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Chiang KJ, Wang YT, Kang E, Wu YC, Huang CU, Lin XY, Tsai FC, Tsai CS, Chen YH, Wang FY, Chen C, Chiu WK, Wang HJ, Chang SC. Is Prompt Hyperbaric Oxygen Adjunctive Therapy Able to Reduce Mortality and Amputation in Management of Necrotizing Soft-Tissue Infection? Surg Infect (Larchmt) 2024. [PMID: 39052528 DOI: 10.1089/sur.2023.353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024] Open
Abstract
Background: Necrotizing soft-tissue infection (NSTI) is a rare and serious disease with high morbidity and mortality. Standard therapeutic concepts have included urgent surgical intervention, broad-spectrum antibiotic treatment, and intensive care. Hyperbaric oxygen therapy (HBOT) is used as adjuvant therapy in some centers, but its benefits remain controversial. Methods: A retrospective analysis was conducted in which 98 patients with a clinical diagnosis of NSTI were treated with standard treatments plus HBOT. The clinical outcomes were wound healing, performance status, hospital length, complication rate, recurrence rate, morbidity (amputation rate), and mortality. Primary or secondary outcomes were compared between the time interval of HBOT and the clinical outcomes. Results: The average times from diagnosis of NSTI to initial HBO treatment and from initial surgery to initial HBO treatment were both significantly longer in dead patients than in surviving patients (P = 0.031; P = 0.020). These two time intervals were both significantly longer in amputated patients than in preserved patients (P = 0.031; P = 0.037). Conclusions: Using combined treatment with early surgical debridement combined with HBOT, it is possible to reduce hospital stay, intensive care unit stay, number of debridements, improve complete wound healing rate, and lower amputation and mortality rates among patients with NSTI. The early onset of HBOT soon after diagnosis, especially during critical conditions, is proved to be associated with higher survival and preservation rates.
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Affiliation(s)
- Kuan-Ju Chiang
- Division of General Medicine, Department of Medical Education, Shuang-Ho Hospital, New Taipei City, Taiwan
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Plastic Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yi-Ting Wang
- Division of General Medicine, Department of Medical Education, Shuang-Ho Hospital, New Taipei City, Taiwan
| | - Enoch Kang
- Evidence-Based Medicine Center, Wan Fang Hospital, Taipei Medical University, New Taipei City, Taiwan
- Institute of Health Policy & Management, College of Public Health, National Taiwan University, New Taipei City, Taiwan
| | - Yi-Chun Wu
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Plastic Surgery, Integrated Burn & Wound Care Center, Department of Surgery, Shuang-Ho Hospital, New Taipei City, Taiwan
- Department of Biomedical Engineering, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ching-Uen Huang
- Division of Plastic Surgery, Integrated Burn & Wound Care Center, Department of Surgery, Shuang-Ho Hospital, New Taipei City, Taiwan
| | - Xin-Yi Lin
- Division of Plastic Surgery, Integrated Burn & Wound Care Center, Department of Surgery, Shuang-Ho Hospital, New Taipei City, Taiwan
| | - Feng-Chou Tsai
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Plastic Surgery, Integrated Burn & Wound Care Center, Department of Surgery, Shuang-Ho Hospital, New Taipei City, Taiwan
| | - Ching-Sung Tsai
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Plastic Surgery, Integrated Burn & Wound Care Center, Department of Surgery, Shuang-Ho Hospital, New Taipei City, Taiwan
| | - Yu-Han Chen
- Division of Plastic Surgery, Integrated Burn & Wound Care Center, Department of Surgery, Shuang-Ho Hospital, New Taipei City, Taiwan
| | | | - Chiehfeng Chen
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Evidence-Based Medicine Center, Wan Fang Hospital, Taipei Medical University, New Taipei City, Taiwan
- Division of Plastic Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Wen-Kuan Chiu
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Plastic Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Hsian-Jenn Wang
- Division of Plastic Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Shun-Cheng Chang
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Plastic Surgery, Integrated Burn & Wound Care Center, Department of Surgery, Shuang-Ho Hospital, New Taipei City, Taiwan
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Devaney B. Equipoise: an important ethical consideration when contemplating participation in a randomised controlled trial of hyperbaric oxygen treatment in necrotising soft tissue infections. Diving Hyperb Med 2024; 54:57-60. [PMID: 38507910 PMCID: PMC11227961 DOI: 10.28920/dhm54.1.57-60] [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] [Received: 11/17/2023] [Accepted: 01/19/2024] [Indexed: 03/22/2024]
Abstract
A proposal for a large, multi-centre, randomised controlled trial investigating the role of hyperbaric oxygen treatment (HBOT) in necrotising soft tissue infections (NSTI) has led to much discussion locally and internationally about whether participation is ethical for a centre where stakeholders already consider HBOT standard practice. This article systematically addresses the concept of clinical equipoise specific to the role of HBOT in NSTI, and presents a series of considerations to be taken into account by key stakeholders at potential participating sites.
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Affiliation(s)
- Bridget Devaney
- Emergency and Trauma Centre, Alfred Health, Melbourne, Australia
- Department of Intensive Care and Hyperbaric Medicine, Alfred Health, Melbourne, Australia
- Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia
- Corresponding author: Dr Bridget Devaney, Head of Hyperbaric Medicine, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia,
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Wackett J, Devaney B, Chau R, Ho J, King N, Grewal J, Armstrong J, Mitra B. Reported outcome measures in necrotising soft tissue infections: a systematic review. Diving Hyperb Med 2024; 54:47-56. [PMID: 38507909 PMCID: PMC11371474 DOI: 10.28920/dhm54.1.47-56] [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] [Received: 11/10/2023] [Accepted: 01/01/2024] [Indexed: 03/22/2024]
Abstract
Introduction There are inconsistencies in outcome reporting for patients with necrotising soft tissue infections (NSTI). The aim of this study was to evaluate reported outcome measures in NSTI literature that could inform a core outcome set (COS) such as could be used in a study of hyperbaric oxygen in this indication. Methods A systematic review of all NSTI literature identified from Cochrane, Ovid MEDLINE and Scopus databases as well as grey literature sources OpenGrey and the New York Academy of Medicine databases which met inclusion criteria and were published between 2010 and 2020 was performed. Studies were included if they reported on > 5 cases and presented clinical endpoints, patient related outcomes, or resource utilisation in NSTI patients. Studies did not have to include intervention. Two independent researchers then extracted reported outcome measures. Similar outcomes were grouped and classified into domains to produce a structured inventory. An attempt was made to identify trends in outcome measures over time and by study design. Results Three hundred and seventy-five studies were identified and included a total of 311 outcome measures. Forty eight percent (150/311) of outcome measures were reported by two or more studies. The four most frequently reported outcome measures were mortality without time specified, length of hospital stay, amputation performed, and number of debridements, reported in 298 (79.5%), 260 (69.3%), 156 (41.6%) and 151 (40.3%) studies respectively. Mortality outcomes were reported in 23 different ways. Randomised controlled trials (RCTs) were more likely to report 28-day mortality or 90-day mortality. The second most frequent amputation related outcome was level of amputation, reported in 7.5% (28/375) of studies. The most commonly reported patient-centred outcome was the SF-36 which was reported in 1.6% (6/375) of all studies and in 2/10 RCTs. Conclusions There was wide variance in outcome measures in NSTI studies, further highlighting the need for a COS.
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Affiliation(s)
| | - Bridget Devaney
- Emergency and Trauma Centre, Alfred Health, Melbourne, Australia
- Department of Intensive Care and Hyperbaric Medicine, Alfred Health, Melbourne, Australia
- Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia
- Corresponding author: Dr Bridget Devaney, Head of Hyperbaric Medicine, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia,
| | | | | | | | - Jasleen Grewal
- Department of Medicine, Alfred Health, Melbourne, Australia
| | | | - Biswadev Mitra
- Emergency and Trauma Centre, Alfred Health, Melbourne, Australia
- Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia
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Vanguardia MKR, Lew C, Prabhakaran S, Kong JCH. Fournier's gangrene: 15-year retrospective study at a tertiary hospital. BJS Open 2024; 8:zrae022. [PMID: 38626185 PMCID: PMC11020226 DOI: 10.1093/bjsopen/zrae022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 12/23/2023] [Accepted: 01/29/2024] [Indexed: 04/18/2024] Open
Affiliation(s)
- Maria Kristina Rey Vanguardia
- Department of General Surgery, The Alfred Hospital, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Chen Lew
- Department of General Surgery, The Alfred Hospital, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Swetha Prabhakaran
- Department of General Surgery, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Joseph C H Kong
- Department of General Surgery, The Alfred Hospital, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
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Serafio-Gómez JL, Bustillos-Ponce M, Almeida-Muñoz DE, Parra-Hernández JA, Pompa-Díaz JC. Unbridled Threat of Gas Gangrene in a Patient With Uncontrolled Diabetes Mellitus: A Compelling Case Report of Clostridium perfringens Infection. Cureus 2023; 15:e50614. [PMID: 38111817 PMCID: PMC10726074 DOI: 10.7759/cureus.50614] [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] [Accepted: 12/16/2023] [Indexed: 12/20/2023] Open
Abstract
Clostridium perfringens, a Gram-positive anaerobic bacterium, is well-known for its association with gas gangrene, a severe and rapidly progressing infection characterized by tissue gas production and necrosis. In this case report, we present the instance of a 64-year-old male with poorly controlled diabetes mellitus who developed a C. perfringens-related infection following a traumatic foot wound. The report emphasizes the critical significance of early diagnosis and aggressive treatment in C. perfringens infections, particularly in patients with underlying risk factors. Detailed accounts of clinical findings, laboratory results, computed tomography, and surgical interventions are provided. A multidisciplinary approach proved essential for successful management. The inherent scholarly value of this case is substantiated by its meticulous documentation of the clinical trajectory, diagnostic modalities, and treatment modalities employed. The intricate collaboration across diverse medical disciplines, the uncommon manifestation of the infection following a traumatic foot wound, and the favorable outcome achieved through prompt and multidisciplinary intervention collectively contribute to the exceptional nature and didactic significance of this case. The dissemination of such clinical experiences assumes paramount importance in advancing medical scholarship, cultivating awareness, and engendering a profound comprehension of the complexities associated with C. perfringens infections, thereby enriching the wider scientific and medical community.
