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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. Pediatrics 2024; 154:e2024066855. [PMID: 38932719 DOI: 10.1542/peds.2024-066855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 06/28/2024] Open
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. J Am Coll Radiol 2024; 21:e37-e69. [PMID: 38944445 DOI: 10.1016/j.jacr.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Yombi JC, Munting A, Lentini A, Putineanu D, Castanares-Zapatero D, Yildiz H. Severe skin and soft tissue infection in cohort patients admitted in a teaching hospital in Belgium: identification of risk factors for surgery. Infect Dis (Lond) 2024; 56:511-520. [PMID: 38475981 DOI: 10.1080/23744235.2024.2327518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 03/02/2024] [Indexed: 03/14/2024] Open
Abstract
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.
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Affiliation(s)
- J C Yombi
- Department of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint-Luc, UClouvain, Bruxelles, Belgium
| | - A Munting
- Department of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint-Luc, UClouvain, Bruxelles, Belgium
| | - A Lentini
- Department of Plastic Surgery, Cliniques Universitaires Saint-Luc, UClouvain, Bruxelles, Belgium
| | - D Putineanu
- Department of Orthopaedic Surgery, Cliniques Universitaires Saint-Luc, UClouvain, Bruxelles, Belgium
| | - D Castanares-Zapatero
- Department of Intensive Care, Cliniques Universitaires Saint-Luc, UClouvain, Bruxelles, Belgium
| | - H Yildiz
- Department of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint-Luc, UClouvain, Bruxelles, Belgium
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Hua R, Zhong J, Xian J, Liang Y, Gan Z, Deng S. Perforation of descending colonic cancer as a rare cause of gas gangrene of the lower limb in an 80-year-old female: a case report. J Surg Case Rep 2024; 2024:rjae033. [PMID: 38605695 PMCID: PMC11007638 DOI: 10.1093/jscr/rjae033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 01/14/2024] [Indexed: 04/13/2024] Open
Abstract
Gas gangrene is a rare, severe gas-producing infection that can be related to colorectal cancer. Gas gangrene can be confirmed by radiologic findings and crepitation on touch. Spontaneous gas gangrene can be associated with colorectal cancer. An 80-year-old female complaint about a sudden abdominal pain, accompanied with progressive swelling pain in thigh and fever. Diagnosis based on assessment findings were gas gangrene and descending colonic cancer perforation. Emergency surgery was performed for debridement and drainage, followed by vacuum sealing drainage (VSD) with polyurethane (PU). Two more surgical interventions were given before the colonic tumor surgery. The patient recovered well in the long-term follow-up. This report demonstrates the diagnosis, treatment, and management of a successful case of gas gangrene caused by perforation of descending colonic cancer. Accurate preoperative diagnosis and reasonable use of VSD (PU) material played an important role in the treatment of this case.
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Affiliation(s)
- Ruoyue Hua
- Burn and Plastic Surgery Department, Wuzhou Gongren Hospital, Wuzhou, Guangxi Zhuang Autonomous Region, China
| | - Jun Zhong
- Burn and Plastic Surgery Department, Wuzhou Gongren Hospital, Wuzhou, Guangxi Zhuang Autonomous Region, China
| | - Jianlin Xian
- Burn and Plastic Surgery Department, Wuzhou Gongren Hospital, Wuzhou, Guangxi Zhuang Autonomous Region, China
| | - Yaoqi Liang
- Burn and Plastic Surgery Department, Wuzhou Gongren Hospital, Wuzhou, Guangxi Zhuang Autonomous Region, China
| | - Zilin Gan
- Burn and Plastic Surgery Department, Wuzhou Gongren Hospital, Wuzhou, Guangxi Zhuang Autonomous Region, China
| | - Shoupeng Deng
- Burn and Plastic Surgery Department, Wuzhou Gongren Hospital, Wuzhou, Guangxi Zhuang Autonomous Region, China
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Burillo A, Pulido-Pérez A, Bouza E. Current challenges in acute bacterial skin infection management. Curr Opin Infect Dis 2024; 37:71-79. [PMID: 38179868 DOI: 10.1097/qco.0000000000000989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
PURPOSE OF REVIEW There are aspects of skin and soft tissue infections (SSTIs) that remain unresolved, such as current numbers, classification criteria, how best to define severity and predict the outcome, what diagnostic tests to perform, what new treatment options are available, or what the duration of antibiotic treatment should be. We have reviewed the literature over the last 18 months to clarify these issues and provide our opinion. RECENT FINDINGS SSTIs are common and among the top 10 most frequent infections worldwide. They represent a burden on the healthcare system and have a major impact on the quality of life of patients. Regarding classification, the Infectious Diseases Society of America (IDSA) provides a practical guide that distinguishes between uncomplicated and complicated infections, acute and chronic wound infections, and necrotising and nonnecrotizing infections based on skin extension and tissue necrosis. With new microbiological and imaging diagnostic techniques, SSTIs can now be better diagnosed. New PCR techniques are available, and mass spectrometry can be applied to samples collected in liquid transport media. Moreover, new treatment methods such as photodynamic therapy, reactive oxygen, and phages are emerging. SSTI patients can be treated with shorter antibiotic courses if they receive an active drug with good tissue penetration. Antibiotic treatment in necrotizing infections can be shortened to 48 h after the last debridement. SUMMARY SSTIs remain a challenge regarding rapid and accurate diagnosis and clinical management.
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Affiliation(s)
- Almudena Burillo
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón
- Medicine Department, School of Medicine, Universidad Complutense de Madrid
- Gregorio Marañón Health Research Institute, (IiSGM)
| | - Ana Pulido-Pérez
- Gregorio Marañón Health Research Institute, (IiSGM)
- Department of Dermatology, Hospital General Universitario Gregorio Marañón
| | - Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón
- Medicine Department, School of Medicine, Universidad Complutense de Madrid
- Gregorio Marañón Health Research Institute, (IiSGM)
- CIBER of Respiratory Diseases (CIBERES CB06/06/0058), Madrid, Spain
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Kircher HL, O'Dell JC, Chollet-Hinton L, Raheel A, Blaser WJ, McCoy CC, Winfield RD, Guidry CA. Assessing Second Debridement Timing and Mortality in Necrotizing Soft Tissue Infections. Am Surg 2024; 90:725-730. [PMID: 37878367 DOI: 10.1177/00031348231209528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
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.
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Affiliation(s)
| | - Jacob C O'Dell
- Department of Surgery, University of Kansas Medical Center, Kansas, KS, USA
| | - Lynn Chollet-Hinton
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas, KS, USA
| | - Amani Raheel
- Department of Surgery, University of Missouri-Kansas City, Kansas, MO, USA
| | - Wolf J Blaser
- University of Kansas School of Medicine, Kansas, KS, USA
| | - Cameron C McCoy
- Department of Surgery, University of Kansas Medical Center, Kansas, KS, USA
| | - Robert D Winfield
- Department of Surgery, University of Kansas Medical Center, Kansas, KS, USA
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Ge X, Sun Y, Lin J, Zhou F, Yao G, Luo B, Su X. Diagnostic Key Points and Surgical Management of Necrotizing Fasciitis: A Retrospective Study. INT J LOW EXTR WOUND 2024; 23:153-160. [PMID: 34612747 PMCID: PMC10949409 DOI: 10.1177/15347346211045282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Necrotizing fasciitis (NF) is a fatal disease with a high mortality rate that can be easily misdiagnosed. The aim of this study was to improve the diagnostic rate of NF and overall survival. We conducted a single-center, retrospective, noncontrolled study involving 36 patients who were admitted to our department between December 2017 and October 2019, and summarized the diagnostic key points and timing of surgical treatment. All patients were diagnosed at our department and underwent multiple courses of treatment. The records included information regarding underlying diseases, bacterial culture results, laboratory risk indicator for necrotizing fasciitis (LRINEC) score, number of procedures, and type of antibiotics. All 36 cases of NF were cured and showed good patient condition on follow-up; the mean number of surgeries was three, and the mean duration of hospitalization was 37 days (range, 21-83 days). The LRINEC scores of 16 patients were ≥8 points. Seventeen patients with underlying diabetic disease had higher inflammatory index scores than those without diabetes. The LRINEC scores of patients with (n = 17) and without (n = 19) DM were 7.40 ± 2.99 and 3.80 ± 2.39, respectively (P < .01). Cases of NF that were treated with early incision and surgical abscess drainage required fewer surgeries and a shorter length of hospitalization. Thus, surgeons should be more aware of NF and aim to make an early and accurate diagnosis using various approaches. Complete surgical debridement plays an essential role in NF treatment, and diabetes mellitus is a significant adverse factor that exacerbates the severity of NF. Negative-pressure techniques are useful in cases involving nonanaerobic infections and cause minimal complications.
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Affiliation(s)
- Xiaojing Ge
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yute Sun
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jing Lin
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Fang Zhou
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Gang Yao
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Binlin Luo
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xin Su
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Brands SR, Nawijn F, Foppen W, Hietbrink F. No role for standard imaging workup of patients with clinically evident necrotizing soft tissue infections: a national retrospective multicenter cohort study. Eur J Trauma Emerg Surg 2024:10.1007/s00068-023-02414-6. [PMID: 38253724 DOI: 10.1007/s00068-023-02414-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 11/25/2023] [Indexed: 01/24/2024]
Abstract
PURPOSE To assess the diagnostic contribution of different imaging studies to diagnose necrotizing soft tissue infections (NSTIs) and the time to surgery in relation to imaging with the hypothesis that imaging studies may lead to significant delays without being able to sufficiently dismiss or confirm the diagnosis since a NSTI is a surgical diagnosis. METHODS A retrospective multicenter cohort study of all NSTI patients between 2010 and 2020 was conducted. The primary outcome was the number of cases in which imaging contributed to or led to change in treatment. The secondary outcomes were time to treatment determined by the time from presentation to surgery and patient outcomes (amputation, intensive care unit (ICU) admission, length of ICU stay, hospital stay, and mortality). RESULTS A total of 181 eligible NSTI patients were included. The overall mortality was 21% (n = 38). Ninety-eight patients (53%) received imaging in the diagnostic workup. In patients with a clinical suspicion of a NSTI, 81% (n = 85) went directly to the operating room and 19% (n = 20) underwent imaging before surgery; imaging was contributing in only 15% (n = 3) by ruling out or determining underlying causes. In patients without a clinical suspicion of a NSTI, the diagnosis of NSTI was considered in 35% and only after imaging was obtained. CONCLUSION In patients with clinically evident NSTIs, there is no role for standard imaging workup unless it is used to examine underlying diseases (e.g., diverticulitis, pancreatitis). In atypical presenting NSTIs, CT or MRI scans provided the most useful information. To prevent unnecessary imaging and radiation and not delay treatment, the decision to perform imaging studies in patients with a clinical suspicion of a NSTI must be made extremely careful.
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Affiliation(s)
- Sanne R Brands
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Femke Nawijn
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wouter Foppen
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Kobayashi N, Toyama S, Yoshida H, Shiraso S, Kawaguchi S. Necrotizing fasciitis wound after debridement could be successfully treated with negative-pressure wound therapy with instillation and dwelling: A case report. Trauma Case Rep 2023; 48:100957. [PMID: 37920808 PMCID: PMC10618752 DOI: 10.1016/j.tcr.2023.100957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2023] [Indexed: 11/04/2023] Open
Abstract
Background Necrotizing fasciitis (NF) is associated with a high mortality rate. Adequate incision and drainage and repeated debridement are necessary for NF management. After drainage, daily local irrigation should be performed. Case presentation A 72-year-old male patient complained of left lower quadrant pain. Computed tomography revealed a 7 cm mass in the descending colon, with retroperitoneal penetration. Hence, he underwent emergency surgery. The left abdomen was widely incised, and a transverse colostomy was performed for local wound control. Daily debridement of necrotic tissue and wound irrigation were continued. On postoperative day 48, the wound was extensive and complex and obtained a positive bacterial culture. Subsequently, we began a negative-pressure wound therapy with instillation and dwelling (NPWTi-d), which was very effective for extensive and complicated wounds with infection. Thereafter, a split-thickness skin was grafted, and the skin graft survived well. Ultimately, the wound successfully closed. Conclusions NPWT is contraindicated for infected wounds, and an infection control period is required. However, NPWTi-d enables early initiation of wound care despite the presence of infection. Therefore, NPWTi-d is effective for extensive and complicated wounds with infection after NF debridement.
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Affiliation(s)
- Naoya Kobayashi
- Department of Surgery, Iwaki City Medical Center, 16 Kusehara, Uchigomimayamachi, Iwaki-shi, Fukushima 973-8555, Japan
| | - Shingo Toyama
- Department of Surgery, Iwaki City Medical Center, 16 Kusehara, Uchigomimayamachi, Iwaki-shi, Fukushima 973-8555, Japan
| | - Hiroshi Yoshida
- Department of Surgery, Iwaki City Medical Center, 16 Kusehara, Uchigomimayamachi, Iwaki-shi, Fukushima 973-8555, Japan
| | - Satoru Shiraso
- Department of Surgery, Iwaki City Medical Center, 16 Kusehara, Uchigomimayamachi, Iwaki-shi, Fukushima 973-8555, Japan
| | - Shinya Kawaguchi
- Department of Surgery, Iwaki City Medical Center, 16 Kusehara, Uchigomimayamachi, Iwaki-shi, Fukushima 973-8555, Japan
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Silver DS, Teng C, Brown JB. Timing, triage, and mode of emergency general surgery interfacility transfers in the United States: A scoping review. J Trauma Acute Care Surg 2023; 95:969-974. [PMID: 37418697 PMCID: PMC10728349 DOI: 10.1097/ta.0000000000004011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2023]
Abstract
ABSTRACT Interfacility transfer of emergency general surgery (EGS) patients continues to rise, especially in the context of ongoing system consolidation. This scoping review aims to identify and summarize the literature on triage, timing, and mode of interfacility emergency general surgery transfer. While common, EGS transfer systems are not optimized to improve outcomes or ensure value-based care. We identified studies investigating emergency general surgery interfacility transfer using Ovid Medline, EMBASE, and Cochrane Library between 1990 and 2022. English studies that evaluated EGS interfacility timing, triage or transfer mode were included. Studies were assessed by two independent reviewers. Studies were limited to English-language articles in the United States. Data were extracted and summarized with a narrative synthesis of the results and gaps in the literature. There were 423 articles identified, of which 66 underwent full-text review after meeting inclusion criteria. Most publications were descriptive studies or outcomes investigations of interfacility transfer. Only six articles described issues related to the logistics behind the interfacility transfer and were included. The articles were grouped into the predefined themes of transfer timing, triage, and mode of transfer. There were mixed results for the impact of transfer timing on outcomes with heterogeneous definitions of delay and populations. Triage guidelines for EGS transfer were consensus or expert opinion. No studies were identified addressing the mode of interfacility EGS transfer. Further research should focus on better understanding which populations of patients require expedited transfer and by what mode. The lack of high-level data supports the need for robust investigations into interfacility transfer processes to optimize triage using scarce resources and optimized value-based care.
