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Schroder̈ A, Gerin A, Firth GB, Hoffmann KS, Grieve A, von Sochaczewski CO. A systematic review of necrotising fasciitis in children from its first description in 1930 to 2018. BMC Infect Dis 2019; 19:317. [PMID: 30975101 PMCID: PMC6458701 DOI: 10.1186/s12879-019-3941-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 03/28/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Necrotising fasciitis is a rapidly progressing soft-tissue infection with a low incidence that carries a relevant risk of morbidity and mortality. Although necrotising fasciitis is often fatal in adults, its case fatality rate seems to be lower in children. A highly variable clinical presentation makes the diagnosis challenging, which often results in misdiagnosis and time-delay to therapy. METHODS We conducted a protocol-based systematic review to identify specific features of necrotising fasciitis in children aged one month to 17 years. We searched 'PubMed', 'Web of Science' and 'SCOPUS' for relevant literature. Primary outcomes were incidence and case fatality rates in population-based studies, and skin symptoms on presentation. We also assessed signs of systemic illness, causative organisms, predisposing factors, and reconstructive procedures as secondary outcomes. RESULTS We included five studies reporting incidence and case fatality rates, two case-control studies, and 298 cases from 195 reports. Incidence rates varied between 0.022 and 0.843 per 100,000 children per year with a case-fatality rate ranging from 0% to 14.3%. The most frequent skin symptoms were erythema (58.7%; 175/298) and swelling (48%; 143/298), whereas all other symptoms occurred in less than 50% of cases. The majority of cases had fever (76.7%; 188/245), but other signs of systemic illness were present in less than half of the cohort. Group-A streptococci accounted for 44.8% (132/298) followed by Gram-negative rods in 29.8% (88/295), while polymicrobial infections occurred in 17.3% (51/295). Extremities were affected in 45.6% (136/298), of which 73.5% (100/136) occurred in the lower extremities. Skin grafts were necessary in 51.6% (84/162) of the pooled cases, while flaps were seldom used (10.5%; 17/162). The vast majority of included reports originate from developed countries. CONCLUSIONS Clinical suspicion remains the key to diagnose necrotising fasciitis. A combination of swelling, pain, erythema, and a systemic inflammatory response syndrome might indicate necrotising fasciitis. Incidence and case-fatality rates in children are much smaller than in adults, although there seems to be a relevant risk of morbidity indicated by the high percentage of skin grafts. Systematic multi-institutional research efforts are necessary to improve early diagnosis on necrotising fasciits.
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Affiliation(s)
- Arne Schroder̈
- Klinik für Anästhesiologie und Intensivmedizin, Marienkrankenhaus Bergisch-Gladbach, Dr.-Robert-Koch-Straße 18, Bergisch-Gladbach, D-51465 Germany
| | - Aurelié Gerin
- Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, 26 Chris Hani Road, Johannesburg, ZA-1860 South Africa
| | - Gregory B. Firth
- Department of Orthopaedic Surgery, Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, 26 Chris Hani Road, Johannesburg, ZA-1860 South Africa
| | - Kelly S. Hoffmann
- Department of Paediatric Surgery, Universitair Medisch Centrum Groningen, Hanzeplein 1, Groningen, NL-9713 The Netherlands
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, 26 Chris Hani Road, Johannesburg, ZA-1860 South Africa
| | - Andrew Grieve
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, 26 Chris Hani Road, Johannesburg, ZA-1860 South Africa
| | - Christina Oetzmann von Sochaczewski
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, 26 Chris Hani Road, Johannesburg, ZA-1860 South Africa
- Klinik und Poliklinik für Kinderchirurgie, Universitätsmedizin Mainz, Langenbeckstraße 1, Mainz, D-55131 Germany
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Pithadia DJ, Weathers EN, Colombo RE, Baer SL. Severe and Progressive Cellulitis Caused by Serratia marcescens Following a Dog Scratch. J Investig Med High Impact Case Rep 2019; 7:2324709619832330. [PMID: 30929475 PMCID: PMC6444764 DOI: 10.1177/2324709619832330] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Soft tissue infections occur in over 30% of patients with chemotherapy-induced neutropenia. Gram-positive bacterial infections predominate early in neutropenia, and likelihood of infection by resistant bacteria and fungi increases with prolonged neutropenia. Prior infections and exposures influence the risk of rare pathogens. A 55-year-old woman with chemotherapy-induced neutropenia was scratched on her forearm by a dog. She cleaned the wound with isopropanol and was treated empirically with amoxicillin-clavulanate. Over the next 4 days, she developed fever along with erythema, edema, and mild tenderness of the forearm without purulence or crepitus. She was hospitalized and received empiric treatment with intravenous vancomycin, piperacillin-tazobactam, tobramycin, and voriconazole. Despite therapy, her fevers persisted and the cellulitis progressed for over a week. After 10 days of hospitalization, her neutrophil count began to recover and a bulla developed at the wound site. Culture of the bullous fluid grew Serratia marcescens, and antibiotics were switched to cefepime based on susceptibility. She defervesced and showed substantial improvement of cellulitis within 48 hours and was discharged on oral ciprofloxacin. Serratia marcescens skin infections are rare, and this may be the first report of Serratia cellulitis associated with trauma from dog contact. This case highlights the need to consider unusual pathogens based on exposure history and immune status and to obtain cultures from fluid collections or tissue in cases of treatment-resistant soft tissue infections.