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Affiliation(s)
- José Luis Serafio-Gómez
- General Surgery, Chihuahua City General Hospital "Dr. Salvador Zubirán Anchondo", Chihuahua, MEX
| | - Melanie Bustillos-Ponce
- General Surgery, Chihuahua City General Hospital "Dr. Salvador Zubirán Anchondo", Chihuahua, MEX
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Kjellberg A, Douglas J, Hassler A, Al-Ezerjawi S, Boström E, Abdel-Halim L, Liwenborg L, Hetting E, Jonasdottir Njåstad AD, Kowalski J, Catrina SB, Rodriguez-Wallberg KA, Lindholm P. COVID-19-Induced Acute Respiratory Distress Syndrome Treated with Hyperbaric Oxygen: Interim Safety Report from a Randomized Clinical Trial (COVID-19-HBO). J Clin Med 2023; 12:4850. [PMID: 37510965 PMCID: PMC10381696 DOI: 10.3390/jcm12144850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 07/16/2023] [Accepted: 07/16/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND A few prospective trials and case series have suggested that hyperbaric oxygen therapy (HBOT) may be efficacious for the treatment of severe COVID-19, but safety is a concern for critically ill patients. We present an interim analysis of the safety of HBOT via a randomized controlled trial (COVID-19-HBO). METHODS A randomized controlled, open-label, clinical trial was conducted in compliance with good clinical practice to explore the safety and efficacy of HBOT for severe COVID-19 in critically ill patients with moderate acute respiratory distress syndrome (ARDS). Between 3 June 2020, and 17 May 2021, 31 patients with severe COVID-19 and moderate-to-severe ARDS, a ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) < 26.7 kPa (200 mmHg), and at least two defined risk factors for intensive care unit (ICU) admission and/or mortality were enrolled in the trial and randomized 1:1 to best practice, or HBOT in addition to best practice. The subjects allocated to HBOT received a maximum of five treatments at 2.4 atmospheres absolute (ATA) for 80 min over seven days. The subjects were followed up for 30 days. The safety endpoints were analyzed. RESULTS Adverse events (AEs) were common. Hypoxia was the most common adverse event reported. There was no statistically significant difference between the groups. Numerically, serious adverse events (SAEs) and barotrauma were more frequent in the control group, and the differences between groups were in favor of the HBOT in PaO2/FiO2 (PFI) and the national early warning score (NEWS); statistically, however, the differences were not significant at day 7, and no difference was observed for the total oxygen burden and cumulative pulmonary oxygen toxicity dose (CPTD). CONCLUSION HBOT appears to be safe as an intervention for critically ill patients with moderate-to-severe ARDS induced by COVID-19. CLINICAL TRIAL REGISTRATION NCT04327505 (31 March 2020) and EudraCT 2020-001349-37 (24 April 2020).
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Affiliation(s)
- Anders Kjellberg
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 77 Stockholm, Sweden
- Perioperative Medicine and Intensive Care Medicine, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Johan Douglas
- Department of Anaesthesia and Intensive Care, Blekingesjukhuset, 371 85 Karlskrona, Sweden
| | - Adrian Hassler
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 77 Stockholm, Sweden
- Acute and Reparative Medicine, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Sarah Al-Ezerjawi
- Acute and Reparative Medicine, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Emil Boström
- Acute and Reparative Medicine, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Lina Abdel-Halim
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Lovisa Liwenborg
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Eric Hetting
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 77 Stockholm, Sweden
| | | | | | - Sergiu-Bogdan Catrina
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76 Stockholm, Sweden
- Academic Specialist Center, Center for Diabetes, 113 65 Stockholm, Sweden
| | - Kenny A Rodriguez-Wallberg
- Department of Oncology and Pathology, Karolinska Institutet, 171 64 Stockholm, Sweden
- Department of Reproductive Medicine, Division of Gynaecology and Reproduction, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Peter Lindholm
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 77 Stockholm, Sweden
- Department of Emergency Medicine, Division of Hyperbaric Medicine, University of California San Diego, La Jolla, CA 92093, USA
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Vittetoe KL, Johnson SR, Benvenuti TA, Schoenecker JG, Moore‐Lotridge SN, Rohde SL. Head and Neck Necrotizing Fasciitis: Abbreviated SOFA Score Associated With Death and Infection Spread. OTO Open 2023; 7:e68. [PMID: 37565057 PMCID: PMC10410339 DOI: 10.1002/oto2.68] [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: 02/17/2023] [Revised: 06/22/2023] [Accepted: 07/14/2023] [Indexed: 08/12/2023] Open
Abstract
Objective Describe features unique to head and neck (H&N) necrotizing fasciitis (NF) compared to other anatomic regions and specify a prognostic score associated with death and descending necrotizing mediastinitis (DNM). Study Design Retrospective cohort. Setting Tertiary care, level 1 trauma center. Methods A single-institution database identified 399 confirmed cases of NF between 2006 and 2021, 33 of which involved the H&N. Patients with confirmed H&N NF were sorted into cohorts based on clinical outcomes, with the "poor" outcomes group defined by death and/or DNM. Results Thirty-three patients with H&N NF were included. Compared to NF of other regions, patients with H&N NF had a significantly lower mortality rate (6.06% vs 20.8%, p = .041) and significantly lower rates of obesity (27.3% vs 63.7%, p < .001) and hypertension (42.4% vs 60.9%, p = .038). Within the H&N group, there were 2 deaths (6.06%) and 8 cases of DNM (24.2%). Diabetes was associated with poor outcomes (p = .047), as was an abbreviated sequential organ failure assessment score for necrotizing fasciitis (nfSOFA) of 2 or greater (p = .015). Conclusion H&N NF is unique among other forms of NF, with a lower mortality rate and lower rates of obesity and hypertension in affected patients. Within the H&N cohort, worse outcomes were associated with diabetes as well as a nfSOFA score of 2 or greater. Timely surgical debridement alongside broad-spectrum antibiotics remains the mainstay of treatment for NF; however, this simple prognostic score may play a role during the early stages of care for patients with H&N NF.
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Affiliation(s)
- Kelly L. Vittetoe
- Department of OtolaryngologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | | | - Teresa A. Benvenuti
- Department of OrthopaedicsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Jonathan G. Schoenecker
- Department of OrthopaedicsVanderbilt University Medical CenterNashvilleTennesseeUSA
- Department of PharmacologyVanderbilt UniversityNashvilleTennesseeUSA
- Department of Pathology, Microbiology, and ImmunologyVanderbilt University Medical CenterNashvilleTennesseeUSA
- Division of Pediatric OrthopaedicsMonroe Carell Jr. Children's HospitalNashvilleTennesseeUSA
- Vanderbilt Center for Bone BiologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Stephanie N. Moore‐Lotridge
- Department of OrthopaedicsVanderbilt University Medical CenterNashvilleTennesseeUSA
- Division of Pediatric OrthopaedicsMonroe Carell Jr. Children's HospitalNashvilleTennesseeUSA
- Vanderbilt Center for Bone BiologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Sarah L. Rohde
- Department of OtolaryngologyVanderbilt University Medical CenterNashvilleTennesseeUSA
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Huang C, Zhong Y, Yue C, He B, Li Y, Li J. The effect of hyperbaric oxygen therapy on the clinical outcomes of necrotizing soft tissue infections: a systematic review and meta-analysis. World J Emerg Surg 2023; 18:23. [PMID: 36966323 PMCID: PMC10040118 DOI: 10.1186/s13017-023-00490-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 03/15/2023] [Indexed: 03/27/2023] Open
Abstract
BACKGROUND To determine the efficacy of hyperbaric oxygen therapy (HBO) in the treatment of necrotizing soft tissue infections (NSTI), we conducted a meta-analysis of the available evidence. METHODS Data sources were PubMed, Embase, Web of Science, Cochrane Library, and reference lists. The study included observational trials that compared HBO with non-HBO, or standard care. The primary outcome was the mortality rate. Secondary outcomes were the number of debridement, amputation rate and complication rate. Relative risks or standardized mean differences with 95% confidence intervals were calculated for dichotomous and continuous outcomes, respectively. RESULTS A total of retrospective cohort and case-control studies were included, including 49,152 patients, 1448 who received HBO and 47,704 in control. The mortality rate in the HBO group was significantly lower than that in the non-HBO group [RR = 0.522, 95% CI (0.403, 0.677), p < 0.05]. However, the number of debridements performed in the HBO group was higher than in the non-HBO group [SMD = 0.611, 95% CI (0.012, 1.211), p < 0.05]. There was no significant difference in amputation rates between the two groups [RR = 0.836, 95% CI (0.619, 1.129), p > 0.05]. In terms of complications, the incidence of MODS was lower in the HBO group than in the non-HBO group [RR = 0.205, 95% CI (0.164, 0.256), p < 0.05]. There was no significant difference in the incidence of other complications, such as sepsis, shock, myocardial infarction, pulmonary embolism, and pneumonia, between the two groups (p > 0.05). CONCLUSION The current evidence suggests that the use of HBO in the treatment of NSTI can significantly reduce the mortality rates and the incidence rates of complications. However, due to the retrospective nature of the studies, the evidence is weak, and further research is needed to establish its efficacy. It is also important to note that HBO is not available in all hospitals, and its use should be carefully considered based on the patient's individual circumstances. Additionally, it is still worthwhile to stress the significance of promptly evaluating surgical risks to prevent missing the optimal treatment time.
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Affiliation(s)
- Chengzi Huang
- Department of Anorectum, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yilian Zhong
- Department of Anorectum, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Chaochi Yue
- Department of Anorectum, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Bin He
- Department of Anorectum, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yaling Li
- Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, Luzhou, China.
| | - Jun Li
- Department of Anorectum, The Affiliated Hospital of Southwest Medical University, Luzhou, China.
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Hedetoft M, Madsen MB, Hyldegaard O. Hyperbaric oxygen treatment in the management of necrotising soft-tissue infections: results from a Danish nationwide registry study. BMJ Open 2023; 13:e066117. [PMID: 36813488 PMCID: PMC9950903 DOI: 10.1136/bmjopen-2022-066117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 02/07/2023] [Indexed: 02/24/2023] Open
Abstract
OBJECTIVES Application of hyperbaric oxygen (HBO2) treatment in the multidisciplinary setting of necrotising soft-tissue infection (NSTI) is debated as a considerable number of studies are of low quality with marked prognostication bias due to inadequately addressing disease severity. The objective of this study was to associate HBO2 treatment with mortality in patients with NSTI including disease severity as a prognostic variable. DESIGN Nationwide population-based register study. SETTING Denmark. PARTICIPANTS Danish residents with NSTI patients between January 2011 and June 2016. PRIMARY AND SECONDARY OUTCOME MEASURES Thirty-day mortality was compared between patients receiving and patients not receiving HBO2 treatment using inverse probability of treatment weighting and propensity-score matching with predetermined variables (age, sex and weighted Charlson comorbidity score, presence of septic shock and Simplified Acute Physiology Score II (SAPS II)). RESULTS A total of 671 NSTI patients were included with a median age of 63 (52-71), 61% male sex, 30% had septic shock and a median SAPS II of 46 (34-58). Patients who received HBO2 treatment (n=266) were younger and had lower SAPS II, but a larger fraction had septic shock compared with patients not receiving HBO2 treatment. Overall, all-cause 30-day mortality was 19% (95% CI 17% to 23%). The statistical models were in general acceptably balanced with covariates reaching <0.1 absolute standardised mean differences and patients receiving HBO2 treatment were associated with lower 30-day mortality (OR 0.40, 95% CI 0.30 to 0.53, p<0.001). CONCLUSIONS In analyses using inverse probability of treatment weighting and propensity score analysis, patients treated with HBO2 treatment were associated with improved 30-day survival.