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Affiliation(s)
- David S. Silver
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
| | - Cindy Teng
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
| | - Joshua B. Brown
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
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Ng JC, Ahmad Zaidi AI, Lee JD, Jabar MF. Meek Micrografting Technique for Reconstruction of Extensive Necrotizing Fasciitis of the Anterior Abdomen and Bilateral Femoral Region: A Case Report. Arch Plast Surg 2023; 50:610-614. [PMID: 38143843 PMCID: PMC10736206 DOI: 10.1055/a-2077-5745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 03/28/2023] [Indexed: 12/26/2023] Open
Abstract
Necrotizing fasciitis is an uncommon yet fatal soft tissue infection. Current recommended treatment includes antibiotics with repeat surgical exploration and wound debridement followed by reconstruction. In burn patients, the Meek micrograft has demonstrated a higher true expansion ratio, faster reepithelialization rate, more resilient toward infection, and reduced risk of graft failure as compared with meshed graft. To our best knowledge, the use of Meek micrografting technique in reconstruction of postdebridement wounds of necrotizing fasciitis has not been reported. Hereby, we present a case of a 57-year-old gentleman who was referred to us for wound reconstruction after surgical debridement of Fournier's gangrene and extensive necrotizing fasciitis involving the anterior abdomen and bilateral femoral region. Meek micrografting technique was used to reconstruct the anterior abdomen as the wound bed was large. Although the graft was complicated with a small area of localized infection, it did not spread across the entire graft and was successfully treated with topical antibiotics and regular wound dressing. In our case, wound reconstruction using Meek micrografting technique in a patient with extensive necrotizing fasciitis was successful and showed positive outcome. Therefore, we suggest further studies to be conducted to investigate the applications and outcomes of the Meek micrografting technique, especially in patients with extensive wound bed and limited donor site availability.
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Affiliation(s)
- Jyi Cheng Ng
- Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | | | - Jun De Lee
- Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Mohd Faisal Jabar
- Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
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12
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Horn DL, Chan JD, Li K, Bulger EM, Lynch JB, Robinson BR, Bryson-Cahn C. Defining the Optimal Antibiotic Duration in Necrotizing Skin and Soft Tissue Infections: Clinical Experience from a Quaternary Referral Center. Surg Infect (Larchmt) 2023; 24:741-748. [PMID: 37751587 PMCID: PMC10615078 DOI: 10.1089/sur.2022.294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023] Open
Abstract
Background: Early initiation of broad-spectrum antibiotic agents is a cornerstone of the care of necrotizing skin and soft tissue infections (NSTI). However, the optimal duration of antibiotic agents is unclear. We sought to characterize antibiotic prescribing patterns for patients with NSTI, as well as associated complications. Patients and Methods: Using an NSTI registry, we characterized antibiotic use at a quaternary referral center. Kaplan-Meier analyses were used to describe overall antibiotic duration and relative to operative source control, stratified by presence of other infections that independently influenced antibiotic duration. Factors associated with successful antibiotic discontinuation were identified using logistic regression. Results: Between 2015 and 2018, 441 patients received antibiotic agents for NSTI with 18% experiencing a complicating secondary infection. Among those without a complicating infection, the median duration of antibiotic administration was 9.8 days (95% confidence interval [CI], 9.2-10.5) overall, and 7.0 days after the final debridement. Perineal NSTI received fewer days of antibiotic agents (8.3 vs. 10.6) compared with NSTI without perineal involvement. White blood cell (WBC) count and fever were not associated with failure of antibiotic discontinuation, however, a chronic wound as the underlying infection etiology was associated with greater odds of antibiotic discontinuation failure (odds ratio [OR], 4.33; 95% CI, 1.24-15.1). Conclusions: A seven-day course of antibiotic agents after final operative debridement may be sufficient for NSTI without any secondary complicating infections, because clinical characteristics do not appear to be associated with differences in successful antibiotic discontinuation.
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Affiliation(s)
- Dara L. Horn
- Division of Trauma and Critical Care, Department of Surgery, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Jeannie D. Chan
- Department of Medicine, Division of Infectious Diseases and Allergy, University of Washington, Seattle, Washington, USA
| | - Kevin Li
- Department of Biomedical Informatics, University of Washington, Seattle, Washington, USA
| | - Eileen M. Bulger
- Division of Trauma and Critical Care, Department of Surgery, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - John B. Lynch
- Department of Medicine, Division of Infectious Diseases and Allergy, University of Washington, Seattle, Washington, USA
| | - Bryce R.H. Robinson
- Division of Trauma and Critical Care, Department of Surgery, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Chloe Bryson-Cahn
- Department of Medicine, Division of Infectious Diseases and Allergy, University of Washington, Seattle, Washington, USA
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13
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Ginzberg SP, Roberson JL, Nehemiah A, Ballester JMS, Warshauer AK, Wachtel H, Erdman MS, Dlugosz KL, George LJ, Lynn JC, Martin ND, Myers JS. Time to Transfer as a Quality Improvement Imperative: Implications of a Hub-and-Spoke Health System Model on the Timing of Emergency Procedures. Jt Comm J Qual Patient Saf 2023; 49:539-546. [PMID: 37422425 DOI: 10.1016/j.jcjq.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 06/08/2023] [Accepted: 06/08/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND In the increasingly prevalent hub-and-spoke health system model, specialized services are centralized at a hub hospital, while spoke hospitals offer more limited services and transfer patients to the hub as needed. In one urban, academic health system, a community hospital without procedural capabilities was recently incorporated as a spoke. The goal of this study was to assess the timeliness of emergent procedures for patients presenting to the spoke hospital under this model. METHODS The authors performed a retrospective cohort study of patients transferred from the spoke hospital to the hub hospital for emergency procedures after the health system restructuring (April 2021-October 2022). The primary outcome was the proportion of patients who arrived within their goal transfer time. Secondary outcomes were time from transfer request to procedure start and whether procedure start occurred within guideline-recommended treatment time frames for ST-elevation myocardial infarction (STEMI), necrotizing soft tissue infection (NSTI), and acute limb ischemia (ALI). RESULTS A total of 335 patients were transferred for emergency procedural intervention during the study period, most commonly for interventional cardiology (23.9%), endoscopy or colonoscopy (11.0%), or bone or soft tissue debridement (10.7%). Overall, 65.7% of patients were transferred within the goal time. 23.5% of patients with STEMI met goal door-to-balloon time, and more patients with NSTI (55.6%) and ALI (100%) underwent intervention within the guideline-recommended time frame. CONCLUSION A hub-and-spoke health system model can provide access to specialized procedures in a high-volume, resource-rich setting. However, ongoing performance improvement is required to ensure that patients with emergency conditions receive timely intervention.
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Nagira K, Ogoshi T, Akahori K, Enokida S, Enokida M, Ueda T, Homma M, Nagashima H. Factors associated with mortality in patients with extremity necrotizing soft-tissue infections: a single academic center experience. Langenbecks Arch Surg 2023; 408:189. [PMID: 37166568 DOI: 10.1007/s00423-023-02929-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 05/04/2023] [Indexed: 05/12/2023]
Abstract
PURPOSE Necrotizing soft-tissue infection (NSTI) is a surgical emergency associated with high mortality. This study primarily aimed to identify the factors associated with in-hospital mortality due to NSTI in the extremities at a single institution. Secondarily, we aimed to clarify the effectiveness of the optimal combination of hyperbaric oxygen therapy (HBOT) and surgery for NSTI treatment. STUDY DESIGN Retrospective observational study. METHODS This study included all patients newly diagnosed with NSTI in the extremity from 2003 to 2021 in our hospital. Factors associated with mortality, including patient's characteristics, duration from onset to hospitalization, NSTI type, and clinical data at the initial visit; acute disseminated intravascular coagulation (DIC), laboratory risk indicator for necrotizing fasciitis score, and sequential organ failure assessment score; treatment, initial surgery, surgery times, amputation, HBOT, combined surgery with HBOT, and clinical outcomes; amputation rate, mortality rate, and hospitalization duration were examined. RESULTS A total of 37 cases were treated for NSTIs. The median age was 64 years (range: 22-86). Five cases (13.5%) died during hospitalization. Ten patients were diagnosed with DIC at the initial visit, of whom four died. HBOT combined with surgery was performed in 23 cases, and 16 cases underwent multiple surgeries. Factors associated with mortality included DIC (p = 0.015, 95% confidence interval [CI]: 0.015-0.633) and multiple surgeries combined with HBOT (p = 0.028, 95% CI: 1.302-95.418). CONCLUSION This study demonstrates that DIC at the initial visit is associated with mortality in extremity NSTI. Additionally, HBOT might improve prognosis when combined with multiple surgeries.
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Affiliation(s)
- Keita Nagira
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, 36-1 Nishi-Cho, Yonago, Tottori, 683-8504, Japan.
| | - Tomofumi Ogoshi
- Department of Emergency and Disaster Medicine, Tottori University, Tottori, Japan
| | - Keiichi Akahori
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, 36-1 Nishi-Cho, Yonago, Tottori, 683-8504, Japan
| | - Shinpei Enokida
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, 36-1 Nishi-Cho, Yonago, Tottori, 683-8504, Japan
| | - Makoto Enokida
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, 36-1 Nishi-Cho, Yonago, Tottori, 683-8504, Japan
| | - Takahiro Ueda
- Department of Emergency and Disaster Medicine, Tottori University, Tottori, Japan
| | - Masato Homma
- Department of Emergency and Disaster Medicine, Tottori University, Tottori, Japan
| | - Hideki Nagashima
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, 36-1 Nishi-Cho, Yonago, Tottori, 683-8504, Japan
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15
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Nguyen QD, Diab J, Khaicy D, Diab V, Hopkins Z, Foong LH, Berney CR. Necrotising Fasciitis During the COVID-19 Pandemic: An Australian Hospital Network Experience. World J Surg 2023; 47:1619-1630. [PMID: 37138038 PMCID: PMC10156078 DOI: 10.1007/s00268-023-07040-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND The clinical presentations of diseases and the provision of global healthcare services have been negatively affected by the COVID-19 pandemic. Our study aimed to determine the impact of this global pandemic on presentations of necrotising fasciitis (NF). METHODS A retrospective study was conducted of adult patients with NF in South West Sydney Local Health District from January 2017 to October 2022. An analysis of sociodemographic and clinical outcomes was performed comparing the COVID-19 cohort (2020-2022) and the pre-COVID-19 cohort (2017-2019). RESULTS Sixty-five patients were allocated to the COVID-19 cohort, and 81 patients were in the control cohort. The presentation to hospitals of the COVID-19 cohort was significantly delayed compared to the control cohort (6.1 vs. 3.2 days, P < 0.001). Patients of the age group of 40 years and younger experienced prolonged operative time (1.8 vs. 1.0 h, P = 0.040), higher number of operations (4.8 vs. 2.1, P = 0.008), and longer total length of stay (LoS) (31.3 vs. 10.3 days, P = 0.035) during the pandemic. The biochemical, clinical, or post-operative outcomes of two groups were not significantly different. CONCLUSION This multi-centre study showed that the COVID-19 pandemic delayed presentations of NF but did not result in any significant overall changes in operative time, ICU admissions, LoS, and mortality rate. Patients aged less than 40 years in the COVID-19 group were likely to experience prolonged operative time, higher number of operations, and greater LoS.
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Affiliation(s)
- Quoc Dung Nguyen
- Department of Emergency Medicine, Bankstown-Lidcombe Hospital, Eldridge Road, Bankstown, NSW, Australia.
