carolina carolina) are declining due to anthropogenic factors and disease, and while mortality investigations have been reported for captive and translocated individuals, few descriptions exist for free-living populations. We report the results of four natural mortality event investigations conducted during routine health surveillance of three Illinois box turtle populations in 2011, 2013, 2014, and 2015. In April 2011, over 50 box turtles were found dead and a polymicrobial necrotizing bacterial infection was diagnosed in five survivors using histopathology and aerobic/anaerobic culture. This represents the first reported occurrence of necrotizing bacterial infection in box turtles. In August 2013, paired histopathology and qPCR ranavirus detection in nine turtles was significantly associated with occupation of moist microhabitats, identification of oral plaques and nasal discharge on physical exam, and increases in the heterophil count and heterophil to lymphocyte ratio (p < 0.05). In July 2014 and 2015, ranavirus outbreaks reoccurred within a 0.2km radius of highly-disturbed habitat containing ephemeral ponds used by amphibians for breeding. qPCR ranavirus detection in five individuals each year was significantly associated with use of moist microhabitats (p < 0.05). Detection of single and co-pathogens (Terrapene herpesvirus 1, adenovirus, and Mycoplasma sp.) was common before, during, and after mortality events, but improved sample size would be necessary to determine the impacts of these pathogens on the occurrence and outcome of mortality events. This study provides novel information about the causes and predictors of natural box turtle mortality events. Continued investigation of health, disease, and death in free-living box turtles will improve baseline knowledge of morbidity and mortality, identify threats to survival, and promote the formation of effective conservation strategies.
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Hyperbaric Oxygen Therapy in Necrotizing Soft Tissue Infections: A Retrospective Study. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1072:263-267. [DOI: 10.1007/978-3-319-91287-5_42] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Malheiro LF, Magano R, Ferreira A, Sarmento A, Santos L. Skin and soft tissue infections in the intensive care unit: a retrospective study in a tertiary care center. Rev Bras Ter Intensiva 2017; 29:195-205. [PMID: 28614442 PMCID: PMC5496754 DOI: 10.5935/0103-507x.20170019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 02/16/2017] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To identify factors that may influence outcomes in patients with severe skin and soft tissue infections in the intensive care unit. METHODS A retrospective observational study was conducted in a cohort of 1,123 critically ill patients admitted to an intensive care unit with a primary or secondary diagnosis of severe skin and soft tissues infection between January 2006 and December 2014. RESULTS Thirty patients were included, 20 (66.7%) of whom were diagnosed with necrotizing fasciitis; in these patients, perineal area involvement was most commonly identified. Abscess was diagnosed in 8 (26.7%) patients, most commonly involving the cervical area. Risk factors such as immunosuppression and previous surgical trauma were commonly observed in this population. The most commonly isolated microorganism was Escherichia coli. Multidrug resistant microorganisms were commonly detected, even in the absence of traditional risk factors; among these patients, previous use of antibiotics was the most common risk factor for drug resistance. The rate of mortality was significantly higher in patients with necrotizing fasciitis (55%, p = 0.035) and associated with disease severity, presence of septic shock, cardiac arrest and leucocytosis. CONCLUSION Different risk factors and etiologies of severe skin and soft tissue infections were identified. Necrotizing fasciitis and drug-resistant bacteria were significant predictors of mortality, even in the absence of traditional risk factors. Obtaining a better understanding of trends in the risk factors and microorganisms associated with severe skin infections may help in the determination of prompt treatment and antibiotic choices.