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Affiliation(s)
- Morten Hedetoft
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Martin Bruun Madsen
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ole Hyldegaard
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Vinkel J, Rib L, Buil A, Hedetoft M, Hyldegaard O. Investigating the Effects of Hyperbaric Oxygen Treatment in Necrotizing Soft Tissue Infection With Transcriptomics and Machine Learning (the HBOmic Study): Protocol for a Prospective Cohort Study With Data Validation. JMIR Res Protoc 2022; 11:e39252. [PMID: 36427229 PMCID: PMC9736759 DOI: 10.2196/39252] [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: 05/06/2022] [Accepted: 10/20/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Necrotizing soft tissue infections (NSTIs) are complex multifactorial diseases characterized by rapid bacterial proliferation and progressive tissue death. Treatment is multidisciplinary, including surgery, broad-spectrum antibiotics, and intensive care; adjunctive treatment with hyperbaric oxygen (HBO2) may also be applied. Recent advances in molecular technology and biological computation have given rise to new approaches to infectious diseases based on identifying target groups defined by activated pathophysiological mechanisms. OBJECTIVE We aim to capture NSTI disease signatures and mechanisms and responses to treatment in patients that receive the highest standard of care; therefore, we set out to investigate genome-wide transcriptional responses to HBO2 treatment during NSTI in the host and bacteria. METHODS The Effects of Hyperbaric Oxygen Treatment Studied with Omics (HBOmic) study is a prospective cohort study including 95 patients admitted for NSTI at the intensive care unit of Copenhagen University Hospital (Rigshospitalet), Denmark, between January 2013 and June 2017. All participants were treated according to a local protocol for management of NSTI, and biological samples were obtained and stored according to a standard operational procedure. In the proposed study, we will generate genome-wide expression profiles of whole-blood samples and samples of infected tissue taken before and after HBO2 treatment administered during the initial acute phase of infection, and we will analyze the profiles with unsupervised hierarchical clustering and machine learning. Differential gene expression will be compared in samples taken before and after HBO2 treatment (N=85), and integration of profiles from blood and tissue samples will be performed. Furthermore, findings will be compared to NSTI patients who did not receive HBO2 treatment (N=10). Transcriptomic data will be integrated with clinical data to investigate associations and predictors. RESULTS The first participant was enrolled on July 27, 2021, and data analysis is expected to begin during autumn 2022, with publication of results immediately thereafter. CONCLUSIONS The HBOmic study will provide new insights into personalized patient management in NSTIs. TRIAL REGISTRATION ClinicalTrials.gov NCT01790698; https://clinicaltrials.gov/ct2/show/NCT01790698. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/39252.
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Affiliation(s)
- Julie Vinkel
- Department of Anaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Leonor Rib
- Biotech Research and Innovation Centre, University of Copenhagen, Copenhagen, Denmark
| | - Alfonso Buil
- Institute for Biological Psychiatry, Center of Psychiatry Sankt Hans, Roskilde, Denmark
| | - Morten Hedetoft
- Department of Anaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Ole Hyldegaard
- Department of Anaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Sethuraman KN, Smolin R, Henry S. Is There a Place for Hyperbaric Oxygen Therapy? Adv Surg 2022; 56:169-204. [PMID: 36096567 DOI: 10.1016/j.yasu.2022.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Hyperbaric oxygen therapy (HBOT) involves treating patients by providing 100% oxygen through inhalation while inside a treatment pressurized chamber. The oxygen acts as a drug and the hyperbaric chamber as the dosing device. The effect of hyperbaric hyperoxia is dose dependent and, therefore, treatment depth and duration are important when considering its use. HBOT can either be the primary method of treatment or used adjunctively to medications or surgical techniques. The underpinning physiology is to bring oxygen-rich plasma to hypoxic tissue, preventing reperfusion injury, strengthening immune responsiveness, and encouraging new collagen deposition as well as endothelial cell formation.
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Affiliation(s)
- Kinjal N Sethuraman
- University of Maryland Medical Center, Hyperbaric and Dive Medicine, 22 South Greene Street, Baltimore, MD 2120, USA
| | - Ryan Smolin
- University of Maryland School of Medicine, 685 West Baltimore Street, Suite 150, Baltimore, MD 21201, USA
| | - Sharon Henry
- University of Maryland Medical Center, R A Cowley Shock Trauma Center, Room T1R59, 22 South Greene Street, Baltimore, MD 21201, USA.
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12
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Indications for Emergent Hyperbaric Oxygen Therapy. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2022. [DOI: 10.1007/s40138-022-00251-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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13
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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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14
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Huang NC, Wu YL, Chao RF. Visualization and Bibliometric Analysis of Research Trends on Hyperbaric Oxygen Therapy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19137866. [PMID: 35805526 PMCID: PMC9265454 DOI: 10.3390/ijerph19137866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/24/2022] [Accepted: 06/24/2022] [Indexed: 11/24/2022]
Abstract
Hyperbaric oxygen therapy (HBOT) is a professional medical regimen with a wide range of clinical applications in various research fields. In addition to treating diving decompression sickness and air embolism, HBOT is used as an adjuvant in the management of various diseases. A large number of studies have been published to confirm its efficacy. Although HBOT has been clinically applied to the treatment of many diseases, the effectiveness of these treatments remains controversial. Exploring and evaluating HBOT will contribute to the future development of research in this field. Through a quantitative analysis of the literature, this paper explores the citation relevance and collaboration map and their impact on research outcomes. This study used bibliometric and cartographic techniques with VOSviewer to identify the most influential countries and scholars using this treatment, based on syndrome differentiation. It also provides continuous quality evaluation and lean management of the medical expenses associated with HBOT.
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Affiliation(s)
- Nan-Chieh Huang
- Department of Information Engineering, I-Shou University, Kaohsiung City 84001, Taiwan;
- Division of Family Medicine, Zuoying Branch of Kaohsiung Armed Forces General Hospital, Kaohsiung City 813204, Taiwan
| | - Yu-Lung Wu
- Department of Information Management, I-Shou University, Kaohsiung City 84001, Taiwan;
| | - Ren-Fang Chao
- Department of Leisure Management, I-Shou University, Kaohsiung City 84001, Taiwan
- Correspondence:
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15
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Abstract
Clostridium perfringens, a prevalent Gram-positive bacterium, causes necrotic diseases associated with abundant life loss and economic burdens of billions of USD. The mechanism of C. perfringens-induced necrotic diseases remains largely unknown, in part, because of the lack of effective animal models and the presence of a large array of exotoxins and diverse disease manifestations from the skin and deep tissues to the gastrointestinal tract. In the light of the advancement of medical and veterinary research, a large body of knowledge is accumulating on the factors influencing C. perfringens-induced necrotic disease onset, development, and outcomes. Here, we present an overview of the key virulence factors of C. perfringens exotoxins. Subsequently, we focus on comprehensively reviewing C. perfringens-induced necrotic diseases such as myonecrosis, acute watery diarrhea, enteritis necroticans, preterm infant necrotizing enterocolitis, and chicken necrotic enteritis. We then review the current understanding on the mechanisms of myonecrosis and enteritis in relation to the immune system and intestinal microbiome. Based on these discussions, we then review current preventions and treatments of the necrotic diseases and propose potential new intervention options. The purpose of this review is to provide an updated and comprehensive knowledge on the role of the host–microbe interaction to develop new interventions against C. perfringens-induced necrotic diseases.
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16
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Stieferman AE, Mazi P, Burnham JP. Severe Skin and Soft-Tissue Infections. Semin Respir Crit Care Med 2022; 43:3-9. [PMID: 35172354 DOI: 10.1055/s-0041-1740974] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Skin and soft-tissue infections (SSTIs) are a common reason for hospital admission. Severe SSTIs, particularly necrotizing infections, often require intensive care. Source control (often with surgical debridement) and broad-spectrum antimicrobials are paramount for minimizing significant morbidity and mortality. Rapid diagnostic tests may help in selection and de-escalation of antimicrobials for SSTIs. Besides early source control and early effective antimicrobial therapy, other patient-level factors such as comorbidities and immune status play a role in clinical outcomes. Intravenous immunoglobulin continues to be studied for severe SSTI, though recruitment in trials continues to be an issue. Severe SSTIs are complex to manage, due in part to regional variation in predominant pathogens and antimicrobial resistance patterns, as well as variations in host immune responses. This review includes descriptions of source control, antimicrobial therapies, intravenous immunoglobulin, and hyperbaric oxygen therapy, as well as host factors in severe SSTIs.
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Affiliation(s)
- Addison E Stieferman
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Patrick Mazi
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri
| | - Jason P Burnham
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri
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17
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Abstract
Necrotizing soft tissue infections of the perineum are rapidly progressing infections associated with significant morbidity and mortality. Prompt diagnosis and management with early surgical debridement is necessary to improve survival from this deadly disease. Repeat debridements are not uncommon. Important adjuncts to surgery include broad-spectrum antibiotics and management in an intensive care unit, as patients frequently develop multisystem organ failure. Once the acute phase is managed, fecal diversion with either an ostomy or fecal management catheter can be considered to decrease soiling of the wound and facilitate healing. Long-term management requires meticulous wound care, often with the assistance of negative pressure wound therapy. Patients may ultimately require skin grafts or tissue flaps for soft tissue coverage following extensive surgical debridements.