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Affiliation(s)
- Deeti J Pithadia
- 1 Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Erena N Weathers
- 1 Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Rhonda E Colombo
- 2 Madigan Army Medical Center, Joint Base Lewis-McChord, WA, USA
| | - Stephanie L Baer
- 1 Medical College of Georgia, Augusta University, Augusta, GA, USA.,3 Charlie Norwood Veterans Affairs Medical Center, Augusta, GA, USA
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Fournier JB, Dabiri G, Thomas V, Skowron G, Carson P, Falanga V. Serratia marcescens Bullous Cellulitis in a Splenectomized Patient: A Case Report and Review of the Literature. INT J LOW EXTR WOUND 2016; 15:161-8. [PMID: 27079487 DOI: 10.1177/1534734616636271] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Serratia marcescens is a Gram-negative bacillus belonging to the Enterobacteriaceae family. Cutaneous infection with Serratia is rare, and usually occurs in immunocompromised individuals. Primary cutaneous infections are uncommon, but they are typically severe and are associated with significant morbidity and mortality. The pathogenetic factors leading to S. marcescens infection are not fully understood, but contributing virulence factors include proteases, secreted exotoxins, and the formation of biofilm. We report a case of cellulitis occurring in a splenectomized patient, which led to multiple wound debridements and a transmetatarsal amputation. This dramatic case led us to review the published literature on soft tissue infections caused by S. marcescens.
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Affiliation(s)
- John B Fournier
- Department of Dermatology, Roger Williams Medical Center, Providence, RI, USA Department of Dermatology, Boston University School of Medicine, Boston, MA, USA
| | - Ganary Dabiri
- Department of Dermatology, Roger Williams Medical Center, Providence, RI, USA
| | - Vinod Thomas
- Department of Medicine, Roger Williams Medical Center Providence, RI, USA
| | - Gail Skowron
- Department of Medicine, Roger Williams Medical Center Providence, RI, USA
| | - Polly Carson
- Department of Dermatology, Boston University School of Medicine, Boston, MA, USA
| | - Vincent Falanga
- Department of Biochemistry, Boston University, School of Medicine, Boston, MA, USA
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Necrotizing soft tissue infection caused by Serratia marcescens: A case report and literature review. J Infect Chemother 2016; 22:335-8. [PMID: 26778253 DOI: 10.1016/j.jiac.2015.11.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 11/11/2015] [Accepted: 11/24/2015] [Indexed: 12/17/2022]
Abstract
A 64-year-old man with advanced liver cirrhosis was transferred to an emergency center due to septic shock and markedly inflamed left leg. Under a clinical diagnosis of necrotizing soft tissue infection (NSTI), the patient undertook intensive therapy but died 25 h after arrival. The pathogenic organism, Serratia marcescens, was later isolated from blood and soft tissue cultures. NSTI is very rarely associated with S. marcescens. A literature review showed that only 16 such cases, including our case, have been reported to date. Our case is the first evidence of an S. marcescens NSTI in a patient with liver cirrhosis. S. marcescens NSTI has an extremely high mortality rate; total mortality and mortality in cases involving the extremities were 75% (12 of 16 cases) and 83.3% (10 of 12 cases), respectively. Physicians need to be aware that S. marcescens can induce fatal infections in community patients.