- School of Medicine, University of New South Wales, Sydney, Australia.
| | - Jason Diab
- Department of Emergency Medicine, Bankstown-Lidcombe Hospital, Eldridge Road, Bankstown, NSW, Australia
- School of Medicine, University of Notre Dame, Sydney, Australia
- School of Medicine, University of New South Wales, Sydney, Australia
| | - David Khaicy
- School of Medicine, University of Notre Dame, Sydney, Australia
| | - Vanessa Diab
- School of Medicine, University of Notre Dame, Sydney, Australia
| | - Zachias Hopkins
- School of Medicine, University of Notre Dame, Sydney, Australia
| | - Lai Heng Foong
- Department of Emergency Medicine, Bankstown-Lidcombe Hospital, Eldridge Road, Bankstown, NSW, Australia
- School of Medicine, University of New South Wales, Sydney, Australia
| | - Christophe R Berney
- Department of Emergency Medicine, Bankstown-Lidcombe Hospital, Eldridge Road, Bankstown, NSW, Australia
- School of Medicine, University of New South Wales, Sydney, Australia
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16
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Williams C, Kellett W, Ireland M, Wahl W, Wisler J, Jalilvand A. Distressed Communities Index Is Not Associated with Mortality for Critically Ill Surgical Patients with Sepsis. Surg Infect (Larchmt) 2023; 24:169-176. [PMID: 36706443 PMCID: PMC9983141 DOI: 10.1089/sur.2022.329] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background: The impact of socioeconomic metrics on outcomes after sepsis is unclear. The Distressed Communities Index (DCI) is a composite score quantifying socioeconomic well-being by zip code. The primary objective of this study was to evaluate the association between DCI and mortality in patients with sepsis admitted to the surgical intensive care unit (SICU). Patients and Methods: All patients with sepsis admitted to the SICU (Sequential Organ Failure Assessment [SOFA] score ≥2) were reviewed retrospectively. Composite DCI scores were obtained for each patient and classified into high-distress (DCI ≥75th percentile; n = 331) and control distress (DCI <50th percentile; n = 666) groups. Baseline demographic and clinical characteristics were compared between groups. The primary outcomes were in-hospital and 90-day mortality. Results: The high-distress cohort was younger and more likely to be African American (19.6% vs. 6.2%), transferred from an outside facility (52% vs. 42%), have chronic obstructive pulmonary disease (25.1% vs. 18.8%), and baseline liver disease (8.2% vs. 4.2%). Sepsis presentation was comparable between groups. Compared with the control cohort, high-distress patients had similar in-house (23% vs. 24%) and 90-day mortality (30% vs. 28%) but were associated with longer hospital stay (23 vs. 19 days). High DCI failed to predict in-hospital or 90-day mortality but was an independent risk factor for longer hospital length of stay (odds ratio [OR], 2.83 ± 1.42; p = 0.047). Conclusions: High DCI was not associated with mortality but did independently predict longer length of stay. This may reflect limitations of DCI score in evaluating mortality for patients with sepsis. Future studies should elucidate its association with length of stay, re-admissions, and follow-up.
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Affiliation(s)
- Chloe Williams
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Whitney Kellett
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Megan Ireland
- University of Toledo College of Medicine, Toledo, Ohio, USA
| | - Wendy Wahl
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jon Wisler
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Anahita Jalilvand
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Hua C, Urbina T, Bosc R, Parks T, Sriskandan S, de Prost N, Chosidow O. Necrotising soft-tissue infections. THE LANCET. INFECTIOUS DISEASES 2023; 23:e81-e94. [PMID: 36252579 DOI: 10.1016/s1473-3099(22)00583-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/05/2022] [Accepted: 08/22/2022] [Indexed: 11/07/2022]
Abstract
The incidence of necrotising soft-tissue infections has increased during recent decades such that most physicians might see at least one case of these potentially life-threatening infections in their career. Despite advances in care, necrotising soft-tissue infections are still associated with high morbidity and mortality, underlining a need for continued education of the medical community. In particular, failure to suspect necrotising soft-tissue infections, fuelled by poor awareness of the disease, promotes delays to first surgical debridement, amplifying disease severity and adverse outcomes. This Review will focus on practical approaches to management of necrotising soft-tissue infections including prompt recognition, initiation of specific management, exploratory surgery, and aftercare. Increased alertness and awareness for these infections should improve time to diagnosis and early referral to specialised centres, with improvement in the prognosis of necrotising soft-tissue infections.
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Affiliation(s)
- Camille Hua
- Service de Dermatologie, Assistance Publique-Hôpitaux de Paris, Créteil, France; Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France; Epidemiology in Dermatology and Evaluation of Therapeutics, Université Paris Est Créteil, Créteil, France; Groupe Infectiologie Dermatologique-Infections Sexuellement Transmissibles, Société Française de Dermatologie, Paris, France
| | - Tomas Urbina
- Service de Médecine Intensive Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Romain Bosc
- Service de Chirurgie Plastique, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Tom Parks
- Department of Infectious Diseases, Imperial College London, London, UK
| | - Shiranee Sriskandan
- Department of Infectious Diseases, Imperial College London, London, UK; MRC Centre for Molecular Bacteriology and Infection, Imperial College London, London, UK
| | - Nicolas de Prost
- Service de Médecine Intensive Réanimation, Assistance Publique-Hôpitaux de Paris, Créteil, France; CARMAS Research Group, UPEC-Université Paris-Est Créteil Val de Marne, Faculté de médecine de Créteil, Créteil, France
| | - Olivier Chosidow
- Service de Dermatologie, Assistance Publique-Hôpitaux de Paris, Créteil, France; Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France; Groupe Infectiologie Dermatologique-Infections Sexuellement Transmissibles, Société Française de Dermatologie, Paris, France; Research group Dynamyc, Faculté de Santé de Créteil, Ecole Nationale Vétérinaire d'Alfort, USC ANSES, Université Paris-Est Créteil, Créteil, France.
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18
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Zhang R, Zhang Y, Hou L, Yan C. Vacuum-assisted closure versus conventional dressing in necrotizing fasciitis: a systematic review and meta-analysis. J Orthop Surg Res 2023; 18:85. [PMID: 36737764 PMCID: PMC9898985 DOI: 10.1186/s13018-023-03561-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 01/23/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Necrotizing fasciitis is a rapid and severe soft tissue infection that targets subcutaneous fat tissue, muscle, and fascia. This study compares the clinical outcomes of vacuum-assisted closure (VAC) versus conventional dressing on necrotizing fasciitis. METHODS We systematically searched Embase, Cochrane, and PubMed for clinical trials (published between January 1, 1995 and September 30, 2021), which compared VAC with conventional dressing for necrotizing fasciitis. The mortality rate of necrotizing fasciitis was the primary outcome of this study. The number of debridements, the total length of hospital stay, and the complication rate were secondary outcomes. A random effects model assessed all pooled data. RESULTS A total of 230 identified studies and seven controlled clinical trials met the inclusion criteria and were included in this analysis (n = 249 participants). Compared to the conventional dressing, patients treated with VAC had a significantly lower mortality rate [OR = 0.27, 95% CI (0.09, 0.87)] (P = 0.03). Total length of hospital stays [MD = 8.46, 95% CI (- 0.53, 17.45)] (P = 0.07), number of debridements [MD = 0.86, 95% CI (- 0.58, 2.30)] (P = 0.24), and complication rate [OR = 0.64, 95% CI (0.07, 5.94)] (P = 0.69) were not significant. These results did not show significant differences between both groups treated with VAC or conventional treatment. CONCLUSION VAC could significantly decrease the death rate compared to conventional dressing. No significant impacts were found on the number of debridements, the total length of hospital stay, and the complication rate in this study. Level of evidence Level-III. Registration Research Registry (reviewregistry1246).
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Affiliation(s)
- Rongli Zhang
- grid.452209.80000 0004 1799 0194Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yahui Zhang
- grid.452209.80000 0004 1799 0194Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Liyuan Hou
- grid.452209.80000 0004 1799 0194Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Chengyong Yan
- grid.452209.80000 0004 1799 0194Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
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19
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Breidung D, Malsagova AT, Loukas A, Billner M, Aurnhammer F, Reichert B, Megas IF. Causative Micro-Organisms in Necrotizing Fasciitis and their Influence on Inflammatory Parameters and Clinical Outcome. Surg Infect (Larchmt) 2023; 24:46-51. [PMID: 36521174 DOI: 10.1089/sur.2022.317] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background: Necrotizing fasciitis (NF) is a potentially fatal soft tissue infection. Four types of pathogens can be distinguished in the pathogen spectrum, although there are strong regional differences with regard to the most common pathogens. Patients and Methods: All cases of NF between 2003 and 2021 with an identified causative agent were analyzed retrospectively. The cases were divided into three groups: polymicrobial, gram-positive and gram-negative. Demographic factors, localization of infection, inflammatory parameters, and clinical outcome were compared between the three groups. Results: A total of 95 cases were analyzed, 41% of which were caused by multiple pathogens. A gram-positive pathogen was reported in 40% of cases and a gram-negative pathogen in 19%. There were significant differences between the three groups with respect to age (with patients in the gram-negative group being on average the oldest) and intensive care unit admissions (which was most frequent in the polymicrobial group). Conclusions: The pathogen spectrum of NF has rarely been studied in a large patient population. Gram-positive pathogens account for the majority of monomicrobial infections in our study. Nevertheless, we recommend calculated broad-spectrum antibiotic therapy given the high number of polymicrobial infections and gram-negative infections. Gram-negative infections may be associated with increased mortality, elevated procalcitonin levels, and are relatively frequent in NF of the lower extremities.
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Affiliation(s)
- David Breidung
- Department of Plastic, Reconstructive, and Hand Surgery, Center for Severe Burn Injuries, Medical Microbiology and Infectiology, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany
| | - Asja T Malsagova
- Department of Plastic, Reconstructive, and Hand Surgery, Center for Severe Burn Injuries, Medical Microbiology and Infectiology, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany
| | - Alexios Loukas
- Department of Genetics, Development, and Molecular Biology, School of Biology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Moritz Billner
- Department of Plastic, Reconstructive, and Hand Surgery, Center for Severe Burn Injuries, Medical Microbiology and Infectiology, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany
| | - Felix Aurnhammer
- Institute of Clinical Hygiene, Medical Microbiology and Infectiology, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany
| | - Bert Reichert
- Department of Plastic, Reconstructive, and Hand Surgery, Center for Severe Burn Injuries, Medical Microbiology and Infectiology, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany
| | - Ioannis-Fivos Megas
- Department of Plastic, Reconstructive, and Hand Surgery, Center for Severe Burn Injuries, Medical Microbiology and Infectiology, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany
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20
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Villarreal ME, Jalilvand A, Schubauer K, Kellet W, DiDonato C, Roberts L, Helkin A, Scarlet S, Wisler J. Comorbidities Matter as Distressed Communities Index Fails to Predict Mortality in Necrotizing Soft Tissue Infection. Surg Infect (Larchmt) 2022; 23:801-808. [DOI: 10.1089/sur.2022.204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Anahita Jalilvand
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Kathryn Schubauer
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Whitney Kellet
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Courtney DiDonato
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Luke Roberts
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Alex Helkin
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sara Scarlet
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jonathan Wisler
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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21
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Breidung D, Grieb G, Malsagova AT, Barth AA, Billner M, Hitzl W, Reichert B, Megas IF. Time Is Fascia: Laboratory and Anamnestic Risk Indicators for Necrotizing Fasciitis. Surg Infect (Larchmt) 2022; 23:747-753. [PMID: 36191292 DOI: 10.1089/sur.2022.222] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023] Open
Abstract
Background: Necrotizing fasciitis is a potentially fatal soft tissue infection in which the timing of surgical intervention significantly affects clinical outcome. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, the Site other than the lower limb, Immunosuppression, Age <60 years, Renal impairment (creatinine >141), and Inflammatory markers (CRP ≥150, WCC >25) (SIARI) score, and procalcitonin levels are intended to aid in the decision-making process to differentiate between necrotizing fasciitis and soft tissue infections. Methods: A retrospective analysis of cases of necrotizing fasciitis and soft tissue infections treated at Klinikum Nürnberg was performed. The two scores as well as procalcitonin levels were tested for their diagnostic value and a new score, the Laboratory and Anamnestic Risk Indicator for Necrotizing Fasciitis (LARINF), was created based on the results. Results: Procalcitonin, LRINEC score, and SIARI score showed insufficient discriminatory ability in our study. The newly created LARINF score combined laboratory parameters of the LRINEC score (hemoglobin and C-reactive protein) with procalcitonin and three comorbidities, resulting in a sensitivity of 84% and a specificity of 75% and the highest area under the receiver operating characteristic (ROC) curve of 0.83. Conclusions: The LARINF score is a novel decision-supporting tool. The decision, in which cases surgical exploration should be initiated, remains a clinical one. However, the score seems to provide an improved basis for identifying a rare clinical picture.
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Affiliation(s)
- David Breidung
- Department of Plastic, Reconstructive and Hand Surgery, Center for Severe Burn Injuries, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany
| | - Gerrit Grieb
- Department of Plastic Surgery and Hand Surgery, Gemeinschaftskrankenhaus Havelhoehe, Berlin, Germany
- Burn Center, Department of Plastic Surgery and Hand Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Asja T Malsagova
- Department of Plastic, Reconstructive and Hand Surgery, Center for Severe Burn Injuries, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany
| | - Andrè A Barth
- Department of Plastic, Reconstructive and Hand Surgery, Center for Severe Burn Injuries, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany
| | - Moritz Billner
- Department of Plastic, Reconstructive and Hand Surgery, Center for Severe Burn Injuries, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany
| | - Wolfgang Hitzl
- Research and Innovation Management (RIM), Paracelsus Medical University Salzburg, Department of Ophthalmology and Optometry, Salzburg, Austria
- Department of Ophthalmology and Optometry, Paracelsus Medical University Salzburg, Salzburg, Austria
- Research Program Experimental Ophthalmology and Glaucoma Research, Paracelsus Medical University, Salzburg, Austria
| | - Bert Reichert
- Department of Plastic, Reconstructive and Hand Surgery, Center for Severe Burn Injuries, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany
| | - Ioannis-Fivos Megas
- Department of Plastic, Reconstructive and Hand Surgery, Center for Severe Burn Injuries, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany
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22
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Nawijn F, Kerckhoffs MC, van Heijl M, Keizer J, van Koperen PJ, Hietbrink F. Impact of Comorbidities on the Cause of Death by Necrotizing Soft Tissue Infections. Surg Infect (Larchmt) 2022; 23:729-739. [PMID: 36067160 DOI: 10.1089/sur.2022.135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background: The aim of this study was to identify the cause of death in patients with necrotizing soft tissue infections (NSTIs) stratified by patient's pre-existing comorbidities (American Society of Anesthesiologists [ASA] classification 3/4 vs. ASA 1/2). Differences in clinical presentation, mortality rate, and factors associated with mortality between those two comorbidity groups were investigated. Patients and Methods: A retrospective multicenter study of patients with NSTIs between 2010 and 2020 was conducted. The primary outcome was the cause of death within the first 30 days. Furthermore, factors associated with mortality were identified. All analysis were stratified by severity of comorbidities (ASA 1/2 or ASA 3/4). Results: Of the 187 patients, 39 patients (21%) died within 30 days. American Society of Anesthesiologists 1/2 patients (overall mortality rate, 11%) died more often as direct result of the infection compared with ASA 3/4 patients (overall mortality rate, 33%) (ASA 1/2 group: 92% vs. ASA 3/4 group: 48%; p = 0.013). American Society of Anesthesiologists 3/4 patients died more often due to withdrawal of life-sustaining therapies based on assumed poor outcome after severe critical illness (ASA 1/2 group: 52% vs. ASA 3/4 group: 8%; p = 0.013). Conclusions: Mortality rates of patients with NSTIs varied from 11% in previously healthy patients to 33% in patients with multiple or severe comorbidities. The predominant cause of mortality was overwhelming infection and associated sepsis in healthy patients whereas in patients with multiple or severe pre-existing medical disease, death most often occurred after treatment limitations based on patient's wishes and prognosis.