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Affiliation(s)
- Bryan P. Kline
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Nimalan A. Jeganathan
- Division of Colon and Rectal Surgery, Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania,Address for correspondence Nimalan A. Jeganathan, MD Division of Colon and Rectal Surgery, Department of Surgery, The Pennsylvania State University, College of Medicine500 University Drive, Hershey, PA 17033-0850
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18
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Dienemann L, Betz T, Töpel I, Steinbauer M. Persönliche Wahrnehmung der CoV-2-Pandemie und reales Risiko einer nekrotisierenden Fasziitis. GEFÄSSCHIRURGIE 2022; 27:51-54. [PMID: 34975232 PMCID: PMC8713545 DOI: 10.1007/s00772-021-00830-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 09/15/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Lucas Dienemann
- Klinik für Gefäßchirurgie, Krankenhaus Barmherzige Brüder Regensburg, Prüfeninger Str. 86, 93049 Regensburg, Deutschland
| | - Thomas Betz
- Klinik für Gefäßchirurgie, Krankenhaus Barmherzige Brüder Regensburg, Prüfeninger Str. 86, 93049 Regensburg, Deutschland
| | - Ingolf Töpel
- Klinik für Gefäßchirurgie, Krankenhaus Barmherzige Brüder Regensburg, Prüfeninger Str. 86, 93049 Regensburg, Deutschland
| | - Markus Steinbauer
- Klinik für Gefäßchirurgie, Krankenhaus Barmherzige Brüder Regensburg, Prüfeninger Str. 86, 93049 Regensburg, Deutschland
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19
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Cracchiolo AN, Palma DM, Palmeri M, Tantillo D, Lo Bue R, Braconi A, Caramanna C, Solazzo L, Genco F, Mirto P. Hyperbaric oxygen therapy as adjuvant therapy for odontogenic necrotizing myositis: A case report. Clin Case Rep 2021; 9:e04726. [PMID: 34484762 PMCID: PMC8405431 DOI: 10.1002/ccr3.4726] [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: 04/14/2021] [Revised: 07/26/2021] [Accepted: 08/02/2021] [Indexed: 11/24/2022] Open
Abstract
In a young man affected by skin soft tissue infections complicated with myositis, the use of hyperbaric oxygen treatment as an adjuvant therapy to surgical debridement and antibiotic therapy could improve management and prognosis.
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Affiliation(s)
- Andrea N. Cracchiolo
- UOC Emergenza Urgenza 118 Servizio di Medicina IperbaricaARNAS Ospedale Civico Di Cristina BenfratelliPalermoItaly
| | - Daniela Maria Palma
- UOS Terapia Intensiva e Trauma Center ARNAS Ospedale Civico Di Cristina BenfratelliPalermoItaly
| | - Marco Palmeri
- UOC Emergenza Urgenza 118 Servizio di Medicina IperbaricaARNAS Ospedale Civico Di Cristina BenfratelliPalermoItaly
| | - Diego Tantillo
- UOC Emergenza Urgenza 118 Servizio di Medicina IperbaricaARNAS Ospedale Civico Di Cristina BenfratelliPalermoItaly
| | - Rosalia Lo Bue
- UOC Emergenza Urgenza 118 Servizio di Medicina IperbaricaARNAS Ospedale Civico Di Cristina BenfratelliPalermoItaly
| | - Andrea Braconi
- UOC Chirurgia Maxillo‐Faciale ARNAS Ospedale Civico Di Cristina BenfratelliPalermoItaly
| | - Claudio Caramanna
- UOC Chirurgia Maxillo‐Faciale ARNAS Ospedale Civico Di Cristina BenfratelliPalermoItaly
| | - Luigi Solazzo
- UOC Chirurgia Maxillo‐Faciale ARNAS Ospedale Civico Di Cristina BenfratelliPalermoItaly
| | - Fabio Genco
- UOC Emergenza Urgenza 118 Servizio di Medicina IperbaricaARNAS Ospedale Civico Di Cristina BenfratelliPalermoItaly
| | - Paola Mirto
- Basingstoke and North Hampshire HospitalHampshireUK
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20
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Hedetoft M, Jensen PØ, Moser C, Vinkel J, Hyldegaard O. Hyperbaric oxygen treatment impacts oxidative stress markers in patients with necrotizing soft-tissue infection. J Investig Med 2021; 69:1330-1338. [PMID: 34006573 PMCID: PMC8485130 DOI: 10.1136/jim-2021-001837] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2021] [Indexed: 02/02/2023]
Abstract
Necrotizing soft-tissue infection (NSTI) is a rare, severe, and fast-progressing bacterial infection associated with a high risk of developing sepsis or septic shock. Increasing evidence indicates that oxidative stress is crucial in the development and progression of sepsis, but its role in NSTI specifically has not been investigated. Some patients with NSTI receive hyperbaric oxygen (HBO2) treatment as the restoration of oxidative stress balance is considered an important mechanism of action, which HBO2 facilitates. However, a gap in knowledge exists regarding the effect of HBO2 treatment on oxidative stress in patients with NSTI. In the present observational study, we aimed to investigate HBO2 treatment effects on known markers of oxidative stress in patients with NSTI. We measured plasma myeloperoxidase (MPO), superoxide dismutase (SOD), heme oxygenase-1 (HO-1) and nitrite+nitrate in 80 patients with NSTI immediately before and after their first HBO2 treatment, and on the following day. We found that HBO2 treatment was associated with a significant increase in MPO and SOD by a median of 3.4 and 8.8 ng/mL, respectively. Moreover, we observed an HBO2 treatment-associated increase in HO-1 in patients presenting with septic shock (n=39) by a median of 301.3 pg/mL. All markers were significantly higher in patients presenting with septic shock compared to patients without shock, and all markers correlated with disease severity. High baseline SOD was associated with 90-day mortality. In conclusion, HBO2 treatment was associated with an increase in MPO and SOD in patients with NSTI, and oxidative stress was more pronounced in patients with septic shock.
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Affiliation(s)
- Morten Hedetoft
- Department of Anaesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Peter Østrup Jensen
- Department of Clinical Microbiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Costerton Biofilm Center, Institute of Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Claus Moser
- Department of Clinical Microbiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Julie Vinkel
- Department of Anaesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ole Hyldegaard
- Department of Anaesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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21
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Devaney B, Pilcher D, Mitra B, Watterson J. Does equipoise exist amongst experts regarding the role of hyperbaric oxygen treatment for necrotising soft tissue infection? ANZ J Surg 2021; 91:485-487. [PMID: 33847053 DOI: 10.1111/ans.16337] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/06/2020] [Accepted: 09/07/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Bridget Devaney
- Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, Alfred Hospital, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - David Pilcher
- Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Biswadev Mitra
- Emergency and Trauma Centre, Alfred Hospital, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,National Trauma Research Institute, Alfred Hospital, Melbourne, Victoria, Australia
| | - Jason Watterson
- Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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22
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Hedetoft M, Bennett MH, Hyldegaard O. Adjunctive hyperbaric oxygen treatment for necrotising soft-tissue infections: A systematic review and meta-analysis. Diving Hyperb Med 2021; 51:34-43. [PMID: 33761539 DOI: 10.28920/dhm51.1.34-43] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 10/29/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Surgical intervention, broad-spectrum antibiotics and intensive care support are the standard of care in the treatment of necrotising soft-tissue infections (NSTI). Hyperbaric oxygen treatment (HBOT) may be a useful adjunctive treatment and has been used for almost 60 years, but its efficacy remains unknown and has not been systematically appraised. The aim was to systematically review and synthesise the highest level of clinical evidence available to support or refute the use of HBOT in the treatment of NSTI. METHODS The review was prospectively registered (PROSPERO; CRD42020148706). MEDLINE, EMBASE, CENTRAL and CINAHL were searched for eligible studies that reported outcomes in both HBOT treated and non-HBOT treated individuals with NSTI. In-hospital mortality was the primary outcome. Odds ratio (ORs) were pooled using random-effects models. RESULTS The search identified 486 papers of which 31 were included in the qualitative synthesis and 21 in the meta-analyses. Meta-analysis on 48,744 patients with NSTI (1,237 (2.5%) HBOT versus 47,507 (97.5%) non-HBOT) showed in-hospital mortality was 4,770 of 48,744 patients overall (9.8%) and the pooled OR was 0.44 (95% CI 0.33-0.58) in favour of HBOT. For major amputation the pooled OR was 0.60 (95% CI 0.28-1.28) in favour of HBOT. The dose of oxygen in these studies was incompletely reported. CONCLUSIONS Meta-analysis of the non-random comparative data indicates patients with NSTI treated with HBOT have reduced odds of dying during the sentinel event and may be less likely to require a major amputation. The most effective dose of oxygen remains unclear.
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Affiliation(s)
- Morten Hedetoft
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Denmark.,Department of Anaesthesia and Hyperbaric Medicine, Prince of Wales Hospital, Sydney, Australia.,Corresponding author: Dr Morten Hedetoft, Department of Anaesthesia, Rigshospitalet, University of Copenhagen, Blegdamsvej 8, 2100 Copenhagen, Denmark,
| | - Michael H Bennett
- Department of Anaesthesia and Hyperbaric Medicine, Prince of Wales Hospital, Sydney, Australia
| | - Ole Hyldegaard
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Denmark
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23
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Hedetoft M, Garred P, Madsen MB, Hyldegaard O. Hyperbaric oxygen treatment is associated with a decrease in cytokine levels in patients with necrotizing soft-tissue infection. Physiol Rep 2021; 9:e14757. [PMID: 33719215 PMCID: PMC7957267 DOI: 10.14814/phy2.14757] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 01/24/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The pathophysiological understanding of the inflammatory response in necrotizing soft-tissue infection (NSTI) and its impact on clinical progression and outcomes are not resolved. Hyperbaric oxygen (HBO2 ) treatment serves as an adjunctive treatment; however, its immunomodulatory effects in the treatment of NSTI remains unknown. Accordingly, we evaluated fluctuations in inflammatory markers during courses of HBO2 treatment and assessed the overall inflammatory response during the first 3 days after admission. METHODS In 242 patients with NSTI, we measured plasma TNF-α, IL-1β, IL-6, IL-10, and granulocyte colony-stimulating factor (G-CSF) upon admission and daily for three days, and before/after HBO2 in the 209 patients recieving HBO2 . We assessed the severity of disease by Simplified Acute Physiology Score (SAPS) II, SOFA score, and blood lactate. RESULTS In paired analyses, HBO2 treatment was associated with a decrease in IL-6 in patients with Group A-Streptococcus NSTI (first HBO2 treatment, median difference -29.5 pg/ml; second HBO2 treatment, median difference -7.6 pg/ml), and overall a decrease in G-CSF (first HBO2 treatment, median difference -22.5 pg/ml; 2- HBO2 treatment, median difference -20.4 pg/ml). Patients presenting with shock had significantly higher baseline cytokines values compared to non-shock patients (TNF-α: 51.9 vs. 23.6, IL-1β: 1.39 vs 0.61, IL-6: 542.9 vs. 57.5, IL-10: 21.7 vs. 3.3 and G-CSF: 246.3 vs. 11.8 pg/ml; all p < 0.001). Longitudinal analyses demonstrated higher concentrations in septic shock patients and those receiving renal-replacement therapy. All cytokines were significantly correlated to SAPS II, SOFA score, and blood lactate. In adjusted analysis, high baseline G-CSF was associated with 30-day mortality (OR 2.83, 95% CI: 1.01-8.00, p = 0.047). CONCLUSION In patients with NSTI, HBO2 treatment may induce immunomodulatory effects by decreasing plasma G-CSF and IL-6. High levels of inflammatory markers were associated with disease severity, whereas high baseline G-CSF was associated with increased 30-day mortality.