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Affiliation(s)
- Luís Filipe Malheiro
- Serviço de Moléstias Infecciosas, Centro Hospitalar de São João - Porto, Portugal.,Grupo de Pesquisa e Desenvolvimento em Nefrologia e Moléstias Infecciosas, Instituto de Engenharia Biomédica, Universidade do Porto - Porto, Portugal
| | - Rita Magano
- Serviço de Moléstias Infecciosas, Centro Hospitalar e Universitário de Coimbra - Coimbra, Portugal
| | - Alcina Ferreira
- Serviço de Moléstias Infecciosas, Centro Hospitalar de São João - Porto, Portugal.,Grupo de Pesquisa e Desenvolvimento em Nefrologia e Moléstias Infecciosas, Instituto de Engenharia Biomédica, Universidade do Porto - Porto, Portugal
| | - António Sarmento
- Serviço de Moléstias Infecciosas, Centro Hospitalar de São João - Porto, Portugal.,Grupo de Pesquisa e Desenvolvimento em Nefrologia e Moléstias Infecciosas, Instituto de Engenharia Biomédica, Universidade do Porto - Porto, Portugal
| | - Lurdes Santos
- Serviço de Moléstias Infecciosas, Centro Hospitalar de São João - Porto, Portugal.,Grupo de Pesquisa e Desenvolvimento em Nefrologia e Moléstias Infecciosas, Instituto de Engenharia Biomédica, Universidade do Porto - Porto, Portugal
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Gregg D, Hiller L, Fabri P. The Need to Feed: Balancing Protein Need in a Critically Ill Patient With Fournier's Gangrene. Nutr Clin Pract 2016; 31:790-794. [PMID: 27296812 DOI: 10.1177/0884533616651296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Necrotizing soft tissue injury (NSTI) is rare with an impressively difficult and dangerous clinical course. While the importance of nutrition as part of the treatment plan for NSTI is recognized as essential to recovery, specific recommendations have not been elucidated. A review of the evidence-based guidelines and published research to accomplish wound healing is presented. The nutrition considerations in the setting of organ failure are also discussed. This article outlines a complicated case of a septic, malnourished man with Fournier's gangrene and acute kidney injury. Protein loss from exudate extracted from a negative-pressure vacuum helped estimate the amount of protein needed to accomplish wound healing and guide clinical care. Development of acute kidney injury resulted in protein restriction at the request of the consulting renal service. This restriction led to insufficient protein intake to meet needs required for wound healing as evidenced by a nitrogen balance study and analysis of wound exudate. The estimated daily protein losses through the wound were within 11-26 g protein (2-4 g nitrogen) per day. Inclusion of wound exudate nitrogen loss in nitrogen balance analyses helped resolve conflicting treatment approaches. Estimating protein loss from wound exudate allows for individualization of protein requirements.
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Affiliation(s)
- Desiree Gregg
- 1 James A. Haley Veterans' Hospital, Tampa, Florida, USA.,2 St. Joseph's Hospital, Tampa, Florida, USA
| | - Lynn Hiller
- 1 James A. Haley Veterans' Hospital, Tampa, Florida, USA
| | - Peter Fabri
- 1 James A. Haley Veterans' Hospital, Tampa, Florida, USA.,3 University of South Florida, Tampa, Florida, USA
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Rios-Diaz AJ, Lin E, Williams K, Jiang W, Patel V, Shimizu N, Metcalfe D, Olufajo OA, Cooper Z, Havens J, Salim A, Askari R. The obesity paradox in patients with severe soft tissue infections. Am J Surg 2016; 214:385-389. [PMID: 28818282 DOI: 10.1016/j.amjsurg.2016.05.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 04/25/2016] [Accepted: 05/01/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND The "obesity paradox" has been demonstrated in chronic diseases but not in acute surgery. We sought to determine whether obesity is associated with improved outcomes in patients with severe soft tissue infections (SSTIs). METHODS The 2006 to 2010 Nationwide Inpatient Sample was used to identify adult patients with SSTIs. Patients were categorized into nonobese and obese (nonmorbid [body mass index 30 to 39.9] and morbid [body mass index ≥ 40]). Logistic regression provided risk-adjusted association between obesity categories and inhospital mortality. RESULTS There were 2,868 records with SSTI weighted to represent 14,080 patients. Obese patients were less likely to die in hospital than nonobese patients (odds ratio [OR] = .42; 95% confidence interval [CI], .25 to .70; P = .001). Subanalysis revealed a similar trend, with lower odds of mortality in nonmorbid obesity (OR = .46; 95% CI, .23 to .91; P = .025) and morbid obesity (OR = .39; 95% CI, .19 to .80; P = .011) groups. CONCLUSIONS Obesity is independently associated with reduced inhospital mortality in patients with SSTI regardless of the obesity classification. This suggests that the obesity paradox exists in this acute surgical population.