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Affiliation(s)
- Femke Nawijn
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Monika C Kerckhoffs
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mark van Heijl
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Surgery, Diakonessenhuis, Utrecht, The Netherlands
| | - Jort Keizer
- Department of Surgery, St. Antonius Hospital, Utrecht, The Netherlands
| | - Paul J van Koperen
- Department of Surgery, Meander Medical Center, Amersfoort, The Netherlands
| | - Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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23
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Mladenov A, Diehl K, Müller O, von Heymann C, Kopp S, Peitsch WK. Outcome of necrotizing fasciitis and Fournier's gangrene with and without hyperbaric oxygen therapy: a retrospective analysis over 10 years. World J Emerg Surg 2022; 17:43. [PMID: 35932075 PMCID: PMC9356491 DOI: 10.1186/s13017-022-00448-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/24/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Necrotizing soft tissue infections (NSTI) require immediate radical debridement, broad-spectrum antibiotics and intensive care. Hyperbaric oxygen therapy (HBOT) may be performed adjunctively, but unequivocal evidence for its benefits is still lacking. METHODS We performed a retrospective single-center study including 192 patients with necrotizing fasciitis or Fournier's gangrene to assess in-hospital mortality and outcome dependent on patient, disease and treatment characteristics with or without HBOT. RESULTS The in-hospital mortality rate was 27.6%. Factors associated with increased mortality according to multivariate analysis were higher age, affection of multiple or problem localizations (odds ratio (OR) = 2.88, P = 0.003), ineligibility for HBOT despite clinical indication (OR = 8.59, P = 0.005), pathogens in blood cultures (OR = 3.36, P = 0.002), complications (OR = 10.35, P < 0.001) and sepsis/organ dysfunction (OR = 19.58, P < 0.001). Factors associated with better survival included vacuum-assisted wound closure (OR = 0.17, P < 0.001), larger number of debridements (OR = 0.83, P < 0.001) and defect closure with mesh graft (OR = 0.06, P < 0.001) or flap (OR = 0.09, P = 0.024). When participants were stratified into subgroups without requirement of HBOT (n = 98), treated with HBOT (n = 83) and ineligible for HBOT due to contraindications (n = 11), the first two groups had similar survival rates (75.5% vs. 73.5%) and comparable outcome, although patients with HBOT suffered from more severe NSTI, reflected by more frequent affection of multiple localizations (P < 0.001), sepsis at admission (P < 0.001) and intensive care treatment (P < 0.001), more debridements (P < 0.001) and a larger number of antibiotics (P = 0.001). In the subgroup ineligible for HBOT, survival was significantly worse (36.4%, P = 0.022). CONCLUSION These results point to a benefit from HBOT for treatment of NSTI in critically ill patients.
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Affiliation(s)
- Assen Mladenov
- Department of Plastic, Reconstructive and Aesthetic Surgery - Center of Wound Medicine, Vivantes Klinikum im Friedrichshain, Berlin, Germany.,Faculty of Medicine, Charité - University Medicine, Berlin, Germany
| | - Katharina Diehl
- Mannheim Institute of Public Health, Social and Preventive Medicine, Heidelberg University, Mannheim, Germany.,Department of Medical Informatics, Biometry and Epidemiology, Professorship of Epidemiology and Public Health, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Oliver Müller
- Center of Hyperbaric Oxygen Therapy and Diving Medicine, Vivantes Klinikum im Friedrichshain, Berlin, Germany.,Department of Anaesthesiology, Intensive Care Medicine, Emergency Care Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Christian von Heymann
- Center of Hyperbaric Oxygen Therapy and Diving Medicine, Vivantes Klinikum im Friedrichshain, Berlin, Germany.,Department of Anaesthesiology, Intensive Care Medicine, Emergency Care Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Susanne Kopp
- Department of Plastic, Reconstructive and Aesthetic Surgery - Center of Wound Medicine, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Wiebke K Peitsch
- Department of Dermatology and Phlebology, Vivantes Klinikum im Friedrichshain, Berlin, Germany.
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24
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A case report of Actinomyces-associated vulvar necrotizing soft tissue infection: Aspects of multidisciplinary care. Int J Surg Case Rep 2022; 96:107314. [PMID: 35753233 PMCID: PMC9249806 DOI: 10.1016/j.ijscr.2022.107314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/12/2022] [Accepted: 06/12/2022] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Necrotizing soft-tissue infections are life-threatening infections with significant morbidity and mortality. CASE PRESENTATION A 36-year-old female gravida 1 para 1001 with a history of intravenous drug use and homelessness presented to the emergency department for a three-day history of labial pain, swelling, and fevers. A contrast tomography scan revealed necrotizing soft tissue infection of the mons and vulva with subcutaneous gas. Empiric broad-spectrum antibiotics were initiated. She underwent an emergent two-staged surgical debridement and delayed primary closure after 1-month in the hospital. She was discharged to complete a 9 to 12 month course of antibiotics. Multidisciplinary team was central to patient care. CLINICAL DISCUSSION Necrotizing soft tissue infections are a diverse group of infections affecting the subcutaneous tissue, muscle, and fascia. Actinomyces is a rare cause and require long-term antibiotics. Early recognition and emergent surgical debridement has been shown to reduce morbidity and mortality. A multidisciplinary approach is critical for proper wound care and healing, pain management, and long-term follow up. CONCLUSIONS Actinomyces-associated vulvar NSTIs are life-threatening infections requiring early surgical debridement, long-term antibiotics, and multidisciplinary approach.
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25
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Huang Y, Haleem Z, Patel H, Pandey A, Sandhu PS, Kim R. Extensive retroperitoneal multiloculated abscesses after open cholecystectomy associated with bile leak: a case report. BJR Case Rep 2022; 8:20210147. [DOI: 10.1259/bjrcr.20210147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 03/29/2022] [Accepted: 04/05/2022] [Indexed: 11/05/2022] Open
Abstract
Retroperitoneal abscesses are rare and life-threatening. The incidence of abscesses after open cholecystectomies is <1% disregarding location. Eleven cases reporting post-cholecystectomy retroperitoneal abscesses were archived on PubMed, seven associated with gallstone retaining or spillage. Hereby, we present a case of extensive retroperitoneal multiloculated abscesses after open cholecystectomy complicated with bile leak, while no gallstone was noted. Early evaluation for retroperitoneal abscesses is critical if the patient does not clinically improve after cholecystectomy. Early treatment with drainage of the abscesses, antibiotics, and ERCP intervention to achieve source control can greatly improve the clinical outcome.
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Affiliation(s)
- Yuting Huang
- University of Maryland Medical Center Midtown Campus, Baltimore, Maryland, United States
| | - Zarah Haleem
- American University of Antigua College of Medicine, Coolidge, Antigua and Barbuda
| | - Harsh Patel
- University of Maryland Medical Center Midtown Campus, Baltimore, Maryland, United States
| | - Ankur Pandey
- University of Maryland Medical Center, Baltimore, Maryland, United States
| | | | - Raymond Kim
- University of Maryland Medical Center, Baltimore, Maryland, United States
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26
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Terzian WTH, Nunn AM, Call EB, Bliss SE, Swinarska JT, Rigdon J, Avery MD, Hoth JJ, Miller PR. Duration of Antibiotic Therapy in Necrotizing Soft Tissue Infections: Shorter is Safe. Surg Infect (Larchmt) 2022; 23:430-435. [PMID: 35451883 DOI: 10.1089/sur.2022.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Early debridement improves outcome in necrotizing soft tissue infection (NSTI), but there is no consensus on duration of antimicrobial therapy. We recently changed practice to discontinue antibiotic agents early with a goal of 48 hours after adequate source control. We hypothesized that discontinuing antibiotic agents after a short course is safe in the treatment of NSTI. Patients and Methods: This was a prospective study of patients with NSTI comparing short duration of antibiotic agents to a control population after a change in practice. In 2018 we began discontinuing antibiotic agents within 48 hours of source control (absence of cellulitis and no evidence of active infection). Previously, antibiotic duration was at the discretion of the attending surgeon (generally 7-10 days). Patients were excluded from analysis if they were initially debrided at a referring facility, immune compromised, or died prior to source control. Patient characteristics and outcomes were evaluated. The primary outcome was treatment failure requiring antibiotic agents to be restarted with or without further debridement of infected tissue. Secondary outcomes included the duration of antibiotic therapy after source control. Results: We evaluated 151 patients; 119 admitted between January 1, 2011 and January 31, 2018 (PRE) and 32 admitted after January 31, 2018 (POST). Patients were not statistically different regarding characteristics, admission physiologic variables, and comorbidities. The median duration of antibiotic agents after source control in the PRE group was 180.3 hours (interquartile range [IQR], 100.7-318.8) versus 48 hours (IQR, 32.3-100.8) in the POST group (p < 0.01). Patients in each group were treated as described above, and treatment failure occurred in seven (5.9%) PRE patients and two (6.3%) POST (99.3% post hoc power at non-inferiority limit 20%, significance p < 0.05). Thirty-day all-cause mortality was not different between groups (6.7% vs. 6.3%; p = 0.94). Conclusions: Short-duration (48 hours) antibiotic agents after NSTI source control is as safe and effective as a longer course.
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Affiliation(s)
- W T Hillman Terzian
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Andrew M Nunn
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Erika B Call
- Novant Health Acute Care Surgery, Winston-Salem, North Carolina, USA
| | - Sara E Bliss
- Department of Pharmacy, Duke University Hospital, Durham, North Carolina, USA
| | - Joanna T Swinarska
- Department of Surgery, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Joseph Rigdon
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Martin D Avery
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - J Jason Hoth
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Preston R Miller
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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27
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Sartelli M, Coccolini F, Kluger Y, Agastra E, Abu-Zidan FM, Abbas AES, Ansaloni L, Adesunkanmi AK, Augustin G, Bala M, Baraket O, Biffl WL, Ceresoli M, Cerutti E, Chiara O, Cicuttin E, Chiarugi M, Coimbra R, Corsi D, Cortese F, Cui Y, Damaskos D, de’Angelis N, Delibegovic S, Demetrashvili Z, De Simone B, de Jonge SW, Di Bella S, Di Saverio S, Duane TM, Fugazzola P, Galante JM, Ghnnam W, Gkiokas G, Gomes CA, Griffiths EA, Hardcastle TC, Hecker A, Herzog T, Karamarkovic A, Khokha V, Kim PK, Kim JI, Kirkpatrick AW, Kong V, Koshy RM, Inaba K, Isik A, Ivatury R, Labricciosa FM, Lee YY, Leppäniemi A, Litvin A, Luppi D, Maier RV, Marinis A, Marwah S, Mesina C, Moore EE, Moore FA, Negoi I, Olaoye I, Ordoñez CA, Ouadii M, Peitzman AB, Perrone G, Pintar T, Pipitone G, Podda M, Raşa K, Ribeiro J, Rodrigues G, Rubio-Perez I, Sall I, Sato N, Sawyer RG, Shelat VG, Sugrue M, Tarasconi A, Tolonen M, Viaggi B, Celotti A, Casella C, Pagani L, Dhingra S, Baiocchi GL, Catena F. WSES/GAIS/WSIS/SIS-E/AAST global clinical pathways for patients with skin and soft tissue infections. World J Emerg Surg 2022; 17:3. [PMID: 35033131 PMCID: PMC8761341 DOI: 10.1186/s13017-022-00406-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/04/2022] [Indexed: 02/08/2023] Open
Abstract
Skin and soft-tissue infections (SSTIs) encompass a variety of pathological conditions that involve the skin and underlying subcutaneous tissue, fascia, or muscle, ranging from simple superficial infections to severe necrotizing infections. Together, the World Society of Emergency Surgery, the Global Alliance for Infections in Surgery, the Surgical Infection Society-Europe, The World Surgical Infection Society, and the American Association for the Surgery of Trauma have jointly completed an international multi-society document to promote global standards of care in SSTIs guiding clinicians by describing reasonable approaches to the management of SSTIs. An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting evidence was shared by an international task force with different clinical backgrounds.