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Affiliation(s)
- Morten Hedetoft
- Department of Anaesthesia, Hyperbaric Unit, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Peter Garred
- Laboratory of Molecular Medicine, Department of Clinical Immunology Section 7631, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Martin Bruun Madsen
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ole Hyldegaard
- Department of Anaesthesia, Hyperbaric Unit, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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24
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Hedetoft M, Moser C, Jensen PØ, Vinkel J, Hyldegaard O. Soluble ICAM-1 is modulated by hyperbaric oxygen treatment and correlates with disease severity and mortality in patients with necrotizing soft-tissue infection. J Appl Physiol (1985) 2021; 130:729-736. [DOI: 10.1152/japplphysiol.00844.2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
HBO2 treatment may be a promising immunomodulatory agent by increasing sICAM-1, thereby lowering risk of collateral damage, especially in the most critically ill patients. sICAM-1 is associated with disease severity in NSTI as emphasized by significant correlations with SAPS II. Low sICAM-1 levels are an independent risk factor of 90-day mortality and appeared to give a good level of diagnostic accuracy, suggesting that sICAM-1 can be used as a prognostic biomarker for NSTI.
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Affiliation(s)
- Morten Hedetoft
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Claus Moser
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Peter Østrup Jensen
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, Costerton Biofilm Center, Institute of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Julie Vinkel
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ole Hyldegaard
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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25
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Rampal S, Maniam S, Lim PY, Ramachandran R, Tan EK, Halim MAHA, Shamsudin Z, Singh SSS, Narayanan P, Neela VK. Necrotizing fasciitis, causative agents and management: a five-year retrospective study in two tertiary care hospitals in Central Malaysia. INTERNATIONAL ORTHOPAEDICS 2021; 45:1399-1405. [PMID: 33484294 DOI: 10.1007/s00264-020-04905-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 12/03/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Necrotizing fasciitis (NF) is a rapidly progressive inflammatory infection of the fascia, with secondary necrosis of the subcutaneous tissues. The severity of the disease depends on the virulence of the organism and host immunity. There is a paucity of reports on the prevalence of NF causing pathogens and management. METHODS Retrospective data of patients treated for NF were collected from two tertiary care hospitals in Central Malaysia between January 2014 and December 2018. RESULTS A total of 469 NF patients were identified. More than half of the NF patients were males (n = 278; 59.28%). The highest number of cases was found among age groups between 30 and 79, with mean age of 56.17. The majority of the NF cases (n = 402; 85.72%) were monomicrobial. Streptococcus spp. (n = 89; 18.98%), Pseudomonas aeruginosa (n = 63; 13.44%) and Staphylococcus spp. (n = 61; 13.01%) were identified as the top three microorganisms isolated. Among the 469 NF cases, 173 (36.8%) were amputated or dead while 296 (63.1%) recovered. Proteus spp. (n = 19; 12.93%), Klebsiella pneumoniae (n = 18; 12.24%) and Escherichia coli (n = 14; 9.52%) were associated with all types of amputations. The most common antibiotic prescribed was unasyn (n = 284; 60.56%), followed by clindamycin (n = 56; 11.94%) and ceftazidime (n = 41; 8.74%). A total of 239 (61.8%) recovered while 148 (38.2%) were either amputated or dead when managed with the unasyn, clindamycin or ceftazidime. CONCLUSION This study represents the largest NF cases series in Malaysia highlighting the causative agents and management.
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Affiliation(s)
- Sanjiv Rampal
- Department of Orthopaedic, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor Darul Ehsan, Malaysia
| | - Sandra Maniam
- Department of Human Anatomy, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor Darul Ehsan, Malaysia
| | - Poh Ying Lim
- Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor Darul Ehsan, Malaysia
| | - Rubenandran Ramachandran
- Department of Orthopaedic, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor Darul Ehsan, Malaysia
| | - Eng Kee Tan
- Department of Orthopaedic, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor Darul Ehsan, Malaysia
| | - Mohd Asyraf Hafizuddin Ab Halim
- Department of Orthopaedic, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor Darul Ehsan, Malaysia
| | - Zulfahrizzat Shamsudin
- Orthopaedic Department, Hospital Tuanku Ja'afar, Jalan Rasah, Bukit Rasah, 70300, Seremban, Negeri Sembilan, Malaysia
| | - Sandeep Singh Sarawan Singh
- Orthopaedic Department, Hospital Ampang, Jalan Mewah Utara, Pandan Mewah, 68000, Ampang, Selangor Darul Ehsan, Malaysia
| | - Pravind Narayanan
- Department of Internal Medicine, Hospital Sarikei, Jalan Rentap, 96100, Sarikei, Sarawak, Malaysia
| | - Vasantha Kumari Neela
- Department of Medical Microbiology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor, Malaysia.
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Lu P, Angliss M, Paul E, Bruscino-Raiola F. Health-related quality of life in necrotising soft tissue infection survivors: perspective from an Australian tertiary referral centre. ANZ J Surg 2021; 91:1733-1738. [PMID: 33438334 DOI: 10.1111/ans.16540] [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: 08/25/2020] [Revised: 12/04/2020] [Accepted: 12/06/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Necrotising soft tissue infection (NSTI) is a life-threatening disease with widespread tissue destruction. Immediate and aggressive surgical debridement remains the main focus of treatment. This results in disfiguring scars, functional limitation and psychological sequelae for survivors. As mortality rate declines with improvements in care, a greater focus should be placed upon the psychological and functional outcomes of survivors. This study aims to assess the health-related quality of life (HRQoL) of patients following NSTI using the Short Form-36 (SF-36) and Derriford Appearance Scale-24 (DAS-24). METHODS All NSTI patients admitted at our tertiary referral centre between 1 January 2013 and 31 December 2019 were invited to complete the DAS-24 and SF-36 surveys. A retrospective chart review was also performed. RESULTS A total of 30 participants responded to the surveys. On comparison against the general Australian population, the NSTI cohort demonstrated significantly reduced physical and mental HRQoL as measured by the SF-36 (P < 0.001). Increased age was significantly associated with a reduced physical HRQoL (P = 0.002), while dysfunction with appearance as measured by the DAS-24 form correlated with both reduced physical and mental HRQoL (P = 0.020). A total of 79.3% of patients expressed concern regarding their appearance with a significantly higher level of distress at their appearance compared to a non-clinical population (P = 0.120). CONCLUSION Despite the rarity of NSTI, this study demonstrates that this disease has a large and persistent burden for survivors, who report significantly reduced HRQoL and distress with appearance. Further research into comprehensive physical and psychosocial services for NSTI survivors is required.
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Affiliation(s)
- Patrick Lu
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,John Anstee Research Group, Department of Plastic, Hand and Faciomaxillary Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Margaret Angliss
- John Anstee Research Group, Department of Plastic, Hand and Faciomaxillary Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Eldho Paul
- Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Frank Bruscino-Raiola
- John Anstee Research Group, Department of Plastic, Hand and Faciomaxillary Surgery, Alfred Health, Melbourne, Victoria, Australia
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Abstract
Necrotizing soft tissue infections occur after traumatic injuries, minor skin lesions, nonpenetrating injuries, natural childbirth, and in postsurgical and immunocompromised patients. Infections can be severe, rapidly progressive, and life threatening. Survivors often endure multiple surgeries and prolonged hospitalization and rehabilitation. Despite subtle nuances that may distinguish one entity from another, clinical approaches to diagnosis and treatment are highly similar. This review describes the clinical and laboratory features of necrotizing soft tissue infections and addresses recommended diagnostic and treatment modalities. It discusses the impact of delays in surgical debridement, antibiotic use, and resuscitation on mortality, and summarizes key pathogenic mechanisms.
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Affiliation(s)
- Dennis L Stevens
- Infectious Diseases Center of Biomedical Research Excellence, Veterans Affairs Medical Center, 500 West Fort Street (Mail Stop 151), Boise, ID 83702, USA
| | - Amy E Bryant
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, Idaho State University, 1311 East Central Drive, Meridian, ID 83642, USA.
| | - Ellie Jc Goldstein
- David Geffen School of Medicine at UCLA, Los Angeles, CA 90074, USA; R M Alden Research Laboratory, 2021 Santa Monica Boulevard, Suite #740 East, Santa Monica, CA 90404, USA
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Hedetoft M, Madsen MB, Madsen LB, Hyldegaard O. Incidence, comorbidity and mortality in patients with necrotising soft-tissue infections, 2005-2018: a Danish nationwide register-based cohort study. BMJ Open 2020; 10:e041302. [PMID: 33067303 PMCID: PMC7569942 DOI: 10.1136/bmjopen-2020-041302] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/11/2020] [Accepted: 09/17/2020] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To assess the incidence, comorbidities, treatment modalities and mortality in patients with necrotising soft-tissue infections (NSTIs) in Denmark. DESIGN Nationwide population-based registry study. SETTING Denmark. PARTICIPANTS Danish residents with NSTI between 1 January 2005 and 31 August 2018. MAIN OUTCOME MEASURE Incidence of disease per 100 000 person/year and all-cause mortality at day 90 obtained from Danish National Patient Registry and the Danish Civil Registration System. RESULTS 1527 patients with NSTI were identified, yielding an incidence of 1.99 per 100 000 person/year. All-cause 30-day, 90-day and 1-year mortality were 19.4% (95% CI 17.4% to 21.5%), 25.2% (95% CI 23.1% to 27.5%) and 30.4% (95% CI 28.0% to 32.8%), respectively. Amputation occurred in 7% of the individuals. Diabetes was the most predominant comorbidity affecting 43% of the cohort, while 26% had no comorbidities. Higher age, female sex and increasing comorbidity index were found to be independent risk factors of mortality. Admission to high-volume hospitals was associated with improved survival (OR 0.59, 95% CI 0.45 to 0.77). Thirty-six per cent received hyperbaric oxygen therapy (HBOT) as an adjunctive therapy. No change in overall mortality was found over the studied time period. CONCLUSION The present study found that in Denmark, the incidence of NSTI increased; mortality rates remained high and largely unaltered. Diabetes was the most common comorbidity, while higher age, female sex and increasing comorbidity index were associated to increased mortality. Survival was improved in those admitted to hospitals with more expertise in treating NSTI. In high-volume hospital, HBOT was associated with decreased odds for mortality.