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Affiliation(s)
- Arturo J Rios-Diaz
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Heath, Boston, MA, USA
| | - Elissa Lin
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Heath, Boston, MA, USA
| | - Katherine Williams
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Heath, Boston, MA, USA; Trauma, Burn and Surgical Critical Care Division, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Wei Jiang
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Heath, Boston, MA, USA
| | - Vihas Patel
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Heath, Boston, MA, USA
| | - Naomi Shimizu
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Heath, Boston, MA, USA
| | - David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Olubode A Olufajo
- Trauma, Burn and Surgical Critical Care Division, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Zara Cooper
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Heath, Boston, MA, USA; Trauma, Burn and Surgical Critical Care Division, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Joaquim Havens
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Heath, Boston, MA, USA; Trauma, Burn and Surgical Critical Care Division, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ali Salim
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Heath, Boston, MA, USA; Trauma, Burn and Surgical Critical Care Division, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Reza Askari
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Heath, Boston, MA, USA; Trauma, Burn and Surgical Critical Care Division, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Frisman E, Rácz O, Beck J, Firment J, Bodnárová L. Fournier's gangrene (necrotising fasciitis) complicated by renal and respiratory insufficiency: a case report. J Wound Care 2016; 25:34, 36-8. [PMID: 26762496 DOI: 10.12968/jowc.2016.25.1.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A case report of a 68-year-old male obese diabetic patient with an abscess of left femoral region, and diffuse inflammation of abdominal wall and genital region developing sepsis, respiratory and renal failure. At admission in the regional hospital a diagnosis of polymicrobial necrotising fasciitis with suspected sepsis was declared. The patient was transferred to the special intensive care unit (SICU) of Burns and reconstructive surgery at the Kosice-Saca. The patient was treated surgically, with hyperbaric oxygen and pharmacologically to control his diabetes. The main aetiological agent of the condition was identified as Stenotrophomonas maltophilia. In addition to respiratory and metabolic acidosis and gastric bleeding occurred. Due to acute renal failure (day 38) the patient was transferred to clinic of anaesthesiology and the intensive care medicine at the University Hospital in Kosice. The patient was treated by continuous veno-venous haemodialysis, mechanical ventilation and nasogastric nutritional support. On day 48 the conscious sub-febrile patient with healed wounds was transferred back to the regional hospital with ventilation support and continuous renal replacement therapy. His diabetes was uncontrolled, and only kidney parameters remained pathological. The survival of this patient with an extremely poor prognosis was achieved through prompt transfer to a specialised centre, early identification of the aetiological agent and immediate appropriate antibiotic treatment as a result of good cooperation between surgeons and laboratory specialists.
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Affiliation(s)
- E Frisman
- Clinic of Burns and Reconstructive Surgery, 1st Private Hospital, Kosice-Saca, Slovakia
| | - O Rácz
- Institute of Pathological Physiology, Medical Faculty, Safarik University, Kosice, Slovakia.,Institute of Nanobiomedicine and Regenerative Medicine, Faculty of Healthcare, Miskolc University, Miskolc Hungary
| | - J Beck
- Clinic of Burns and Reconstructive Surgery, 1st Private Hospital, Kosice-Saca, Slovakia
| | - J Firment
- Clinic of Anesthesiology and Intensive Care Medicine, Medical Faculty, Safarik University, Kosice, Slovakia
| | - L Bodnárová
- Clinic of Burns and Reconstructive Surgery, 1st Private Hospital, Kosice-Saca, Slovakia
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Abstract
Necrotizing fasciitis (NF) is a severe and rapidly progressive infectious disease that attacks superficial an as well as deep fascia, subcutaneous fat tissue, and muscle. Although the incidence is of relatively low frequency, the median mortality is high. NF is a great burden to patients and hospitals. The most common cause of NF is trauma injuries, followed by other conditions with comorbidity. A classification for NF was presented concerning microbial cause, depth of infection, and anatomy. But the value of classification is not convincing. Early diagnosis of NF is essential and still to be realized by far. Information from clinic or laboratory might contribute to the purpose. Surgery is used in exploration debridement and tissue reconstruction as the main method with NF. Negative pressure wound therapy has proved to be useful in improving wound bed preparation and healing.