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Affiliation(s)
| | - Federico Coccolini
- grid.144189.10000 0004 1756 8209Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Yoram Kluger
- grid.413731.30000 0000 9950 8111Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ervis Agastra
- General Surgery Department, Regional Hospital of Durres, Durres, Albania
| | - Fikri M. Abu-Zidan
- grid.43519.3a0000 0001 2193 6666Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Ashraf El Sayed Abbas
- grid.469958.fDepartment of General and Emergency Surgery Faculty of Medicine, Mansoura University Hospital, Mansoura, Egypt
| | - Luca Ansaloni
- grid.8982.b0000 0004 1762 5736Department of Surgery, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Abdulrashid Kayode Adesunkanmi
- grid.10824.3f0000 0001 2183 9444Department of Surgery, Faculty of Clinical Sciences, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Osun State Nigeria
| | - Goran Augustin
- grid.412688.10000 0004 0397 9648Department of Surgery, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Miklosh Bala
- grid.17788.310000 0001 2221 2926Trauma and Acute Care Surgery Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Oussama Baraket
- grid.12574.350000000122959819Department of General Surgery Bizerte Hospital, Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
| | - Walter L. Biffl
- grid.415401.5Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA USA
| | - Marco Ceresoli
- grid.7563.70000 0001 2174 1754Emergency and General Surgery Department, University of Milan-Bicocca, Milan, Italy
| | - Elisabetta Cerutti
- grid.415845.9Anesthesia and Transplant Surgical Intensive Care Unit, Ospedali Riuniti, Ancona, Italy
| | - Osvaldo Chiara
- grid.4708.b0000 0004 1757 2822Department of Pathophysiology, ASST Niguarda Ca’Granda Hospital, University of Milano, Milan, Italy
| | - Enrico Cicuttin
- grid.144189.10000 0004 1756 8209Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Massimo Chiarugi
- grid.144189.10000 0004 1756 8209Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Raul Coimbra
- grid.43582.380000 0000 9852 649XRiverside University Health System, CECORC Research Center, Loma Linda University, Loma Linda, USA
| | - Daniela Corsi
- General Direction, Area Vasta 3, ASUR Marche, Macerata, Italy
| | | | - Yunfeng Cui
- grid.265021.20000 0000 9792 1228Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Dimitris Damaskos
- grid.418716.d0000 0001 0709 1919Department of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Nicola de’Angelis
- Minimally Invasive and Robotic Digestive Surgery Unit, Regional General Hospital F. Miulli, Bari, Italy
- grid.410511.00000 0001 2149 7878Université Paris Est, UPEC, Creteil, France
| | - Samir Delibegovic
- grid.412410.20000 0001 0682 9061Department of Surgery, University Clinical Center of Tuzla, Tuzla, Bosnia and Herzegovina
| | - Zaza Demetrashvili
- Department General Surgery, Kipshidze Central University Hospital, Tbilisi, Georgia
| | - Belinda De Simone
- grid.418056.e0000 0004 1765 2558Department of General, Digestive and Metabolic Minimally Invasive Surgery, Centre Hospitalier Intercommunal De Poissy/St Germain en Laye, Poissy, France
| | - Stijn W. de Jonge
- grid.7177.60000000084992262Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Stefano Di Bella
- grid.5133.40000 0001 1941 4308Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Trieste, Italy
| | - Salomone Di Saverio
- Department of General Surgery, “Madonna del Soccorso” San Benedetto del Tronto Hospital, San Benedetto del Tronto, Italy
| | - Therese M. Duane
- grid.429044.f0000 0004 0402 1407Department of Surgery, Texas Health Resources, Ft Worth, TX USA
| | - Paola Fugazzola
- grid.8982.b0000 0004 1762 5736Department of Surgery, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Joseph M. Galante
- grid.27860.3b0000 0004 1936 9684Division of Trauma and Acute Care Surgery, Department of Surgery, University of California Davis, Sacramento, CA USA
| | - Wagih Ghnnam
- grid.10251.370000000103426662Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - George Gkiokas
- grid.5216.00000 0001 2155 0800Second Department of Surgery, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Carlos Augusto Gomes
- Department of Surgery, Hospital Universitário Terezinha de Jesus, Faculdade de Ciências Médicas E da Saúde de Juiz de Fora, Juiz de Fora, Brazil
| | - Ewen A. Griffiths
- grid.415490.d0000 0001 2177 007XDepartment of Upper GI Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Timothy C. Hardcastle
- Trauma Service, Inkosi Albert Luthuli Central Hospital and Department of Surgery, Nelson R Mandela School of Clinical Medicine, Durban, South Africa
| | - Andreas Hecker
- grid.411067.50000 0000 8584 9230Department of General and Thoracic Surgery, University Hospital Giessen, Giessen, Germany
| | - Torsten Herzog
- grid.416438.cDepartment of Surgery, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Aleksandar Karamarkovic
- grid.7149.b0000 0001 2166 9385Surgical Clinic “Nikola Spasic”, Faculty of Medicine University of Belgrade, Belgrade, Serbia
| | - Vladimir Khokha
- Department of Emergency Surgery, City Hospital, Mozyr, Belarus
| | - Peter K. Kim
- grid.251993.50000000121791997Department of Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY USA
| | - Jae Il Kim
- grid.411633.20000 0004 0371 8173Department of Surgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Republic of Korea
| | - Andrew W. Kirkpatrick
- grid.414959.40000 0004 0469 2139General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB Canada
| | - Victor Kong
- grid.414386.c0000 0004 0576 7753Department of Surgery, Edendale Hospital, Pietermaritzburg, South Africa
| | - Renol M. Koshy
- grid.412570.50000 0004 0400 5079Department of General Surgery, University Hospital of Coventry and Warwickshire, Coventry, UK
| | - Kenji Inaba
- grid.42505.360000 0001 2156 6853Division of Trauma and Surgical Critical Care, Department of Surgery, University of Southern California, Los Angeles, CA USA
| | - Arda Isik
- grid.411776.20000 0004 0454 921XDepartment of General Surgery, School of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Rao Ivatury
- grid.224260.00000 0004 0458 8737Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA USA
| | | | - Yeong Yeh Lee
- grid.11875.3a0000 0001 2294 3534School of Medical Sciences, Universitiy Sains Malaysia, Kota Bharu, Kelantan Malaysia
| | - Ari Leppäniemi
- grid.15485.3d0000 0000 9950 5666Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Andrey Litvin
- grid.410686.d0000 0001 1018 9204Department of Surgical Disciplines, Immanuel Kant Baltic Federal University, Regional Clinical Hospital, Kaliningrad, Russia
| | - Davide Luppi
- Department of General and Emergency Surgery, ASMN, Reggio Emilia, Italy
| | - Ronald V. Maier
- grid.34477.330000000122986657Department of Surgery, University of Washington, Seattle, WA USA
| | - Athanasios Marinis
- grid.417374.2First Department of Surgery, Tzaneion General Hospital, Piraeus, Greece
| | - Sanjay Marwah
- grid.412572.70000 0004 1771 1642Department of Surgery, Post-Graduate Institute of Medical Sciences, Rohtak, India
| | - Cristian Mesina
- Second Surgical Clinic, Emergency Hospital of Craiova, Craiova, Romania
| | - Ernest E. Moore
- grid.239638.50000 0001 0369 638XErnest E Moore Shock Trauma Center at Denver Health, Denver, USA
| | - Frederick A. Moore
- grid.15276.370000 0004 1936 8091Department of Surgery, Division of Acute Care Surgery, and Center for Sepsis and Critical Illness Research, University of Florida College of Medicine, Gainesville, FL USA
| | - Ionut Negoi
- Department of Surgery, Emergency Hospital of Bucharest, Bucharest, Romania
| | - Iyiade Olaoye
- grid.412975.c0000 0000 8878 5287Department of Surgery, University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Carlos A. Ordoñez
- grid.477264.4Division of Trauma and Acute Care Surgery, Fundacion Valle del Lili, Cali, Colombia
- grid.8271.c0000 0001 2295 7397Department of Surgery, Universidad del Valle, Cali, Colombia
| | - Mouaqit Ouadii
- grid.412817.90000 0004 5938 8644Department of Surgery, Hassan II University Hospital, Medical School of Fez, Sidi Mohamed Benabdellah University, Fez, Morocco
| | - Andrew B. Peitzman
- grid.21925.3d0000 0004 1936 9000Department of Surgery, University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, USA
| | - Gennaro Perrone
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
| | - Tadeja Pintar
- grid.29524.380000 0004 0571 7705Department of Surgery, UMC Ljubljana, Ljubljana, Slovenia
| | - Giuseppe Pipitone
- grid.419995.9Department of Internal Medicine, Division of Infectious Disease, ARNAS Civico-Di Cristina Hospital, Palermo, Italy
| | - Mauro Podda
- grid.7763.50000 0004 1755 3242Department of General and Emergency Surgery, Cagliari University Hospital, Cagliari, Italy
| | - Kemal Raşa
- Department of Surgery, Anadolu Medical Center, Kocaeli, Turkey
| | - Julival Ribeiro
- grid.414433.5Infection Control, Hospital de Base, Brasília, DF Brazil
| | - Gabriel Rodrigues
- grid.411639.80000 0001 0571 5193Department of General Surgery, Kasturba Medical College and Hospital, Manipal Academy of Higher Education, Manipal, India
| | - Ines Rubio-Perez
- grid.81821.320000 0000 8970 9163General Surgery Department, Colorectal Surgery Unit, La Paz University Hospital, Madrid, Spain
| | - Ibrahima Sall
- General Surgery Department, Military Teaching Hospital, Dakar, Senegal
| | - Norio Sato
- grid.255464.40000 0001 1011 3808Department of Aeromedical Services for Emergency and Trauma Care, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Robert G. Sawyer
- grid.268187.20000 0001 0672 1122Department of Surgery, Western Michigan University School of Medicine, Kalamazoo, MI USA
| | - Vishal G. Shelat
- grid.240988.f0000 0001 0298 8161Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Michael Sugrue
- grid.415900.90000 0004 0617 6488Donegal Clinical Research Academy Emergency Surgery Outcome Project, Letterkenny University Hospital, Donegal, Ireland
| | - Antonio Tarasconi
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
| | - Matti Tolonen
- grid.15485.3d0000 0000 9950 5666Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Bruno Viaggi
- grid.24704.350000 0004 1759 9494Department of Anesthesiology, Neuro Intensive Care Unit, Florence Careggi University Hospital, Florence, Italy
| | | | - Claudio Casella
- grid.7637.50000000417571846Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Leonardo Pagani
- Department of Infectious Diseases, Bolzano Hospital, Bolzano, Italy
| | - Sameer Dhingra
- grid.464629.b0000 0004 1775 2698Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research (NIPER), Hajipur, Bihar India
| | - Gian Luca Baiocchi
- Department of Surgery, AAST Cremona, Cremona, Italy
- grid.7637.50000000417571846Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Fausto Catena
- grid.414682.d0000 0004 1758 8744Department of Surgery, “Bufalini” Hospital, Cesena, Italy
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28
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Sjeklocha L, Tiffany L, Tran Q, Abdel-Wahab M, Widjaja A, Aligabi A, Albelo F, Asunción S, Gelmann D, Haase D, Henry S, Leibner E. Outcomes and factors associated with occult septic shock in emergency department patients with soft tissue Infection. J Emerg Trauma Shock 2022; 15:128-134. [PMID: 36353407 PMCID: PMC9639725 DOI: 10.4103/jets.jets_38_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/11/2022] [Accepted: 08/08/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction: Patients who develop occult septic shock (OSS) are associated with worse outcomes than those with early septic shock (ESS). Patients with skin and soft tissue infection (SSTI) may have underlying organ dysfunction due to OSS, yet the prevalence and the outcomes of patients with SSTI and early versus occult shock have not been described. This study compared the clinical characteristics of SSTI patients and the prevalence of having no septic shock (NSS), ESS, or OSS. Methods: We retrospectively analyzed charts of adult patients who were transferred from any emergency department to our academic center between January 1, 2014, and December 31, 2016. Outcomes of interest were the development of OSS and acute kidney injury (AKI). We performed logistic regressions to measure the association between clinical factors with the outcomes and created probability plots to show the relationship between key clinical variables and outcomes of OSS or AKI. Results: Among 269 patients, 218 (81%) patients had NSS, 16 (6%) patients had ESS, and 35 (13%) patients had OSS. Patients with OSS had higher mean serum lactate concentrations than patients with NSS (3.5 vs. 2.1 mmol/L, P < 0.01). Higher sequential organ failure assessment (SOFA) score was associated with higher likelihood of developing OSS (odds ratio [OR] 1.41, 95% confidence interval [CI] 1.23–1.62, P < 0.001). NSS was associated with very low odds of developing AKI (OR 0.16, 95% CI 0.08–0.33, P < 0.001). Conclusions: 13% of the patients with SSTI developed OSS. Patients with OSS had elevated serum lactate concentration and higher SOFA score than those with NSS. Increased SOFA score is a predictor for the development of OSS.
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29
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Nguyen QD, Diab J, Khaicy D, Diab V, Hopkins Z, Foong LH, Berney CR. OUP accepted manuscript. J Surg Case Rep 2022; 2022:rjac015. [PMID: 35145627 PMCID: PMC8826021 DOI: 10.1093/jscr/rjac015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 01/06/2022] [Indexed: 11/13/2022] Open
Abstract
The purpose of this study was to determine the impact of coronavirus disease 2019 (COVID-19) on the delayed presentation of necrotising fasciitis (NF). A retrospective study was conducted of adult patients (≥16 years old) diagnosed with NF at a hospital from 2017 to 2020. A quantitative comparative analysis for the COVID-19 group and control group between 2017 and 2019. Structured interviews were conducted to examine the impact of COVID-19 on patients. There were 6 patients in the COVID-19 group and 10 patients in the control group. The COVID-19 group had a longer mean onset of symptoms till hospital presentation of 4.1 days and a longer mean operative time. The COVID-19 group was more likely to be admitted to intensive care unit. Three patients in the COVID-19 group did not survive compared to survival in the counterparts. Participant responses indicated the COVID-19 pandemic did not prevent them from presenting to ED.