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Majumdar R, Crum-Cianflone NF. Necrotizing fasciitis due to Serratia marcescens: case report and review of the literature. Infection 2015; 44:371-7. [PMID: 26498285 DOI: 10.1007/s15010-015-0855-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 10/06/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Necrotizing fasciitis is a severe, life-threatening infection. Serratia marcescens, a Gram-negative bacterium, is an extremely rare cause of necrotizing fasciitis. METHODS A case of S. marcescens necrotizing fasciitis is described, and a comprehensive review of the literature (1966-2015) of monomicrobial cases due to this organism performed. RESULTS We report the first case of S. marcescens necrotizing fasciitis in the setting of calciphylaxis associated with end-stage renal disease. A comprehensive review of the literature of S. marcescens necrotizing fasciitis is provided to enhance the awareness of this increasingly recognized infection, and to provide a concise summary of risk factors, treatment, and outcome. CONCLUSIONS Our case and review highlight the potential risk factors for S. marcescens necrotizing fasciitis, including underlying renal disease and open wounds, and demonstrate the emergence of this organism as a cause of severe, life-threatening soft tissue infections.
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Affiliation(s)
- Rohit Majumdar
- Infectious Diseases Department, Scripps Mercy Hospital, 4077 Fifth Ave, San Diego, CA, 92103, USA.
| | - Nancy F Crum-Cianflone
- Infectious Diseases Department, Scripps Mercy Hospital, 4077 Fifth Ave, San Diego, CA, 92103, USA.
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Ray U, Dutta S, Chakravarty C, Sutradhar A. A case of multiple cutaneous lesions due to Serratia marcescens in an immunocompromised patient. JMM Case Rep 2015. [DOI: 10.1099/jmmcr.0.000059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Ujjwayini Ray
- Apollo Gleneagles Hospitals, 58 Canal Circular Road, Kolkata 54, West Bengal
| | - Soma Dutta
- Apollo Gleneagles Hospitals, 58 Canal Circular Road, Kolkata 54, West Bengal
| | | | - Arpita Sutradhar
- Apollo Gleneagles Hospitals, 58 Canal Circular Road, Kolkata 54, West Bengal
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Lakhani NA, Narsinghani U, Kumar R. Necrotizing Fasciitis of the Abdominal Wall Caused by Serratia Marcescens. Infect Dis Rep 2015; 7:5774. [PMID: 26294949 PMCID: PMC4508534 DOI: 10.4081/idr.2015.5774] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 02/09/2015] [Accepted: 02/10/2015] [Indexed: 11/23/2022] Open
Abstract
In this article, we present the first case of necrotizing fasciitis affecting the abdominal wall caused by Serratia marcescens and share results of a focused review of S. marcescens induced necrotizing fasciitis. Our patient underwent aorto-femoral bypass grafting for advanced peripheral vascular disease and presented 3 weeks postoperatively with pain, erythema and discharge from the incision site in the left lower abdominal wall and underwent multiple debridement of the affected area. Pathology of debrided tissue indicated extensive necrosis involving the adipose tissue, fascia and skeletal muscle. Wound cultures were positive for Serratia marcescens. She was successfully treated with antibiotics and multiple surgical debridements. Since necrotizing fasciitis is a medical and surgical emergency, it is critical to examine infectivity trends, clinical characteristics in its causative spectrum. Using PubMed we found 17 published cases of necrotizing fasciitis caused by Serratia marcescens, and then analyzed patterns among those cases. Serratia marcescens is prominent in the community and hospital settings, and information on infection presentations, risk factors, characteristics, treatment, course, and complications as provided through this study can help identify cases earlier and mitigate poor outcomes. Patients with positive blood cultures and those patients where surgical intervention was not provided or delayed had a higher mortality. Surgical intervention is a definite way to establish the diagnosis of necrotizing infection and differentiate it from other entities.
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Affiliation(s)
- Naheed A Lakhani
- Department of Family and Preventive Medicine, Emory University School of Medicine , Dunwoody, GA, USA
| | - Umesh Narsinghani
- Department of Pediatrics, Mercer University School of Medicine , Macon, GA, USA
| | - Ritu Kumar
- Department of Internal Medicine, Mercer University School of Medicine , Macon, GA, USA
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