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Affiliation(s)
- Xiaofang Sun
- Shanghai 9th People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ting Xie
- Shanghai 9th People's Hospital, Shanghai Jiao Tong University, Shanghai, China
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16
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Hua C, Bosc R, Sbidian E, De Prost N, Jabre P, Chosidow O, Le Cleach L. Interventions for necrotizing soft tissue infections in adults. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [DOI: 10.1002/14651858.cd011680] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Camille Hua
- Hôpital Henri Mondor; Department of Dermatology; 51 Avenue du Maréchal de Lattre de Tassigny Créteil France 94000
| | - Romain Bosc
- Hôpital Henri Mondor; Department of Plastic, Reconstructive and Aesthetic Surgery; 51 Avenue du Maréchal de Lattre de Tassigny Créteil France 94000
| | - Emilie Sbidian
- Hôpital Henri Mondor; Department of Dermatology; 51 Avenue du Maréchal de Lattre de Tassigny Créteil France 94000
| | - Nicolas De Prost
- Hôpital Henri Mondor; Medical Intensive Care Unit; 51 Avenue du Maréchal de Lattre de Tassigny Créteil France 94000
| | - Patricia Jabre
- Hôpital Universitaire Necker-Enfants Malades; Assistance Publique-Hôpitaux de Paris (AP-HP), SAMU (Service d'Aide Médicale Urgente) de Paris; 149 Rue de Sèvres Paris France 75015
- Institut national de la santé et de la recherche médicale (Inserm) U970, Paris-Centre de recherche Cardiovasculaire (PARCC), Université Paris Descartes; Paris France
| | - Olivier Chosidow
- Hôpital Henri Mondor; Department of Dermatology; 51 Avenue du Maréchal de Lattre de Tassigny Créteil France 94000
| | - Laurence Le Cleach
- Hôpital Henri Mondor; Department of Dermatology; 51 Avenue du Maréchal de Lattre de Tassigny Créteil France 94000
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Sartelli M, Malangoni MA, May AK, Viale P, Kao LS, Catena F, Ansaloni L, Moore EE, Moore FA, Peitzman AB, Coimbra R, Leppaniemi A, Kluger Y, Biffl W, Koike K, Girardis M, Ordonez CA, Tavola M, Cainzos M, Di Saverio S, Fraga GP, Gerych I, Kelly MD, Taviloglu K, Wani I, Marwah S, Bala M, Ghnnam W, Shaikh N, Chiara O, Faro MP, Pereira GA, Gomes CA, Coccolini F, Tranà C, Corbella D, Brambillasca P, Cui Y, Segovia Lohse HA, Khokha V, Kok KY, Hong SK, Yuan KC. World Society of Emergency Surgery (WSES) guidelines for management of skin and soft tissue infections. World J Emerg Surg 2014; 9:57. [PMID: 25422671 PMCID: PMC4242587 DOI: 10.1186/1749-7922-9-57] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 09/26/2014] [Indexed: 12/16/2022] Open
Abstract
Skin and soft tissue infections (SSTIs) encompass a variety of pathological conditions ranging from simple superficial infections to severe necrotizing soft tissue infections. Necrotizing soft tissue infections (NSTIs) are potentially life-threatening infections of any layer of the soft tissue compartment associated with widespread necrosis and systemic toxicity. Successful management of NSTIs involves prompt recognition, timely surgical debridement or drainage, resuscitation and appropriate antibiotic therapy. A worldwide international panel of experts developed evidence-based guidelines for management of soft tissue infections. The multifaceted nature of these infections has led to a collaboration among surgeons, intensive care and infectious diseases specialists, who have shared these guidelines, implementing clinical practice recommendations.