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Affiliation(s)
- Quoc Dung Nguyen
- Bankstown-Lidcombe Hospital, Bankstown, NSW, Australia
- The University of New South Wales, Faculty of Medicine, Kensington, NSW, Australia
- Correspondence address. Emergency Department, Bankstown-Lidcombe Hospital, Eldridge Road, Bankstown, NSW, Australia. Tel: +61-(2)-9722-8000; Fax: +61-(2)-9722-8570; E-mail:
| | - Jason Diab
- Bankstown-Lidcombe Hospital, Bankstown, NSW, Australia
- The University of Notre Dame, School of Medicine, Darlinghurst, NSW, Australia
| | - David Khaicy
- The University of Notre Dame, School of Medicine, Darlinghurst, NSW, Australia
| | - Vanessa Diab
- The University of Notre Dame, School of Medicine, Darlinghurst, NSW, Australia
| | - Zachias Hopkins
- The University of Notre Dame, School of Medicine, Darlinghurst, NSW, Australia
| | - Lai Heng Foong
- Bankstown-Lidcombe Hospital, Bankstown, NSW, Australia
- The University of New South Wales, Faculty of Medicine, Kensington, NSW, Australia
| | - Christophe R Berney
- Bankstown-Lidcombe Hospital, Bankstown, NSW, Australia
- The University of New South Wales, Faculty of Medicine, Kensington, NSW, Australia
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Nawijn F, de Gier B, Brandwagt DAH, Groenwold RHH, Keizer J, Hietbrink F. Incidence and mortality of necrotizing fasciitis in The Netherlands: the impact of group A Streptococcus. BMC Infect Dis 2021; 21:1217. [PMID: 34872527 PMCID: PMC8650531 DOI: 10.1186/s12879-021-06928-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 11/26/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Little is known about the exact incidence of necrotizing soft tissue infections. The few incidences reported in international literature are not directly relatable to the Netherlands, or other European countries, due to geographic heterogeneity in causative micro-organisms involved. This resulted in the aim of this study to map the incidence, mortality rate and hospital course of necrotizing fasciitis infections in the Netherlands to gain insight in the incidence of necrotizing fasciitis in the Netherlands and the associated mortality and health care burden. METHODS This nationwide retrospective database study used three distinct data sources to map the incidence of necrotizing fasciitis in the Netherlands between 2014 and 2019, being data from the Dutch Hospital Data (DHD) foundation, data from Osiris-AIZ, which is a database of notifiable diseases managed by regional Public Health Services (GGD) and the National Institute for Public Health and the Environment (RIVM), and previously published studies on necrotizing fasciitis conducted in the Netherlands. RESULTS The incidence of necrotizing fasciitis in the Netherlands is estimated to be approximately 1.1 to 1.4 cases per 100,000 person years, which corresponds to 193-238 patients per year. Of all necrotizing fasciitis infections, 34 to 42% are caused by the group A Streptococcus. Annually, 56 patients die as a result of a necrotizing fasciitis infection (mortality of 23-29%) and 26 patients undergo an amputation for source control (11-14%). Patients stay a mean of 6 to 7 days at the intensive care unit and have a mean hospital length of stay of 24 to 30 days. CONCLUSION The combination of nationwide databases provides reliable insight in the epidemiology of low-incidence and heterogenic diseases. In the Netherlands, necrotizing fasciitis is a rare disease with group A Streptococcus being the most common causative micro-organism of necrotizing fasciitis. The prior Dutch cohort studies on necrotizing fasciitis report slightly higher sample mortality rates, compared to the population mortality. However, necrotizing fasciitis remain associated with substantial morbidity and mortality, risk at amputation and health care burden characterized by prolonged ICU and hospital stay.
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Affiliation(s)
- Femke Nawijn
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Brechje de Gier
- Center for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Utrecht, The Netherlands
| | - Diederik A H Brandwagt
- Department of Infectious Diseases, Public Health Service (GGD) Region Utrecht, Utrecht, The Netherlands
| | - Rolf H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jort Keizer
- Department of Surgery, Sint Antonius Hospital, Utrecht, The Netherlands
| | - Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
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Nawijn F, Hietbrink F, Peitzman AB, Leenen LPH. Necrotizing Soft Tissue Infections, the Challenge Remains. Front Surg 2021; 8:721214. [PMID: 34568417 PMCID: PMC8458892 DOI: 10.3389/fsurg.2021.721214] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/17/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Necrotizing Soft Tissue Infections (NSTIs) are uncommon rapidly spreading infection of the soft tissues for which prompt surgical treatment is vital for survival. Currently, even with sufficient awareness and facilities available, ambiguous symptoms frequently result in treatment delay. Objectives: To illustrate the heterogeneity in presentation of NSTIs and the pitfalls entailing from this heterogeneity. Discussion: NSTI symptoms appear on a spectrum with on one side the typical critically ill patient with fast onset and progression of symptoms combined with severe systemic toxicity resulting in severe physical derangement and sepsis. In these cases, the suspicion of a NSTI rises quickly. On the other far side of the spectrum is the less evident type of presentation of the patient with gradual but slow progression of non-specific symptoms over the past couple of days without clear signs of sepsis initially. This side of the spectrum is under represented in current literature and some physicians involved in the care for NSTI patients are still unaware of this heterogeneity in presentation. Conclusion: The presentation of a critically ill patient with evident pain out of proportion, erythema, necrotic skin and bullae is the classical presentation of NSTIs. On the other hand, non-specific symptoms without systemic toxicity at presentation frequently result in a battery of diagnostics tests and imaging before the treatment strategy is determined. This may result in a delay in presentation, delay in diagnosis and delay in definitive treatment. This failure to perform an adequate exploration expeditiously can result in a preventable mortality.
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Affiliation(s)
- Femke Nawijn
- Department of Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Andrew B Peitzman
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, Netherlands
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Miller AC, Koeneman SH, Arakkal AT, Cavanaugh JE, Polgreen PM. Incidence, Duration, and Risk Factors Associated With Missed Opportunities to Diagnose Herpes Simplex Encephalitis: A Population-Based Longitudinal Study. Open Forum Infect Dis 2021; 8:ofab400. [PMID: 34514018 PMCID: PMC8415533 DOI: 10.1093/ofid/ofab400] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 07/25/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Delays in diagnosing herpes simplex encephalitis (HSE) are associated with increased morbidity and mortality. The purpose of this paper is to determine the frequency and duration of diagnostic delays for HSE and risk factors for diagnostic delays. METHODS Using data from the IBM Marketscan Databases, 2001-2017, we performed a retrospective cohort study of patients with HSE. We estimated the number of visits with HSE-related symptoms before diagnosis that would be expected to occur in the absence of delays and compared this estimate to the observed pattern of visits. Next, we used a simulation-based approach to compute the number of visits representing a delay, the number of missed diagnostic opportunities per case patient, and the duration of delays. We also investigated potential risk factors for delays. RESULTS We identified 2667 patients diagnosed with HSE. We estimated 45.9% (95% confidence interval [CI], 43.6%-48.1%) of patients experienced at least 1 missed opportunity; 21.9% (95% CI, 17.3%-26.3%) of these patients had delays lasting >7 days. Risk factors for delays included being seen only in the emergency department, age <65, or a history of sinusitis or schizophrenia. CONCLUSIONS Many patients with HSE experience multiple missed diagnostic opportunities before diagnosis.
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Affiliation(s)
- Aaron C Miller
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Scott H Koeneman
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Alan T Arakkal
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Joseph E Cavanaugh
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Philip M Polgreen
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa, USA
- Division of Infectious Diseases, Department of Internal Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
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Cioci AC, Cioci AL, Mantero AMA, Parreco JP, Yeh DD, Rattan R. Advanced Statistics: Multiple Logistic Regression, Cox Proportional Hazards, and Propensity Scores. Surg Infect (Larchmt) 2021; 22:604-610. [PMID: 34270359 DOI: 10.1089/sur.2020.425] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: Randomized controlled trials (RCTs) are generally regarded as the gold standard for demonstrating causality because they effectively mitigate bias from both known and unknown confounders. However, conducting an RCT is not always feasible because of logistical and ethical considerations. This is especially true when evaluating surgical interventions, and non-randomized study designs must be utilized instead. Methods: Statistical methods that adjust for baseline differences in non-randomized studies were reviewed. Results: The three methods used most commonly to adjust for confounding factors are multiple logistic regression, Cox proportional hazard, and propensity scoring. Multiple logistic regression (MLR) is implemented to analyze the influence of categorical and/or continuous variables on a single dichotomous outcome. The model controls for multiple covariates while also quantifying the magnitude of each covariate's influence on the outcome. Selecting which variables to include in a model should be the most important consideration, and authors must report how and why variables were chosen. Cox proportional hazards modeling is conceptually similar to logistic regression and is used when analyzing survival data. When applied to survival curves, Cox proportional hazards can adjust for baseline group differences and provide a hazard ratio to quantify the effect that any single factor contributes to the survival curve. Propensity scores (PS) range from zero to one and are defined as the probability of receiving an intervention based on observed baseline characteristics. Propensity score matching (PSM) is especially useful when the outcome of interest is a rare event. Treated and untreated subjects with similar propensity scores are paired, forming balanced samples for further analysis. Conclusions: The method by which to address confounding should be selected according to the data format and sample size. Reporting of methods should provide justification for selected covariates, confirmation that data did not violate model assumptions, and measures of model performance.
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Affiliation(s)
- Alessia C Cioci
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Anthony L Cioci
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | | | - Joshua P Parreco
- Florida State University College of Medicine, Tallahassee, Florida, USA
| | - D Dante Yeh
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Rishi Rattan
- University of Miami Miller School of Medicine, Miami, Florida, USA
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Tran Z, Cho NY, Verma A, Sanaiha Y, Williamson C, Hadaya J, Gandjian M, Benharash P. Clinical and Financial Outcomes of Necrotizing Soft-Tissue Infections in Safety-Net Hospitals. J Surg Res 2021; 267:124-131. [PMID: 34147002 DOI: 10.1016/j.jss.2021.05.012] [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: 01/23/2021] [Revised: 04/04/2021] [Accepted: 05/07/2021] [Indexed: 11/16/2022]
Abstract
Background Prior work has demonstrated inferior outcomes for a multitude of medical and surgical conditions at hospitals with high burdens of underinsured patients (safety-net). The present study aimed to evaluate trends in incidence, clinical outcomes and resource utilization in the surgical management of necrotizing soft-tissue infections (NSTI) at safety-net hospitals. Materials and methods Adults requiring surgical debridement/amputation following NSTI-related hospitalizations were identified in the 2005-2018 National Inpatient Sample. Safety-net status (SNH) was assigned to institutions in the top tertile for annual proportion of underinsured patients. Logistic multivariable regression was utilized to evaluate the association of SNH with mortality, hospitalization duration (LOS), costs and discharge disposition. Results Of an estimated 212,692 patients, 76,719 (36.1%) were managed at SNH. The annual incidence of NSTI admissions increased overall while associated mortality declined. After adjustment, SNH status was associated with greater odds of mortality (adjusted odds ratios: 1.14, 95% CI: 1.03-1.26), LOS (β: +1.8 d, 95% CI: 1.3-2.2) and costs (β: +$4,400, 95% CI: 2,900-5,800). SNH patients had similar rates of amputation but lower likelihood of care facility or home health discharge. Conclusion With a rising incidence and overall reduction in mortality, safety-net hospitals persistently exhibit greater mortality and resource use for surgical NSTI admissions. Variation in access, disease presentation and timeliness of operative intervention may explain the observed findings.
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Affiliation(s)
- Zachary Tran
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, California
| | - Nam Yong Cho
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, California
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, California
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, California
| | - Catherine Williamson
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, California
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, California
| | - Matthew Gandjian
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, California
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, California.
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Quah GS, Cheng Q, Prabhu K, Edye MB. Necrotising soft tissue infection in western Sydney: An 8-year experience. ANZ J Surg 2021; 91:1813-1818. [PMID: 34075682 DOI: 10.1111/ans.16961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 05/05/2021] [Accepted: 05/10/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND This study aimed to assess the risk factors, management, imaging validity, Laboratory Risk Indicator for Necrotising infection (LRINEC) score and outcomes of necrotising soft tissue infection (NSTI) at a western Sydney tertiary hospital. METHODS A retrospective study was conducted of all patients with NSTI from 2012 to 2019 at our institution. Patient characteristics, imaging, microbiology and site, LRINEC score, surgical management and outcomes/disposition were collected. RESULTS Thirty-six patients met the inclusion criteria with mean age of 52 years and body mass index of 38.1; 55.6% were male, 48% of Polynesian descent and 55.6% were diabetic. The most frequent sites of NSTI were perineal (30.6%), lower limb (30.6%), perianal (19.3%) and trunk (11.1%). A total of 64% of patients underwent computed tomography radiological imaging with diagnostic accuracy of 50%. The mean LRINEC score was 7 (1-20). A total of 52.8% were transferred from another facility or non-surgical teams which delayed surgical review by 11.4 h (P < 0.03) and operating time by 12.4 h (P < 0.04) compared with direct emergency department referrals to the on-call surgical team. There was no statistical difference in outcomes in both groups. The overall average time to surgical debridement was 16.2 h (standard deviation 19.6, range 3.4-105.1). The mean hospital length of stay was 20.9 days; 44.4% of patients were transferred for rehabilitation or plastic reconstruction with a single mortality from multi-organ failure. CONCLUSION The optimal management of NSTI requires a high index of suspicion and LRINEC score is a useful adjunct in aiding a clinician's decision. Early surgical debridement within 24 h of diagnosis and a multidisciplinary approach is associated with a lower mortality rate.
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Affiliation(s)
- Gaik S Quah
- Department of Surgery, Blacktown and Mount Druitt Hospitals, Sydney, New South Wales, Australia
| | - Qiuye Cheng
- Department of Surgery, Blacktown and Mount Druitt Hospitals, Sydney, New South Wales, Australia
| | - Komal Prabhu
- Department of Surgery, Blacktown and Mount Druitt Hospitals, Sydney, New South Wales, Australia
| | - Michael B Edye
- Department of Surgery, Blacktown and Mount Druitt Hospitals, Sydney, New South Wales, Australia
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Fujinaga J, Kuriyama A, Ikegami T, Onodera M. Laboratory Risk Indicator for Necrotizing Fasciitis Score and Patient Outcomes. J Emerg Trauma Shock 2021; 14:38-41. [PMID: 33911435 PMCID: PMC8054806 DOI: 10.4103/jets.jets_17_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 03/05/2020] [Accepted: 06/01/2020] [Indexed: 11/15/2022] Open
Abstract
Context: The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score helps to diagnose necrotizing soft-tissue infection (NSTI). The LRINEC score has been reported to be associated with poor prognosis, although few studies have evaluated this association. Aims: We aimed to describe the characteristics of NSTI and assess whether the LRINEC score was associated with mortality and amputation. Settings and Design: We conducted a retrospective observational study from January 2007 to May 2018, in a Japanese tertiary care hospital. Subjects and Methods: Patients with NSTI were identified through our hospital database using the discharge diagnosis. We extracted data on patient characteristics, laboratory examinations, microbiological information, treatment, and in-hospital mortality. Statistical Analysis Used: We estimated the odds ratios (ORs) and associated 95% confidence intervals (CIs) for in-hospital mortality using logistic regression models. Results: We identified 58 patients. The median LRINEC score was 8 (interquartile range [IQR]: 6–9). Forty-four patients (75.9%) scored 6 or more. The eight patients with amputations had a median score of 6 (IQR: 4.5–7.5) versus 8 (IQR: 7–9) for patients who underwent debridement (P = 0.091). Survivors and nonsurvivors had median scores of 8 (IQR: 6–9) and 6 (IQR: 5–8), respectively (P = 0.148). The OR for mortality in patients with liver cirrhosis was 10.5 (95% CI: 1.00–110.36; P = 0.050). Conclusions: There was no association between the LRINEC score and patients' outcomes: mortality and amputation. Further studies are warranted to evaluate the utility of the LRINEC score and factors associated with poor prognosis in patients with NSTI.