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Affiliation(s)
- Morten Hedetoft
- Department of Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Martin Bruun Madsen
- Department of Intensive Care, 4131, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Lærke Bruun Madsen
- Department of Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ole Hyldegaard
- Department of Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Leiblein M, Wagner N, Adam EH, Frank J, Marzi I, Nau C. Clostridial Gas Gangrene - A Rare but Deadly Infection: Case series and Comparison to Other Necrotizing Soft Tissue Infections. Orthop Surg 2020; 12:1733-1747. [PMID: 33015993 PMCID: PMC7767692 DOI: 10.1111/os.12804] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 08/07/2020] [Accepted: 08/18/2020] [Indexed: 02/06/2023] Open
Abstract
Objective Clostridial gas gangrene (GG) or clostridial myonecrosis is a very rare but life‐threatening necrotizing soft tissue infection (NSTI) caused by anaerobic, spore‐forming, and gas‐producing clostridium subspecies. It is the most rapidly spreading and lethal infection in humans, also affecting muscle tissue. The high mortality, of up to 100%, in clostridial GG is mediated by potent bacterial exotoxins. Necrotizing fasciitis (NF) is an important differential diagnosis, most often caused by group A streptococci, primarily not affecting musculature but the subcutaneous tissue and fascia. In the early stages of the infection, it is difficult to distinguish between GG and NF. Therefore, we compare both infection types, identify relevant differences in initial clinical presentation and later course, and present the results of our patients in a retrospective review. Methods Patients diagnosed with GG from 2008 to 2018 in our level one trauma center were identified. Their charts were reviewed retrospectively and data analyzed in terms of demographic information, microbiological and histological results, therapeutic course, outcome, and mortality rates. The laboratory risk indicator for NF (LRINEC) score was applied on the first blood work acquired. Results were compared to those of a second group diagnosed with NF. Results Five patients with GG and nine patients with NF were included in the present study. Patients with GG had a mortality rate of 80% compared to 0% in patients with NF. In eight patients with NF, affected limbs could be salvaged; one NF underwent amputation. LRINEC did not show significant differences between the groups; however, C‐reactive protein was significantly increased (P = 0.009) and hemoglobin (Hb) was significantly decreased (P = 0.02) in patients with GG. Interleukin‐6 and procalcitonin levels did not show significant difference. Patients with GG were older (70.2 vs 50 years). Of the isolated bacteria, 86% were sensitive to the initial calculated antibiotic treatment with ampicillin‐sulbactam or imipenem plus metronidazole plus clindamycin. Conclusion Both GG and NF need full‐scale surgical, antibiotic, and intensive care treatment, especially within the first days. Among patients with NSTI, those with clostridial GG have a significantly increased mortality risk due to early septic shock caused by clostridial toxins. In the initial stages, clinical differences are hardly detectable. Immediate surgical debridement is the key to successful therapy for NSTI and needs to be performed as early as possible. However, patients should be treated in a center with an experienced interdisciplinary intensive care team based on a predetermined treatment plan.
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Affiliation(s)
- Maximilian Leiblein
- Department of Trauma, Hand, and Reconstructive Surgery, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Nils Wagner
- Department of Trauma, Hand, and Reconstructive Surgery, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Elisabeth H Adam
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Johannes Frank
- Department of Trauma, Hand, and Reconstructive Surgery, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Ingo Marzi
- Department of Trauma, Hand, and Reconstructive Surgery, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Christoph Nau
- Department of Trauma, Hand, and Reconstructive Surgery, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
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Abstract
PURPOSE OF REVIEW To review the salient features of the management of severe skin and soft tissue infections (SSTIs), including toxic shock syndrome, myonecrosis/gas gangrene, and necrotizing fasciitis. RECENT FINDINGS For severe SSTIs, intensive care, source control, and broad-spectrum antimicrobials are required for the initial phase of illness. There is an increasing focus on the utility of rapid diagnostic tests to help in selection and de-escalation of antimicrobials for SSTIs. In addition, clinical prediction scores have shown promise in helping predict patients who do not require antimicrobials directed against methicillin-resistant Staphylococcus aureus. Immune status has been shown to be important in clinical outcomes of some, but not all types of SSTIs. The debate for benefits of intravenous immunoglobulin continues to be waged in the recent literature. SUMMARY Severe SSTIs are common and their management complex due to regional variation in predominant pathogens and antimicrobial resistance patterns, as well variations in host immune responses. Unique aspects of care for severe SSTIs are discussed including the role of surgical consultation and source control. The unique features of SSTIs in immunocompromised hosts are also described.
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Peetermans M, de Prost N, Eckmann C, Norrby-Teglund A, Skrede S, De Waele JJ. Necrotizing skin and soft-tissue infections in the intensive care unit. Clin Microbiol Infect 2019; 26:8-17. [PMID: 31284035 DOI: 10.1016/j.cmi.2019.06.031] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 06/19/2019] [Accepted: 06/22/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Necrotizing skin and soft-tissue infections (NSTI) are rare but potentially life-threatening and disabling infections that often require intensive care unit admission. OBJECTIVES To review all aspects of care for a critically ill individual with NSTI. SOURCES Literature search using Medline and Cochrane library, multidisciplinary panel of experts. CONTENT The initial presentation of a patient with NSTI can be misleading, as features of severe systemic toxicity can obscure sometimes less impressive skin findings. The infection can spread rapidly, and delayed surgery worsens prognosis, hence there is a limited role for additional imaging in the critically ill patient. Also, the utility of clinical scores is contested. Prompt surgery with aggressive debridement of necrotic tissue is required for source control and allows for microbiological sampling. Also, prompt administration of broad-spectrum antimicrobial therapy is warranted, with the addition of clindamycin for its effect on toxin production, both in empirical therapy, and in targeted therapy for monomicrobial group A streptococcal and clostridial NSTI. The role of immunoglobulins and hyperbaric oxygen therapy remains controversial. IMPLICATIONS Close collaboration between intensive care, surgery, microbiology and infectious diseases, and centralization of care is fundamental in the approach to the severely ill patient with NSTI. As many aspects of management of these rare infections are supported by low-quality data only, multicentre trials are urgently needed.
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Affiliation(s)
- M Peetermans
- Department of Critical Care, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - N de Prost
- Service de Réanimation Médicale, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris, Créteil, France; Groupe de Recherche Clinique CARMAS, Université Paris-Est Créteil, IMRB, Créteil, France
| | - C Eckmann
- Department of General, Visceral and Thoracic Surgery, Klinikum Peine, Academic Hospital of Medical University Hannover, Germany
| | - A Norrby-Teglund
- Centre for Infectious Medicine, Karolinska Institute, Karolinska University Hospital, Huddinge, Sweden
| | - S Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway
| | - J J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium.
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The Role of Streptococcal and Staphylococcal Exotoxins and Proteases in Human Necrotizing Soft Tissue Infections. Toxins (Basel) 2019; 11:toxins11060332. [PMID: 31212697 PMCID: PMC6628391 DOI: 10.3390/toxins11060332] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 06/04/2019] [Accepted: 06/10/2019] [Indexed: 12/31/2022] Open
Abstract
Necrotizing soft tissue infections (NSTIs) are critical clinical conditions characterized by extensive necrosis of any layer of the soft tissue and systemic toxicity. Group A streptococci (GAS) and Staphylococcus aureus are two major pathogens associated with monomicrobial NSTIs. In the tissue environment, both Gram-positive bacteria secrete a variety of molecules, including pore-forming exotoxins, superantigens, and proteases with cytolytic and immunomodulatory functions. The present review summarizes the current knowledge about streptococcal and staphylococcal toxins in NSTIs with a special focus on their contribution to disease progression, tissue pathology, and immune evasion strategies.
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Faunø Thrane J, Ovesen T. Scarce evidence of efficacy of hyperbaric oxygen therapy in necrotizing soft tissue infection: a systematic review. Infect Dis (Lond) 2019; 51:485-492. [PMID: 30985236 DOI: 10.1080/23744235.2019.1597983] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Background: Necrotizing soft tissue infection (NSTI) is a rare and potentially life-threatening disease. Rapid surgical intervention, antibiotics and intensive care are the mainstay of treatment. Hyperbaric oxygen therapy (HBOT) is used as adjuvant therapy in some centres but there is a lack of research-based evidence of efficacy. Methods: Following the PRISMA guideline we conducted a systematic review on the efficacy of HBOT on NSTI with mortality as primary outcome. Through January 2019 major databases were searched and relevant literature assessed. The criteria for study inclusion were research of any design and any period of time comparing HBOT vs. non-HBOT in a population of NSTI-patients. Studies were analysed using the modified Delphi method and risk of bias in non-randomized studies - of interventions tool. Relative risk (RR) on mortality was calculated for each study individually. Results: A number of 1733 studies were identified through database search. Ultimately, 21 studies were included of which 19 were case series with a control group. The majority of the studies performed poor in quality assessment and all featured a high to critical risk of bias. The association of HBOT on mortality was generally reported as positive, however, the results should be considered with great scepticism. Conclusions: The evidence of HBOT in NSTI is poor and biased. There is a strong need for randomized controlled trials (RCTs) to shed light on a potential life-saving treatment.
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Affiliation(s)
- Jens Faunø Thrane
- a Department of Otorhinolaryngology, Head & Neck Surgery , Aarhus University Hospital , Aarhus , Denmark.,b Department of Otorhinolaryngology, Head & Neck Surgery , Aalborg University Hospital , Aalborg , Denmark
| | - Therese Ovesen
- c Department of Clinical Medicine , Aarhus University , Aarhus , Denmark.,d Department of Otorhinolaryngology, Head & Neck Surgery , Region Hospital Holstebro , Holstebro , Denmark
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Kapp DL, Rogers M, Hermans MHE. Necrotizing Fasciitis: An Overview and 2 Illustrative Cases. INT J LOW EXTR WOUND 2018; 17:295-300. [PMID: 30422020 DOI: 10.1177/1534734618804037] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Necrotizing fasciitis is the generic term for a series of progressive gangrenous infections of the skin and subcutaneous tissues. Typically, necrotizing fasciitis start with an, often small, infected lesion with atypical symptoms, which then quickly develops into a rapidly spreading, massive infection. The primary therapy is excision of all necrotic tissue in combination with treatment of systemic symptoms such as shock. The defects resulting from rigorous excision are often very large. Once they are clean, they require closure with an autograft. This article reviews the symptoms and treatment of necrotizing fasciitis. In addition, it illustrates, with 2 cases, how a hyaluronic-based extracellular matrix can be used to "fill in" with neodermis for the lost dermis and can create a wound bed most suitable for grafting.