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Affiliation(s)
- Massimo Sartelli
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, Macerata, 62019 Italy
| | | | - Addison K May
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee USA
| | - Pierluigi Viale
- Clinic of Infectious Diseases, St Orsola-Malpighi University Hospital, Bologna, Italy
| | - Lillian S Kao
- Department of Surgery, The University of Texas Medical School, Houston, USA
| | - Fausto Catena
- Emergency Surgery Department, Maggiore Parma Hospital, Parma, Italy
| | - Luca Ansaloni
- General Surgery I, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Ernest E Moore
- Department of Surgery, Denver Health Medical Center, Denver, USA
| | - Fred A Moore
- Department of Surgery, University of Florida, Gainesville, Florida USA
| | - Andrew B Peitzman
- Department of Surgery, University of Pittsburgh, Medical Center, Pittsburgh, USA
| | - Raul Coimbra
- Department of Surgery, UC San Diego Health System, San Diego, USA
| | - Ari Leppaniemi
- Department of Abdominal Surgery, University Hospital Meilahti, Helsinki, Finland
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Walter Biffl
- Department of Surgery, University of Florida, Gainesville, Florida USA
| | - Kaoru Koike
- Department of Primary Care & Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Carlos A Ordonez
- Department of Surgery, Fundación Valle del Lilí, Universidad del Valle, Cali, Colombia
| | - Mario Tavola
- Department of Anesthesia and ICU, Villa Scazzi Hospital, Genoa, Italy
| | - Miguel Cainzos
- Department of Surgery, University of Santiago de Compostela, Santiago de Compostela, Spain
| | | | - Gustavo P Fraga
- Division of Trauma Surgery, Hospital de Clinicas, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Igor Gerych
- Department of Surgery 1, Lviv Regional Hospital, DanyloHalytskyLviv National Medical University, Lviv, Ukraine
| | | | - Korhan Taviloglu
- Department of General Surgery, Istanbul Doctor's Center, Istanbul, Turkey
| | - Imtiaz Wani
- Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Sanjay Marwah
- Department of Surgery, Pt BDS Post-graduate Institute of Medical Sciences, Rohtak, India
| | - Miklosh Bala
- General Surgery and Trauma Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Wagih Ghnnam
- Department of Surgery Mansoura, Faculty of medicine, Mansoura University, Mansoura, Egypt
| | - Nissar Shaikh
- Department of Anesthesia and ICU, Hamad Medical Corporation, Doha, Qatar
| | - Osvaldo Chiara
- Emergency Department, Niguarda Ca'Granda Hospital, Milan, Italy
| | - Mario Paulo Faro
- Department of General and Gastrointestinal Surgery, Trauma and Emergency Surgery Division, ABC Medical School, Santo André, SP Brazil
| | - Gerson Alves Pereira
- Emergency Surgery and trauma Unit, Department of Surgery, Ribeirão, Preto Brazil
| | - Carlos Augusto Gomes
- Hospital Universitário Therezinha de Jesus, Faculdade de Ciências Médicas e da Saúde de Juiz de Fora (SUPREMA), Universidade Federal de Juiz de Fora (UFJF), Minas Gerais, Brasil
| | | | - Cristian Tranà
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, Macerata, 62019 Italy
| | - Davide Corbella
- Department of Anestesiology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | | | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Helmut A Segovia Lohse
- II Cátedra de Clínica Quirúrgica, Hospital de Clínicas, Universidad Nacional de Asunción, San Lorenzo, Paraguay
| | | | - Kenneth Yy Kok
- Department of Surgery, Ripas Hospital, Bandar Seri Begawan, Brunei
| | - Suk-Kyung Hong
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Ulsan, Seoul, Republic of Korea
| | - Kuo-Ching Yuan
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan
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BRINK M, ARNELL P, LYCKE H, ROSEMAR A, HAGBERG L. A series of severe necrotising soft-tissue infections in a regional centre in Sweden. Acta Anaesthesiol Scand 2014; 58:882-90. [PMID: 24924532 DOI: 10.1111/aas.12345] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2014] [Indexed: 01/27/2023]
Abstract
BACKGROUND Necrotising soft-tissue infections (NSTIs) are rare conditions with high morbidity and mortality. Patients with NSTIs are often transferred to tertiary hospitals, but the question of whether the potential benefits of highly specialised care outweigh the risks associated with inter-hospital transfers has been raised. METHODS Prospective study including all patients with NSTIs treated at the intensive care unit at Sahlgrenska University Hospital/East between January 2008 and December 2011. RESULTS Twenty-nine patients with NSTIs were identified. Their median age was 54 years and 69% were men. Major co-morbidities were present in 45%. Seventeen patients (59%) were referred from other hospitals. Only 33% of the patients were correctly diagnosed or suspected of having NSTIs in the emergency department. Group A Streptococcus was the most common microbiological finding (41%), followed by Enterobacteriaceae (17%). The median time from hospitalisation to the first dose of antibiotics was 6 h and the median time to primary surgery was 16 h. Hyperbaric oxygen therapy was given to 86%, and intravenous immunoglobulin was given in 52% of the cases. The 30-day mortality was 14% (4/29). The times to the first dose of antibiotics, intensive care unit admission and primary surgery did not differ between transferred and directly admitted patients, and there was no difference in outcome between the groups. CONCLUSIONS Patients with NSTIs develop severe local and systemic symptoms and require extremely resource-demanding hospitalisation. Inter-hospital transfer was not associated with a delay in key interventions and could not be identified as a risk factor for adverse outcome.