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Affiliation(s)
- Jun Fujinaga
- Emergency and Critical Care Center, Kurashiki Central Hospital, Kurashiki City, Okayama, Japan.,Department of Epidemiology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Akira Kuriyama
- Emergency and Critical Care Center, Kurashiki Central Hospital, Kurashiki City, Okayama, Japan
| | - Tetsunori Ikegami
- Emergency and Critical Care Center, Kurashiki Central Hospital, Kurashiki City, Okayama, Japan
| | - Mutsuo Onodera
- Emergency and Critical Care Center, Kurashiki Central Hospital, Kurashiki City, Okayama, Japan
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Mastrocco A, Prittie J. Early and aggressive surgical debridement and negative pressure wound therapy to treat necrotizing fasciitis in three dogs. Vet Surg 2021; 50:1662-1669. [PMID: 33724500 DOI: 10.1111/vsu.13576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 12/04/2020] [Accepted: 12/13/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To report the management and outcomes of dogs with necrotizing fasciitis (NF) treated with early, aggressive surgical debridement and negative pressure wound therapy (NPWT). STUDY DESIGN Short case series. ANIMALS Three dogs surgically treated for NF. METHODS Clinical signs in the three dogs included an identified wound, severe pain, fever, and progressive erythema. A tentative diagnosis of NF was based on the presence of suppurative inflammation and intracellular bacteria seen in fine needle aspirates and clinical progression in each case. Each dog was treated with surgical debridement within 6 hours of clinical suspicion for NF. Necrosis affected multiple tissue layers was noted surgical exploration. Systemic supportive care and antibiotherapy were also provided for 3 to 4 weeks postoperatively. RESULTS Three surgical debridements were required in two dogs, and four surgical debridements were required in one dog. All of the surgical sites were managed with NPWT until final primary closure was possible at 4, 5, and 6 days after initial surgery. Results of histopathology and culture of the surgical sites were consistent with NF as described in each case. All dogs survived to discharge and long-term follow up. CONCLUSION Management with early surgery, multiple debridements, and the use of NPWT led to resolution of NF in three dogs.
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Affiliation(s)
- Alicia Mastrocco
- Emergency and Critical Care, The Animal Medical Center, New York
| | - Jennifer Prittie
- Emergency and Critical Care, The Animal Medical Center, New York
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Zhang BR, Fan X, Zhao JC, Shi K, Yu JA. Negative pressure wound therapy with instillation and dwell time in the wound management of necrotizing fasciitis. J Tissue Viability 2021; 30:262-266. [PMID: 33707160 DOI: 10.1016/j.jtv.2021.02.012] [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: 07/23/2020] [Revised: 02/20/2021] [Accepted: 02/28/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Recent literature has shown that negative pressure wound therapy with instillation and dwell time (NPWTi-d) is a valid method of managing complex wounds and gained increasingly wider interest due in part to the increasing complexity of wounds. The purpose of this case study was to obtain information on the profile of NPWTi-d in necrotizing fasciitis patients, investigate the role it play in wound bed preparation, length of hospital stay and number of debridement operations. METHODS NPWTi-d has been used in patients with necrotizing fasciitis with either normal saline or Prontosan® solution and complete the treatment were involved in the present study. Following aggressive surgical debridement, NPWTi-d was initiated by instilling solution with a set dwell time of 5-10 min, followed by continuous NPWT of -125 mm Hg for 3-5 h. The system was changed on a 3-5 days schedule until sufficient granulation tissue was evident. Patients received systemic antibiotics and underwent wound debridement as indicated. Data of wound bed preparation, length of hospital stay, duration of NPWTi-d therapy, number of surgical interventions were collected retrospectively from patient medical records. RESULTS A total of 32 patients with diagnosis of necrotizing fasciitis received NPWTi-d were included. Granulation tissue was found to be sufficient in 9-16 days. The mean duration of NPWTi-d therapy was 12.5 days prior to wound closure by split-thickness autograft (n = 21), suture (n = 9), or flap transplantation (n = 2).Patients received NPWTi-d treatment over a period of 8-16 days. The mean length of hospitalization was 22.8 days. All wounds were successfully closed and no recurrence of infection or adverse event was observed during NPWTi-d treatment. CONCLUSION In these patients, NPWTi-d facilitates wound cleansing and wound bed preparation and offers the clinician an additional tool for the management of necrotizing fasciitis. Further well designed prospective investigations with low risk of bias are needed to confirm these findings in the future work.
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Affiliation(s)
- Bo-Ru Zhang
- Cardiothoracic Surgery Care Platform, The First Hospital of Jilin University, Changchun, 130021, PR China
| | - Xing Fan
- Department of Burn Surgery, The First Hospital of Jilin University, Changchun, 130021, PR China
| | - Jing-Chun Zhao
- Department of Burn Surgery, The First Hospital of Jilin University, Changchun, 130021, PR China.
| | - Kai Shi
- Department of Burn Surgery, The First Hospital of Jilin University, Changchun, 130021, PR China
| | - Jia-Ao Yu
- Department of Burn Surgery, The First Hospital of Jilin University, Changchun, 130021, PR China
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Li Z, Tang Y, Wang P, Ren J. Diagnosis and Treatment of Retroperitoneal Infection. Surg Infect (Larchmt) 2020; 22:477-484. [PMID: 33146587 DOI: 10.1089/sur.2020.126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: Retroperitoneal infection is a persistent and widespread infectious disease that is difficult to treat. It is usually caused by secondary complications such as inflammation, damage, or perforation of adjacent organs in the retroperitoneal space. Pathogenic bacteria invade the retroperitoneal space through retroperitoneal and interstitial organs, peripheral tissue, and the blood. As a result, infections mostly arise from severe acute pancreatitis, acute colonic diverticulitis, inflammatory bowel disease, kidney abscess, and biliary tract injury. Initially manifested by the presence of lumbago, this disease spreads easily, is persistent, and is often misdiagnosed. Methods: Review and synthesis of pertinent literature and guidelines pertaining to abdominal infection and retroperitoneal infection. Results: Recent data indicate that mortality rates associated with retroperitoneal infection have been increasing annually. Early diagnosis and treatment have been shown to improve the prognosis. In the early stage, infection is insidious and lacks typical symptoms, and is primarily diagnosed with computed tomography (CT). Strategies that control the source of infection, rational use of antibiotic agents, and nutritional interventions are the primary approaches to treat the infections. Emergence of minimally invasive drainage technologies, including the ultrasound/CT-guided puncture and drainage, percutaneous nephroscope puncture and drainage, and drainage using a catheter through an abdominal puncture device (trocar) have shortened the treatment cycle and disease burden. However, current diagnosis and treatment for retroperitoneal infection are not sufficiently effective because some patients do not show typical clinical manifestations. Moreover, sensitivity and specificity of available auxiliary examination methods are not supported by sufficient evidence-based medical research. Additionally, there are no uniform standards on the timing of surgical intervention and treatment options. Therefore, we summarized the progresses on current diagnosis and treatment approaches for retroperitoneal infection.
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Affiliation(s)
- Ze Li
- Department of Emergency Surgery, The Affiliated Hospital of Qingdao University, Qingdao, P.R. China
| | - Yinbing Tang
- Department of General Surgery, The Affiliated People's Hospital of Jiangsu University, Zhenjiang, P.R. China
| | - Peige Wang
- Department of Emergency Surgery, The Affiliated Hospital of Qingdao University, Qingdao, P.R. China
| | - Jianan Ren
- Department of Emergency Surgery, The Affiliated Hospital of Qingdao University, Qingdao, P.R. China.,Lab for Trauma and Surgical Infections, Department of Surgery, Jinling Hospital, Affiliated to Southeast University, Nanjing, P.R. China
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Getting it Right the First Time: Frozen Sections for Diagnosing Necrotizing Soft Tissue Infections. World J Surg 2020; 45:148-159. [PMID: 32995933 PMCID: PMC7752879 DOI: 10.1007/s00268-020-05786-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2020] [Indexed: 12/19/2022]
Abstract
Background The aim of this study was to investigate which histopathologic findings are most indicative for necrotizing soft tissue infections (NSTIs) in ambivalent cases. Methods Patients undergoing surgical exploration for suspected NSTIs with obtainment of incisional biopsies for histopathological assessment were included from January 2013 until August 2019. The frozen sections and formalin-fixed paraffin-embedded (FFPE) samples were retrospectively re-assessed. The primary outcome was the discharge diagnosis. Results Twenty-seven (69%) biopsies of the 39 included samples were from patients with NSTIs. Microscopic bullae (p = 0.043), severe fascial inflammation (p < 0.001) and fascial necrosis (p < 0.001) were significantly more often present in the NSTI group compared to the non-NSTI group. Muscle edema (n = 5), severe muscle inflammation (n = 5), muscle necrosis (n = 8), thrombosis (n = 10) and vasculitis (n = 5) were most frequently only seen in the NSTI group. In thirteen tissues samples, there were some discrepancies between the severity of findings in the frozen section and the FFPE samples. None of these discrepancies resulted in a different diagnosis or treatment strategy. Conclusion Microscopic bullae, severe fascial or muscle inflammation, fascial or muscle necrosis, muscle edema, thrombosis and vasculitis upon histopathological evaluation all indicate a high probability of a NSTI. At our institution, diagnosing NSTIs is aided by using intra-operative frozen section as part of triple diagnostics in ambivalent cases. Based on the relation between histopathologic findings and final presence of NSTI, we recommend frozen section for diagnosing NSTIs in ambivalent cases.
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Kim MC, Kim S, Cho EB, Lee GY, Choi SH, Kim SO, Chung JW. Utility of Magnetic Resonance Imaging for Differentiating Necrotizing Fasciitis from Severe Cellulitis: A Magnetic Resonance Indicator for Necrotizing Fasciitis (MRINEC) Algorithm. J Clin Med 2020; 9:jcm9093040. [PMID: 32967282 PMCID: PMC7564512 DOI: 10.3390/jcm9093040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/15/2020] [Accepted: 09/18/2020] [Indexed: 11/16/2022] Open
Abstract
We developed a new magnetic resonance indicator for necrotizing fasciitis (MRINEC) algorithm for differentiating necrotizing fasciitis (NF) from severe cellulitis (SC). All adults with suspected NF between 2010 and 2018 in a tertiary hospital in South Korea were enrolled. Sixty-one patients were diagnosed with NF and 28 with SC. Among them, 34 with NF and 15 with SC underwent magnetic resonance imaging (MRI). The MRINEC algorithm, a two-step decision tree including T2 hyperintensity of intermuscular deep fascia and diffuse T2 hyperintensity of deep peripheral fascia, diagnosed NF with 94% sensitivity (95% confidence interval (CI), 80–99%) and 60% specificity (95% CI, 32–84%). The algorithm accurately diagnosed all 15 NF patients with a high (≥8) laboratory risk indicator for necrotizing fasciitis (LRINEC) score. Among the five patients with an intermediate (6–7) LRINEC score, sensitivity and specificity were 100% (95% CI, 78–100%) and 0% (95% CI, 0–84%), respectively. Finally, among the 29 patients with a low (≤5) LRINEC score, the algorithm had a sensitivity and specificity of 88% (95% CI, 62–98%) and 69% (95% CI, 39–91%), respectively. The MRINEC algorithm may be a useful adjuvant method for diagnosing NF, especially when NF is suspected in patients with a low LRINEC score.
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Affiliation(s)
- Min-Chul Kim
- Division of Infectious Diseases, Department of Internal Medicine, Chung-Ang University Hospital, Seoul 06973, Korea; (M.-C.K.); (E.B.C.); (S.-H.C.)
| | - Sujin Kim
- Department of Radiology, Chung-Ang University Hospital, Seoul 06973, Korea;
- Correspondence: (S.K.); (J.-W.C.); Tel.: +82-2-6299-2646 (S.K.); +82-2-6299-1402 (J.-W.C.)
| | - Eun Been Cho
- Division of Infectious Diseases, Department of Internal Medicine, Chung-Ang University Hospital, Seoul 06973, Korea; (M.-C.K.); (E.B.C.); (S.-H.C.)
| | - Guen Young Lee
- Department of Radiology, Chung-Ang University Hospital, Seoul 06973, Korea;
| | - Seong-Ho Choi
- Division of Infectious Diseases, Department of Internal Medicine, Chung-Ang University Hospital, Seoul 06973, Korea; (M.-C.K.); (E.B.C.); (S.-H.C.)
| | - Seon Ok Kim
- Departments of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea;
| | - Jin-Won Chung
- Division of Infectious Diseases, Department of Internal Medicine, Chung-Ang University Hospital, Seoul 06973, Korea; (M.-C.K.); (E.B.C.); (S.-H.C.)
- Correspondence: (S.K.); (J.-W.C.); Tel.: +82-2-6299-2646 (S.K.); +82-2-6299-1402 (J.-W.C.)