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Urbina T, Hua C, Sbidian E, Ingen-Housz-Oro S, Duong TA, Wolkenstein P, Bosc R, Razazi K, Carteaux G, Chosidow O, Mekontso Dessap A, de Prost N. Urgences dermatologiques en réanimation : infections nécrosantes de la peau et des parties molles et toxidermies graves. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Les urgences dermatologiques nécessitant une admission en réanimation sont rares mais associées à une mortalité élevée et à de lourdes séquelles à long terme. Elles sont essentiellement représentées par les infections nécrosantes des tissus mous (également appelées : dermohypodermites bactériennes nécrosantes-fasciites nécrosantes [DHBN-FN]) et par les toxidermies graves que sont les nécrolyses épidermiques (comprenant le syndrome de Lyell ou nécrolyse épidermique toxique [NET], le syndrome de Stevens-Johnson [SJS] et le DRESS (drug reaction with eosinophilia and systemic symptoms)). Elles ont pour caractéristiques communes un diagnostic souvent difficile, la nécessité d’une approche multidisciplinaire et de soins paramédicaux lourds et spécifiques, imposant fréquemment le transfert dans un centre expert. Le traitement des DHBN-FN est médicochirurgical, associant un débridement chirurgical précoce et une antibiothérapie probabiliste à large spectre. La présence de signes de gravité locaux (nécrose, crépitation, douleur intense) ou généraux (sepsis, choc septique) est une indication d’urgence à l’exploration chirurgicale. Sa précocité est le principal facteur pronostique modifiable, les recommandations de thérapeutiques complémentaires (immunoglobulines intraveineuses, oxygénothérapie hyperbare, pansement à pressions négatives, ...) reposant à ce jour sur un faible niveau de preuve. L’élément essentiel de la prise en charge des toxidermies graves est la recherche et l’arrêt du médicament imputable, facteur essentiel du pronostic. Le SJS et le NET, en général associés à une ou plusieurs atteintes muqueuses, entraînent dans les formes les plus graves une défaillance cutanée aiguë. La prise en charge repose sur les soins de support (correction des troubles hydroélectrolytiques, prévention de l’hypothermie, prévention et traitement des épisodes infectieux, analgésie et anxiolyse, soins locaux). Les complications infectieuses et respiratoires sont les principales causes de décès à la phase aiguë. Aucun traitement spécifique n’a fait la preuve de son efficacité à ce jour. Le diagnostic de DRESS est difficile, et la prise en charge doit être multidisciplinaire. Sa gravité tient aux possibles atteintes viscérales associées (hépatique, rénale et cardiaque) qui justifient dans les formes graves d’une corticothérapie urgente.
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Rosén A, Arnell P, Madsen MB, Nedrebø BG, Norrby-Teglund A, Hyldegaard O, Dos Santos VM, Bergey F, Saccenti E, Skrede S. Diabetes and necrotizing soft tissue infections-A prospective observational cohort study: Statistical analysis plan. Acta Anaesthesiol Scand 2018; 62:1171-1177. [PMID: 29671865 DOI: 10.1111/aas.13130] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 03/09/2018] [Accepted: 03/21/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Necrotizing soft tissue infections (NSTIs) are rare but carry a high morbidity and mortality. The multicenter INFECT project aims to improve the understanding of the pathogenesis, clinical characteristics, diagnosis, and prognosis of NSTIs. This article describes the study outline and statistical analyses that will be used. METHODS Within the framework of INFECT project, patients with NSTI at 5 Scandinavian hospitals are enrolled in a prospective observational cohort study. The goal is to evaluate outcome and characteristics for patients with NSTI and diabetes compared to patients with NSTI without diabetes. The primary outcome is mortality at 90 days after inclusion. Secondary outcomes include days alive and out of ICU and hospital, SAPS II, SOFA score, infectious etiology, amputation, affected body area, and renal replacement therapy. Comparison in mortality between patients with diabetes type 1 and 2 as well as between insulin-treated and non-insulin-treated diabetes patients will be made. Clinical data for diabetic patients with NSTI will be reported. CONCLUSION The study will provide important data on patients with NSTI and diabetes.
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Affiliation(s)
- A Rosén
- Department of Anaesthesia and Intensive Care Medicine, Sahlgrenska University Hospital/Ostra, Gothenburg, Sweden
| | - P Arnell
- Department of Anaesthesia and Intensive Care Medicine, Sahlgrenska University Hospital/Ostra, Gothenburg, Sweden
| | - M B Madsen
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - B G Nedrebø
- Department of Medicine, Haugesund County Hospital, Haugesund, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - A Norrby-Teglund
- Centre for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - O Hyldegaard
- Department of Anaesthesia, Center of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - V M Dos Santos
- LifeGlimmer GmbH, Berlin, Germany
- Laboratory of Systems and Synthetic Biology, Wageningen University & Research, Wageningen, The Netherlands
| | - F Bergey
- LifeGlimmer GmbH, Berlin, Germany
| | - E Saccenti
- Laboratory of Systems and Synthetic Biology, Wageningen University & Research, Wageningen, The Netherlands
| | - S Skrede
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
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Hyperbaric Oxygen Therapy and Utilization in Infectious Disease. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2018. [DOI: 10.1007/s40138-018-0166-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Hot topics in necrotising skin and soft tissue infections. Int J Antimicrob Agents 2018; 52:1-10. [DOI: 10.1016/j.ijantimicag.2018.02.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 01/22/2018] [Accepted: 02/17/2018] [Indexed: 12/16/2022]
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Baraket O, Triki W, Ayed K, Hmida SB, Lahmidi MA, Baccar A, Bouchoucha S. [Therapeutic factors affecting the healing process in patients with gangrene of the perineum]. Pan Afr Med J 2018; 29:70. [PMID: 29875951 PMCID: PMC5987071 DOI: 10.11604/pamj.2018.29.70.14669] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 01/08/2018] [Indexed: 11/11/2022] Open
Abstract
Fournier gangrene is a rare and severe necrotizing fasciitis. It is burdened with high morbi-mortality, requiring early and massive medical and surgical management. Initial treatment is based on patient's resuscitation associated with surgical debridement. Subsequently, the main challenge is the healing process and its possible sequelae. Several therapeutic approaches are currently available to improve and accelerate the healing process. We conducted a retrospective study of 20 cases. The median age of our patients was 56 years. The study included 16 men and 7 women. Comorbidity was present in 15 patients. Antibiotic therapy was administered in all cases, with a median duration of 15 days. All patients underwent surgery. Iterative reviews were necessary in all patients, who needed, on average, 3 dressing changes. Colostomy was performed in 6 cases. Hyperbaric oxygen therapy was performed in 4 cases. Vacuum assisted closure was performed in 1 case. Soft tissue coverage was necessary in 2 cases. The mean duration of healing was 15 days with oxygen therapy versus 24 days in the absence of this treatment. The mean duration of hospitalization was 20 days. Four patients died. Healing process without sequelae is a therapeutic challenge. Despite the addition of new therapeutic approaches, outcomes are not satisfactory. However, multidisciplinary approach associated with oxygen therapy and vacuum assisted closure might improve patients outcomes.
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Affiliation(s)
- Oussama Baraket
- Service de Chirurgie Générale, Hôpital Habib Bougatfa de Bizerte, Tunisie
- Faculté de Médecine de Tunis, Université Tunis El Manar, Tunis
| | - Wissem Triki
- Service de Chirurgie Générale, Hôpital Habib Bougatfa de Bizerte, Tunisie
- Faculté de Médecine de Tunis, Université Tunis El Manar, Tunis
| | - Karim Ayed
- Service de Chirurgie Générale, Hôpital Habib Bougatfa de Bizerte, Tunisie
- Faculté de Médecine de Tunis, Université Tunis El Manar, Tunis
| | - Sonia Ben Hmida
- Faculté de Médecine de Tunis, Université Tunis El Manar, Tunis
- Service de Gastro Entérologie, Hôpital Habib Bougatfa de Bizerte, Tunisie
| | - Mohamed Amine Lahmidi
- Service de Chirurgie Générale, Hôpital Habib Bougatfa de Bizerte, Tunisie
- Faculté de Médecine de Tunis, Université Tunis El Manar, Tunis
| | - Abdelamjid Baccar
- Service de Chirurgie Générale, Hôpital Habib Bougatfa de Bizerte, Tunisie
- Faculté de Médecine de Tunis, Université Tunis El Manar, Tunis
| | - Samy Bouchoucha
- Service de Chirurgie Générale, Hôpital Habib Bougatfa de Bizerte, Tunisie
- Faculté de Médecine de Tunis, Université Tunis El Manar, Tunis
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Affiliation(s)
- Dennis L Stevens
- From the Veterans Affairs Medical Center, Boise, ID; and the University of Washington School of Medicine, Seattle
| | - Amy E Bryant
- From the Veterans Affairs Medical Center, Boise, ID; and the University of Washington School of Medicine, Seattle
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Polzik P, Johansson PI, Hyldegaard O. How biomarkers reflect the prognosis and treatment of necrotising soft tissue infections and the effects of hyperbaric oxygen therapy: the protocol of the prospective cohort PROTREAT study conducted at a tertiary hospital in Copenhagen, Denmark. BMJ Open 2017; 7:e017805. [PMID: 28982834 PMCID: PMC5640072 DOI: 10.1136/bmjopen-2017-017805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Not enough is known regarding the prognosis and treatment of necrotising soft tissue infections (NSTIs). Mortality has been shown to be 25%-35%, with survivors coping with amputations and prolonged rehabilitation. This study will evaluate soluble urokinase-type plasminogen activator receptor (suPAR) as a possible prognostic marker of NSTI severity and mortality, as well as whether hyperbaric oxygen therapy (HBOT) can modulate markers of endothelial damage during NSTI. We hypothesise that in patients with NSTI, suPAR can provide prognostic risk assessment on hospital admission and that HBOT can reduce the endothelial damage that these patients are exposed to. METHODS AND ANALYSIS This is a prospective observational study. Biomarkers will be measured in 150 patients who have been diagnosed with NSTI. On admission, baseline blood samples will be obtained. Following surgery and HBOT, daily blood samples will be obtained in order to measure endothelial and prognostic biomarkers (soluble thrombomodulin, syndecan-1, sE-selectin, vascular endothelial (VE)-cadherin, protein C and suPAR levels). Clinical data will be acquired during the first 7 days of stay in the intensive care unit. The primary outcomes in studies I and II will be endothelial biomarker levels after HBOT, and in study III suPAR levels as a marker of disease prognosis and severity. ETHICS AND DISSEMINATION The study has been approved by the Regional Scientific Ethical Committee of Copenhagen (H-16021845) and the Danish Data Protection Agency (RH-2016-199). Results will be presented at national and international conferences and published in peer-reviewed scientific journals. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Identifier NCT03147352. (Pre-results).