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Affiliation(s)
- M. BRINK
- Department of Infectious Diseases; The Sahlgrenska Academy at the University of Gothenburg; Gothenburg Sweden
| | - P. ARNELL
- Department of Anaesthesia and Intensive Care; Sahlgrenska University Hospital; Gothenburg Sweden
| | - H. LYCKE
- Department of Anaesthesia and Intensive Care; Sahlgrenska University Hospital; Gothenburg Sweden
| | - A. ROSEMAR
- Department of Surgery; Sahlgrenska University Hospital; Gothenburg Sweden
| | - L. HAGBERG
- Department of Infectious Diseases; The Sahlgrenska Academy at the University of Gothenburg; Gothenburg Sweden
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Hakkarainen TW, Kopari NM, Pham TN, Evans HL. Necrotizing soft tissue infections: review and current concepts in treatment, systems of care, and outcomes. Curr Probl Surg 2014; 51:344-62. [PMID: 25069713 DOI: 10.1067/j.cpsurg.2014.06.001] [Citation(s) in RCA: 223] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 06/05/2014] [Indexed: 01/17/2023]
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Septic shock due to community-acquired Pseudomonas aeruginosa necrotizing fasciitis: A case report and literature review. Exp Ther Med 2014; 7:1545-1548. [PMID: 24926341 PMCID: PMC4043593 DOI: 10.3892/etm.2014.1628] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 03/07/2014] [Indexed: 12/29/2022] Open
Abstract
Necrotizing fasciitis is a rare but fatal infection, characterized by the rapid progression of necrosis of the fascia, skin, soft tissue and muscle. The most common bacteria associated with necrotizing fasciitis is group A streptococcus, although other pathogens have also been implicated. In the present study, a case of community-acquired necrotizing fasciitis, complicated with septic shock and multiple organ dysfunction syndromes due to Pseudomonas aeruginosa, is presented. Despite intensive medical treatment, the condition of the patient deteriorated rapidly and the patient subsequently succumbed to multiple organ failure. In view of the rapid progression and high mortality rate of this disease, early surgery, as well as novel therapeutic approaches for septic shock are required to improve the outcome for patients.
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Ali A, Botha J, Tiruvoipati R. Fatal skin and soft tissue infection of multidrug resistant Acinetobacter baumannii: A case report. Int J Surg Case Rep 2014; 5:532-6. [PMID: 25016080 PMCID: PMC4147652 DOI: 10.1016/j.ijscr.2014.04.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 01/22/2014] [Accepted: 04/17/2014] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION Acinetobacter baumannii is usually associated with respiratory tract, urinary tract and bloodstream infections. Recent reports suggest that it is increasingly causing skin and soft tissue infections. It is also evolving as a multidrug resistant organism that can be difficult to treat. We present a fatal case of multidrug resistant A. baumannii soft tissue infection and review of relevant literature. PRESENTATION OF CASE A 41 year old morbidly obese man, with history of alcoholic liver disease presented with left superficial pre-tibial abrasions and cellulitis caused by multidrug resistant (MDR) A. baumannii. In spite of early antibiotic administration he developed extensive myositis and fat necrosis requiring extensive and multiple surgical debridements. He deteriorated despite appropriate antibiotic therapy and multiple surgical interventions with development of multi-organ failure and died. DISCUSSION Managing Acinetobacter infections remains difficult due to the array of resistance and the pathogens ability to develop new and ongoing resistance. The early diagnosis of necrotizing soft tissue infection may be challenging, but the key to successful management of patients with necrotizing soft tissue infection are early recognition and complete surgical debridement. CONCLUSION A. baumannii is emerging as an important cause of severe, life-threatening soft tissue infections. Multidrug resistant A. baumannii soft tissue infections may carry a high mortality in spite of early and aggressive treatment. Clinicians need to consider appropriate early empirical antibiotic coverage or the use of combination therapy to include MDR A. baumannii as a cause of skin and soft tissue infections.