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Predictors of mortality, limb loss, and discharge disposition at admission among patients with necrotizing skin and soft tissue infections. J Trauma Acute Care Surg 2020; 89:186-191. [PMID: 32102045 DOI: 10.1097/ta.0000000000002636] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Necrotizing soft tissue infections (NSTI) represent a heterogeneous group of rapidly progressive skin and soft tissue infections associated with significant morbidity and mortality. Efforts to identify factors associated with death have produced mixed results, and little or no data is available for other adverse outcomes. We sought to determine whether admission variables were associated with mortality, limb loss, and discharge disposition in patients with NSTI. METHODS We analyzed prospectively collected data of adult patients with surgically confirmed NSTI from an NSTI registry maintained at a quaternary referral center. Factors independently associated with mortality, amputation, and skilled nursing facility discharge were identified using logistic regression. RESULTS Between 2015 and 2018, 446 patients were identified. The median age was 55 years (interquartile range, 43-62). The majority of patients were male (65%), white (77%), and transferred from another facility (90%). The perineum was most commonly involved (37%), followed by the lower extremity (34%). The median number of operative debridements was 3 (interquartile range, 2-4). Overall mortality was 15%, and 21% of extremity NSTI patients required amputation. Age greater than 60 years; creatinine greater than 2 mg/dL; white blood cell count greater than 30 x 10^ /μl, platelets less than 150 × 10/μL, and clostridial involvement were independently associated with greater odds of death; perineal involvement was associated with lower odds of death. Age greater than 60 years; sex, male; nonwhite race; diabetes; chronic wound as etiology; leg involvement; transfer status; and sodium, less than 130 mEq/L were independently associated with amputation. Age greater than 60 years; sex, female; nonwhite race; perineal involvement; and amputation were associated with skilled care facility discharge. CONCLUSION Necrotizing soft tissue infections are a heterogeneous group of infections involving significantly different patient populations with different outcomes; efforts to differentiate and predict adverse outcomes in NSTI should include laboratory data, comorbidities, infection site, and/or etiology to improve predictions and better account for this heterogeneity. LEVEL OF EVIDENCE Prognostic, Level III.
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May AK, Talisa VB, Wilfret DA, Bulger E, Dankner W, Bernard A, Yende S. Estimating the Impact of Necrotizing Soft Tissue Infections in the United States: Incidence and Re-Admissions. Surg Infect (Larchmt) 2020; 22:509-515. [PMID: 32833599 DOI: 10.1089/sur.2020.099] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: Previous estimates of the incidence of necrotizing soft tissue infections (NSTI) in the United States have substantial limitations and underestimate its occurrence. Improvements in hospital mortality after NSTI have increased the number of survivors at risk for long-term sequelae. This study estimates the incidence of NSTI and the burden of re-admission and associated healthcare spending in patients who survived admission for NSTI. Methods: Index admissions for NSTI were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes combined with either Current Procedural Technology (CPT) or diagnosis-related group codes to increase specificity. Two separate datasets were used to provide primary and secondary estimates of the annual incidence of NSTIs in the United States: the National Inpatient Sample (NIS) for the years 2012-2016 and the Watson Health dataset for 2009-2013, respectively, and extrapolated to estimate the incidence for 2018. The Nationwide Readmissions Database (NRD) from 2013-2015 was used to estimate of the risk for re-admission, cost of re-admissions, and to compare 90-day re-admission rates for NSTI to common medical conditions. Results: National Inpatient Sample and Watson Health datasets demonstrated an increasing annual incidence and estimated 33,600 and 28,500 cases in 2018, respectively. The estimated annual incidences in the United States in 2018 were 10.3 and 8.7 per 100,000 persons, respectively. Risk of 90-day re-admission ranged from 24%-29% over the 3 years, 89% of which were unplanned. Of those re-admitted, 90% had one or more comorbidities, the most common diagnoses associated with re-admission were infection in 65%, acute kidney injury in 22%, and shock in 10%. The median re-admission length of stay was seven days (interquartile range [IQR]: 4-13 days) with a median cost of re-admission of $13,590 (IQR: $7186-$27440). Conclusion: The incidence of NSTI is more common than generally reported. Re-admission within 90 days is common, occurring in more than one in four survivors resulting in high healthcare costs.
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Affiliation(s)
- Addison K May
- Carolinas Medical Center, Atrium Health, Charlotte, North Carolina, USA
| | - Victor B Talisa
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center and Department of Critical Care Medicine, University of Pittsburgh, Pennsylvania, USA
| | | | - Eileen Bulger
- University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | | | - Andrew Bernard
- Department of Surgery, University of Kentucky, Lexington, Kentucky, USA
| | - Sachin Yende
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center and Department of Critical Care Medicine, University of Pittsburgh, Pennsylvania, USA
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Guevel LH, Shifrin MM. Necrotizing Fasciitis in the Adult Patient: Implications for Nurse Practitioners. J Nurse Pract 2020. [DOI: 10.1016/j.nurpra.2020.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Nawijn F, Smeeing DPJ, Houwert RM, Leenen LPH, Hietbrink F. Time is of the essence when treating necrotizing soft tissue infections: a systematic review and meta-analysis. World J Emerg Surg 2020; 15:4. [PMID: 31921330 PMCID: PMC6950871 DOI: 10.1186/s13017-019-0286-6] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 12/24/2019] [Indexed: 12/18/2022] Open
Abstract
Background Although the phrase “time is fascia” is well acknowledged in the case of necrotizing soft tissue infections (NSTIs), solid evidence is lacking. The aim of this study is to review the current literature concerning the timing of surgery in relation to mortality and amputation in patients with NSTIs. Methods A systematic search in PubMed/MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Controlled Register of Trials (CENTRAL) was performed. The primary outcomes were mortality and amputation. These outcomes were related to the following time-related variables: (1) time from onset symptoms to presentation; (2) time from onset symptoms to surgery; (3) time from presentation to surgery; (4) duration of the initial surgical procedure. For the meta-analysis, the effects were estimated using random-effects meta-analysis models. Result A total of 109 studies, with combined 6051 NSTI patients, were included. Of these 6051 NSTI patients, 1277 patients died (21.1%). A total of 33 studies, with combined 2123 NSTI patients, were included for quantitative analysis. Mortality was significantly lower for patients with surgery within 6 h after presentation compared to when treatment was delayed more than 6 h (OR 0.43; 95% CI 0.26–0.70; 10 studies included). Surgical treatment within 6 h resulted in a 19% mortality rate compared to 32% when surgical treatment was delayed over 6 h. Also, surgery within 12 h reduced the mortality compared to surgery after 12 h from presentation (OR 0.41; 95% CI 0.27–0.61; 16 studies included). Patient delay (time from onset of symptoms to presentation or surgery) did not significantly affect the mortality in this study. None of the time-related variables assessed significantly reduced the amputation rate. Three studies reported on the duration of the first surgery. They reported a mean operating time of 78, 81, and 102 min with associated mortality rates of 4, 11.4, and 60%, respectively. Conclusion Average mortality rates reported remained constant (around 20%) over the past 20 years. Early surgical debridement lowers the mortality rate for NSTI with almost 50%. Thus, a sense of urgency is essential in the treatment of NSTI.
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Affiliation(s)
- Femke Nawijn
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Diederik P J Smeeing
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Roderick M Houwert
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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Howell EC, Keeley JA, Woods AL, Kaji AH, Deane MR, Kim DY, Neville AL. Wound Culture Utility in Negative Surgical Exploration for Necrotizing Soft Tissue Infection. Am Surg 2019. [DOI: 10.1177/000313481908501022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Early surgical intervention decreases mortality in necrotizing soft tissue infections (NSTIs). Yet, a subset of patients will not have NSTIs (non-NSTIs) at the time of exploration. We hypothesized that NSTI and non-NSTI patients had similar causative organisms and that intraoperative wound cultures could help guide management. Culture results and outcomes were compared for all patients undergoing surgery for suspected NSTIs over a seven-year-period. Of 295 patients, 240 (81.4%) had NSTIs. Of the 55 non-NSTI patients (18.6%), 50 had cellulitis and 5 had abscesses. NSTI and non-NSTI patients had similar rates of bacteremia (20.4% vs 17.6%, P = 0.66), septic shock (15.9% vs 12.7%, P = 0.68), and mortality (10.4% vs 7.2%, P = 0.62). Wound cultures were collected more often in NSTI patients (229/240, 95.4%) than in non-NSTI patients (42/55, 76.4%, P < 0.01). Non-NSTI patients had positive deep wound cultures more than half of the time (23/42, 54.8%). The microbiologic profile was similar between groups, with Methicillin Resistant Staphylococcus aureus and Group A Streptococcus occurring with the same frequency. We advocate for deep wound cultures in all patients being evaluated operatively for NSTIs even if the exploration is considered negative because these patients have similar clinical characteristics and virulent microbiology, and culture results can help guide antimicrobial therapy.
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Affiliation(s)
- Erin C. Howell
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
| | | | - Alexis L. Woods
- David Geffen School of Medicine at UCLA, Los Angeles, California; and
| | - Amy H. Kaji
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Molly R. Deane
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Dennis Y. Kim
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Angela L. Neville
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
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Tong KS, Williams DC, Seifman MA, Hunter-Smith DJ, Rozen WM. Synchronous multifocal necrotizing soft tissue infections: a case report and literature review. EUROPEAN JOURNAL OF PLASTIC SURGERY 2019. [DOI: 10.1007/s00238-019-1503-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Schuster K, Davis K, Hernandez M, Holena D, Salim A, Crandall M. American Association for the Surgery of Trauma emergency general surgery guidelines gap analysis. J Trauma Acute Care Surg 2019; 86:909-915. [PMID: 30768554 DOI: 10.1097/ta.0000000000002226] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Emergency general surgery (EGS) has been rapidly adopted as one of the major components of acute care surgery. Although heterogenous, the most common disease states that comprise EGS often have published guidelines containing recommendations for their diagnosis and management. Not all diseases included within EGS however have published guidelines and existing guidelines may have important gaps in their recommendations. We present a thorough assessment of the existing guidelines for the most common EGS diseases and highlight gaps that will require additional literature review or new research to fill. METHODS Literature searches for existing comprehensive guidelines were performed. These guidelines were summarized based on level of supporting evidence and further subcategorized based on American Association for the Surgery of Trauma (AAST) grade of disease. Using these summaries, gaps in the exiting recommendations were then generated and refined through review by at least two authors. RESULTS The initial gap analysis focused on diverticulitis, acute pancreatitis, small bowel obstruction and acute cholecystitis. Despite extensive research into each of these disease processes, critical questions regarding diagnosis and management remain to be answered. Gaps were the result of either low quality research or a complete lack of research. The use of the AAST grade of disease established a framework for evaluating these guidelines and grouping the recommendations. CONCLUSIONS Despite extensive prior research, EGS diseases have multiple areas where additional research would likely result in improved patient care. Consensus on the most important areas for additional research can be obtained through analysis of gaps in existing guidelines. This gap analysis has the potential to inform efforts around developing a research agenda for EGS.
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Affiliation(s)
- Kevin Schuster
- From the Department of Surgery (K.S.), Department of Surgery (K.D.), Yale School of Medicine, New Haven, Connecticut; Department of Surgery (M.H.), Mayo Medical Center, Rochester, Minnesota; Department of Surgery (D.H.), University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (M.C.), Brigham and Women's Hospital, Boston, Massachusetts
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Howell EC, Keeley JA, Kaji AH, Deane MR, Kim DY, Putnam B, Lee SL, Woods AL, Neville AL. Chance to cut: defining a negative exploration rate in patients with suspected necrotizing soft tissue infection. Trauma Surg Acute Care Open 2019; 4:e000264. [PMID: 30899795 PMCID: PMC6407535 DOI: 10.1136/tsaco-2018-000264] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Necrotizing soft tissue infections (NSTI) are aggressive infections associated with significant morbidity and mortality. Despite multiple predictive models for the identification of NSTI, a subset of patients will not have an NSTI at the time of surgical exploration. We hypothesized there is a subset of patients without NSTI who are clinically indistinguishable from those with NSTI. We aimed to characterize the differences between NSTI and non-NSTI patients and describe a negative exploration rate for this disease process. Methods We conducted a retrospective review of adult patients undergoing surgical exploration for suspected NSTI at our county-funded, academic-affiliated medical center between 2008 and 2015. Patients were identified as having NSTI or not (non-NSTI) based on surgical findings at the initial operation. Pathology reports were reviewed to confirm diagnosis. The NSTI and non-NSTI patients were compared using χ2 test, Fisher's exact test, and Wilcoxon rank-sum test as appropriate. A p value <0.05 was considered significant. Results Of 295 patients undergoing operation for suspected NSTI, 232 (79%) were diagnosed with NSTI at the initial operation and 63 (21%) were not. Of these 63 patients, 5 (7.9%) had an abscess and 58 (92%) had cellulitis resulting in a total of 237 patients (80%) with a surgical disease process. Patients with NSTI had higher white cell counts (18.5 vs. 14.9 k/mm3, p=0.02) and glucose levels (244 vs. 114 mg/dL, p<0.0001), but lower sodium values (130 vs. 134 mmol/L, p≤0.0001) and less violaceous skin changes (9.2% vs. 23.8%, p=0.004). Eight patients (14%) initially diagnosed with cellulitis had an NSTI diagnosed on return to the operating room for failure to improve. Conclusions Clinical differences between NSTI and non-NSTI patients are subtle. We found a 20% negative exploration rate for suspected NSTI. Close postoperative attention to this cohort is warranted as a small subset may progress. Level of evidence Retrospective cohort study, level III.
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Affiliation(s)
- Erin C Howell
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Jessica A Keeley
- Department of Surgery, University of California, San Francisco East Bay, Oakland, California, USA
| | - Amy H Kaji
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Molly R Deane
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Dennis Y Kim
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Brant Putnam
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Steven L Lee
- Division of Pediatric Surgery, UCLA Mattel Children's Hospital, Los Angeles, California, USA
| | - Alexis L Woods
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Angela L Neville
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California, USA
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