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Affiliation(s)
- Peter Polzik
- Department of Anesthesiology, Center of Head and Orthopedics, Copenhagen University Hospital (Rigshospitalet), Copenhagen Ø, Denmark
| | - Pär I Johansson
- Department of Clinical Immunology, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
| | - Ole Hyldegaard
- Department of Anesthesiology, Center of Head and Orthopedics, Copenhagen University Hospital (Rigshospitalet), Copenhagen Ø, Denmark
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Rox K, Jansen R, Loof TG, Gillen CM, Bernecker S, Walker MJ, Chhatwal GS, Müller R. Linoleic and palmitoleic acid block streptokinase-mediated plasminogen activation and reduce severity of invasive group A streptococcal infection. Sci Rep 2017; 7:11798. [PMID: 28924140 PMCID: PMC5603603 DOI: 10.1038/s41598-017-11276-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 08/17/2017] [Indexed: 01/06/2023] Open
Abstract
In contrast to mild infections of Group A Streptococcus (GAS) invasive infections of GAS still pose a serious health hazard: GAS disseminates from sterile sites into the blood stream or deep tissues and causes sepsis or necrotizing fasciitis. In this case antibiotics do not provide an effective cure as the bacteria are capable to hide from them very quickly. Therefore, new remedies are urgently needed. Starting from a myxobacterial natural products screening campaign, we identified two fatty acids isolated from myxobacteria, linoleic and palmitoleic acid, specifically blocking streptokinase-mediated activation of plasminogen and thereby preventing streptococci from hijacking the host’s plasminogen/plasmin system. This activity is not inherited by other fatty acids such as oleic acid and is not attributable to the killing of streptococci. Moreover, both fatty acids are superior in their inhibitory properties compared to two clinically used drugs (tranexamic or ε-amino caproic acid) as they show 500–1000 fold lower IC50 values. Using a humanized plasminogen mouse model mimicking the clinical situation of a local GAS infection that becomes systemic, we demonstrate that these fatty acids ameliorate invasive GAS infection significantly. Consequently, linoleic and palmitoleic acid are possible new options to combat GAS invasive diseases.
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Affiliation(s)
- Katharina Rox
- Department of Microbial Natural Products, Helmholtz Institute for Pharmaceutical Research (HIPS), Helmholtz Centre for Infection Research (HZI), Saarland University, Saarbrücken, Germany.,Department of Medical Microbiology, Helmholtz Centre for Infection Research (HZI), Braunschweig, Germany.,Central facility for Microscopy, Helmholtz Centre for Infection Research (HZI), Braunschweig, Germany.,German Centre for Infection Research (DZIF), Partner Site Braunschweig-Hannover, Hannover, Germany
| | - Rolf Jansen
- Department of Microbial Drugs, Helmholtz Centre for Infection Research (HZI), Braunschweig, Germany.,German Centre for Infection Research (DZIF), Partner Site Braunschweig-Hannover, Hannover, Germany
| | - Torsten G Loof
- Department of Medical Microbiology, Helmholtz Centre for Infection Research (HZI), Braunschweig, Germany.,Infection Immunology Research Group, Helmholtz Centre for Infection Research (HZI), Braunschweig, Germany
| | - Christine M Gillen
- School of Chemistry and Molecular Biosciences and Australian Infectious Disease Research Centre, The University of Queensland, St. Lucia, Queensland, Australia
| | - Steffen Bernecker
- Department of Microbial Drugs, Helmholtz Centre for Infection Research (HZI), Braunschweig, Germany.,German Centre for Infection Research (DZIF), Partner Site Braunschweig-Hannover, Hannover, Germany
| | - Mark J Walker
- School of Chemistry and Molecular Biosciences and Australian Infectious Disease Research Centre, The University of Queensland, St. Lucia, Queensland, Australia
| | - Gursharan Singh Chhatwal
- Department of Medical Microbiology, Helmholtz Centre for Infection Research (HZI), Braunschweig, Germany
| | - Rolf Müller
- Department of Microbial Natural Products, Helmholtz Institute for Pharmaceutical Research (HIPS), Helmholtz Centre for Infection Research (HZI), Saarland University, Saarbrücken, Germany. .,German Centre for Infection Research (DZIF), Partner Site Braunschweig-Hannover, Hannover, Germany.
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Mina M, Mina P, Reid M, Chavan A. Importance of early detection and management of necrotising myositis as demonstrated by the case of an 8-year-old female. J Paediatr Child Health 2017; 53:817-820. [PMID: 28770573 DOI: 10.1111/jpc.13634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 01/11/2017] [Accepted: 02/27/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Mina Mina
- Cairns Hospital and Hinterland Hospital and Health Service, Cairns, Queensland, Australia
| | - Paula Mina
- Cairns Hospital and Hinterland Hospital and Health Service, Cairns, Queensland, Australia
| | - Michael Reid
- Cairns Hospital and Hinterland Hospital and Health Service, Cairns, Queensland, Australia.,James Cook University, Cairns, Queensland, Australia
| | - Arjun Chavan
- Townsville Hospital, Townsville Hospital and Health Service, Townsville, Queensland, Australia
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Frawley L, Devaney B, Tsouras T, Frawley G. Performance of the BBraun perfusor space syringe driver under hyperbaric conditions. Diving Hyperb Med 2017; 47:38-43. [PMID: 28357823 DOI: 10.28920/dhm47.1.38-43] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 01/16/2017] [Indexed: 11/05/2022]
Abstract
BACKGROUND The BBraun Perfusor Space™ syringe driver is already in use by ambulance services and retrieval teams but has not previously been assessed for hyperbaric chamber use. METHODS Pump flow accuracy was tested at rates between 1 and 40 ml· h⁻¹ using three different brands of 50 ml syringe. Function of the occlusion alarms was assessed using the same syringes. The hyperbaric profile involved pressurisation to 284 kPa at 30 kPa· min⁻¹, 30 min at 284 kPa and decompression at 30 kPa· min⁻¹. Output was recorded from differences in weight of collection containers. A single device was tested. RESULTS Performance was highly dependent on the syringe type used, with two of the three 50 ml syringes used demonstrating 'stiction' at both low and high occlusion pressure alarm settings, most marked during pressurisation. On decompression from 284 kPa all syringes alarmed at significantly lower pressures. Because of the stiction problems only the flow measurements for the BBrown Omni¬ x 50 ml syringes are reported. At a pressure of 284 kPa, the difference between programmed and delivered rates was within the manufacturer's specification of 10%: at 40 ml· h⁻¹ (median variation 1.25%, IQR 0.5-1.7%), 10 ml· h⁻¹ (8.6%, IQR 8-9.2%), 5 ml· h⁻¹ (-8.8%, IQR - 1.6-8.8%) and 1 ml· h⁻¹ (-4%, IQR 4-12%). Pressurisation was associated with significantly lower flow rates whilst decompression was associated with significantly increased rates. Limited testing at 405 kPa was also within the manufacturer's specifications. CONCLUSION A BBraun Infusor Space syringe driver performed within acceptable performance criteria but is highly dependent on syringe type and flow rates. The potential for the device to under deliver on pressurisation and over deliver on depressurisation, however, suggests vigilance and appropriate rate adjustments may be necessary during these phases.
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Affiliation(s)
- Lachlan Frawley
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Australia
| | - Bridget Devaney
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Australia
| | - Theo Tsouras
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Australia
| | - Geoff Frawley
- Department Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Commercial Road, Prahran, Victoria, Australia, 3181,
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Kerbaj J, Aubry C, Prost C, Brouqui P. Thigh abscess and necrotizing fasciitis following an inside-out transobturator tape intervention: a case report. J Med Case Rep 2016; 10:146. [PMID: 27256334 PMCID: PMC4890333 DOI: 10.1186/s13256-016-0942-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 05/10/2016] [Indexed: 01/04/2023] Open
Abstract
Background Tension-free vaginal transobturator tapes are used worldwide in the treatment of urinary incontinence in women. Very few severe complications have been described following this procedure, with no standard treatment yet established. Case presentation We present the case of a 36-year-old French white woman with no remarkable medical history, presenting with an abscess and necrotizing fasciitis 48 hours after an inside-out tension-free transobturator procedure. Samples were collected by guided puncture from the abscess, retrieving Staphylococcus aureus and Citrobacter koseri. Conclusions Severe complications following this procedure are rare, although it can have the potential for significant morbidity and even mortality, which is worth highlighting. We recommend early surgical treatment in combination with broad-spectrum antibiotics and coverage for Staphylococcus aureus, which may be a causative agent. Electronic supplementary material The online version of this article (doi:10.1186/s13256-016-0942-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jad Kerbaj
- Maladies Infectieuses et Tropicales, CHU Nord, AP-HM, Pôle des Maladies Infectieuses et Tropicales, Marseille, France.,Aix Marseille Université, URMITE, UM63, CNRS 7278, IRD 198, Inserm 1095, 13005, Marseille, France
| | - Camille Aubry
- Maladies Infectieuses et Tropicales, CHU Nord, AP-HM, Pôle des Maladies Infectieuses et Tropicales, Marseille, France.,Aix Marseille Université, URMITE, UM63, CNRS 7278, IRD 198, Inserm 1095, 13005, Marseille, France.,Institut Hospitalo-Universitaire Méditerranée Infection, 13005, Marseille, France
| | - Caroline Prost
- Service d'imagerie Médicale, CHU Nord, AP-HM, Marseille, France
| | - Philippe Brouqui
- Maladies Infectieuses et Tropicales, CHU Nord, AP-HM, Pôle des Maladies Infectieuses et Tropicales, Marseille, France. .,Aix Marseille Université, URMITE, UM63, CNRS 7278, IRD 198, Inserm 1095, 13005, Marseille, France. .,Institut Hospitalo-Universitaire Méditerranée Infection, 13005, Marseille, France.
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Gorman D. Does Hyperbaric Oxygen Improve Survival in Necrotising Soft Tissue Infections? Anaesth Intensive Care 2015; 43:683-4. [DOI: 10.1177/0310057x1504300603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- D. Gorman
- The University of Auckland, Auckland, New Zealand
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