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Affiliation(s)
- Aqsa Ali
- Department of Intensive Care Medicine Frankston Hospital, Frankston, Victoria 3199, Australia.
| | - John Botha
- Department of Intensive Care Medicine Frankston Hospital, Frankston, Victoria 3199, Australia.
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Necrotizing Soft Tissue Infections: Surgeon's Prospective. Int J Inflam 2013; 2013:609628. [PMID: 24455410 PMCID: PMC3886590 DOI: 10.1155/2013/609628] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 09/08/2013] [Accepted: 10/11/2013] [Indexed: 12/17/2022] Open
Abstract
Necrotizing soft tissue infections (NSTIs) are fulminant infections of any layer of the soft tissue compartment associated with widespread necrosis and systemic toxicity. Delay in diagnosing and treating these infections increases the risk of mortality. Early and aggressive surgical debridement with support for the failing organs significantly improves the survival. Although there are different forms of NSTIs like Fournier's gangrene or clostridial myonecrosis, the most important fact is that they share common pathophysiology and principles of treatment. The current paper summarizes the pathophysiology, clinical features, the diagnostic workup required and the treatment principles to manage these cases.
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Bruun T, Kittang B, de Hoog B, Aardal S, Flaatten H, Langeland N, Mylvaganam H, Vindenes H, Skrede S. Necrotizing soft tissue infections caused by Streptococcus pyogenes and Streptococcus dysgalactiae subsp. equisimilis of groups C and G in western Norway. Clin Microbiol Infect 2013; 19:E545-50. [DOI: 10.1111/1469-0691.12276] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 05/07/2013] [Accepted: 05/07/2013] [Indexed: 01/22/2023]
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Abstract
Necrotizing soft tissue infections (NSTIs) are infrequent yet highly lethal infections, and a high index of suspicion is required for early diagnosis. Diagnosing NSTIs early can be challenging, and knowledge of the available tools is essential to provide appropriate treatment. The mainstay of treatment is early and complete surgical debridement combined with antimicrobial therapy, close monitoring with further debridement as needed, and physiologic support. Mortality continues to be high, and delayed surgical treatment is the most important risk factor. For the long-term recovery of patients with NSTI, providing early physiologic and nutritional support and physical rehabilitation is essential.
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HELLGREN EM, LAGERGREN P, LARSSON AC, SCHANDL AR, SACKEY PV. Body image and psychological outcome after severe skin and soft tissue infection requiring intensive care. Acta Anaesthesiol Scand 2013; 57:220-8. [PMID: 23167497 DOI: 10.1111/aas.12015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2012] [Indexed: 01/22/2023]
Abstract
BACKGROUND Patients with severe skin and soft tissue infection (SSTI) requiring intensive care unit (ICU) stay are commonly treated with antibiotics, surgery and in some centers also with hyperbaric oxygen therapy. Long-term follow-up of body image and psychological outcome has not been described despite extensive surgery, potentially altered body image and subsequent psychological problems. The aim was to describe perceived body image and its relation to anxiety, depression and post-traumatic stress disorder (PTSD)-related symptoms in patients with severe SSTI 1 year after ICU stay. Specifically, we aimed to assess potential differences related to gender and anatomic site of infection. METHODS Fifty patients treated for severe SSTI in the General ICU, Karolinska University Hospital 2008-2010 received the body image scale (BIS), impact of event scale (IES), and hospital anxiety and depression scale (HADS) 1 year after ICU discharge. RESULTS Abdominoperineal SSTI was associated with more body image problems than other anatomic sites of infection in both men and women. Generally, women reported higher BIS scores than men (median 9.5 vs. 3.0 of total 30, P < 0.03) indicating more negative body image. A substantial number of patients reported scar dissatisfaction (63.9%), body dissatisfaction (51.1%) and body feeling less whole (51.0%). BIS scores correlated with HADS anxiety (r = 0.59, P < 0.01), depression (r = 0.60, P < 0.01) and IES (r = 0.61, P < 0.01) scores. CONCLUSION One year after severe SSTI requiring intensive care, women and patients with abdominoperineal SSTI reported significantly more body image problems. Negative body image was associated with anxiety, depression and PTSD-related symptoms. Specific follow-up for SSTI patients is warranted.
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Affiliation(s)
| | - P. LAGERGREN
- Unit of Upper Gastrointestinal Research (UGIR); Department of Molecular Medicine and Surgery; Karolinska Institutet; Stockholm; Sweden
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Janny S, Bert F, Dondero F, Chanoine MHN, Belghiti J, Mantz J, Paugam-Burtz C. Fatal Escherichia coli skin and soft tissue infections in liver transplant recipients: report of three cases. Transpl Infect Dis 2012; 15:E49-53. [PMID: 23278949 DOI: 10.1111/tid.12046] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 09/26/2012] [Accepted: 10/15/2012] [Indexed: 10/27/2022]
Abstract
Gram-negative bacilli are unusual agents of skin and soft tissue infections. Most previous cases have been reported in cirrhotic or immunocompromised patients, including a single case in a liver transplant recipient. The present report describes 3 cases of fatal skin or soft tissue infections caused by Escherichia coli that occurred in the postoperative course of liver transplantation. The 3 patients were profoundly immunosuppressed as a result of pre-transplant cirrhosis and the postoperative administration of a potent immunosuppressive therapy. Skin and soft tissue infections developed within the first week after liver transplantation, while graft liver function was satisfactory. The 3 patients presented with fever and skin lesions with or without bullae. Despite prompt appropriate antibiotic therapy and surgical debridement, the outcome was rapidly fatal (24 h on average). E. coli was isolated from subcutaneous tissues in 2 cases and from several blood cultures in the third one. The 3 isolates belonged to distinct phylogenetic groups, and did not harbor most of the virulence factors usually reported in extraintestinal pathogenic E. coli isolates. Our report suggests that E. coli can cause severe skin or soft tissue infection in the postoperative course of liver transplantation. The onset of infection is very early and the outcome is extremely poor, despite prompt adapted medical and surgical treatment. Host factors, rather than E. coli bacterial virulence potential, appear to be the major determinants of severity in these patients.
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Affiliation(s)
- S Janny
- Department of Anaesthesiology and Intensive Care, AP-HP Hôpital Beaujon, Clichy, France.
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Pakula AM, Kapadia R, Freeman B, Skinner RA. A 3-Year Experience with Necrotizing Fasciitis: Favorable Outcomes despite Operative Delays in a Busy Acute Care Hospital. Am Surg 2012. [DOI: 10.1177/000313481207801010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Necrotizing fasciitis is a rare severe soft tissue infection that has historically been associated with high mortality. We sought to evaluate our experience with necrotizing fasciitis focusing on outcomes based on timing of operative intervention. Our study hypothesis was that delays in surgical management would negatively impact outcomes. Fifty-four patients were identified for a retrospective chart review from January 2008 to January 2011. Data analysis included demographics, admission laboratory values, imaging results, examination findings, timing and nature of operations, length of stay (LOS), and outcomes. Surgical intervention in 12 hours or more was considered a delay in care. Our study cohort was high risk based on a high prevalence of intravenous drug abuse, diabetes mellitus, hypertension, and end-stage liver disease. The average time to surgical intervention was 18 ± 25 hours and the overall mortality rate was 16 per cent. A delay to surgery did not impact mortality or the number of débridements and LOS. Mortality was high, 45 per cent, in patients requiring amputation. We observed a high-risk population managed with aggressive surgical care for necrotizing fasciitis. Our mortality was low compared with historical data and surgical delays did not impact outcomes. Those patients requiring amputation had worse outcomes.
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Affiliation(s)
- Andrea M. Pakula
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kern Medical Center, Bakersfield, California
| | - Ravi Kapadia
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kern Medical Center, Bakersfield, California
| | - Brandon Freeman
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kern Medical Center, Bakersfield, California
| | - Ruby A. Skinner
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kern Medical Center, Bakersfield, California
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Abstract
OBJECTIVE To provide a contemporary review of the diagnosis and management of necrotizing soft-tissue infections. DATA SOURCES Scientific literature and internet sources. STUDY SELECTION Major articles of importance in this area. CONCLUSIONS The mortality for necrotizing soft-tissue infections appears to be decreasing, possibly due to improved recognition and earlier delivery of more effective therapy. Establishing a diagnosis and initiating treatment as soon as possible provides the best opportunity for a good outcome.
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