A systematic review of necrotising fasciitis in children from its first description in 1930 to 2018

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report

Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report

Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.

A Cross-Sectional Analysis of Pediatric Necrotizing Soft Tissue Infection Cases and Racial Disparities From the 2016 to 2020 National Inpatient Sample

INTRODUCTION

The incidence, treatment, and outcomes of necrotizing soft tissue infections (NSTIs) and associated racial disparities have been described in adults, but research in the pediatric population is limited. The purpose of this study is to provide a nationally representative characterization of pediatric NSTI and determine the presence of any racial disparities.

METHODS

The National Inpatient Sample was analyzed from 2016 through 2020. Patients aged less than 20 y with a diagnosis of necrotizing fasciitis, Fournier's gangrene, or gas gangrene (based on International Classification of Diseases, Tenth Revision, Clinical Modification codes) were included for analysis.

RESULTS

A total of 355 patients were identified. Black and Hispanic patients accounted for the most admissions in 2016 and 2018, respectively (P = 0.024). Compared to White patients, more Black patients were insured by Medicaid (P = 0.037) and were in the first zip code-based income quartile (P = 0.005). The leading infection overall was necrotizing fasciitis and most patients (81.7%) underwent a surgical procedure by the first calendar day after admission. Although the proportion of Black patients undergoing subcutaneous tissue and fascia excisions was more than that of White patients (P = 0.005), there were no significant differences by race in the time to first procedure, the total number of procedures, or number of postoperative complications. Our amputation and mortality rates were low and unreportable, but there were no differences by race.

CONCLUSIONS

NSTI is rare in the pediatric population and mortality is low. Black patients are disproportionately diagnosed, but these disparities do not extend to disease treatment or outcomes.

Necrotising Fasciitis of Neck in a 7 Day Neonate Following Insect Bite

Necrotizing fasciitis is severe inflammation of the muscle sheath that leads to necrosis of the subcutaneous tissue and adjacent fascia. The disease entity is more commonly described in adults and the literature seems quite sparse with respect to children and even lesser in neonates. Monomicrobial infection with necrotizing fasciitis in Neck following insect bite is rare and even rarer in neonates. 07 day old neonate had history of rapid onset discoloration and swelling of the Right side of Neck following an insect bite which was followed fever and irritability and eventually black discoloration. The neonate was irritable with excessive crying, had tachycardia, tachypnea and was febrile. There was a diffuse swelling in the right side of neck with multiple patchy areas of tissue necrosis in form of blackening of the skin over the swelling Management: Necrotizing fasciitis was identified early and the neonate prepped for surgery. All the biochemical parameters were WNL. CRP was raised. Empirical treatment with Cefotaxime, Clindamycin and cloxacillin started and neonate taken for local debridement. All necrotic tissue was removed including tail of parotid. Over next 5 days serial debridement and wound wash with Hydrogen peroxidase, Betadine, saline and metronidazole was done. The edges of the wound became healthy with no new slough formation and necrotic tissue. An early diagnosis and definitive management with both surgery and antibiotics is the key to a reduce mortality in the neonates. It needs to be followed up with good local wound care.

Morbidity and Mortality of Necrotizing Fasciitis and Their Prognostic Factors in Children

BACKGROUND

This is a prospective study of the clinico-etiologic profile and factors affecting outcomes in 40 children managed for necrotizing fasciitis (NF).

MATERIALS AND METHODS

Demographic details, clinical characteristics, and laboratory parameters were recorded, and the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was calculated. Primary outcome (survival vs. nonsurvival) was noted, and prognostic factors were identified.

RESULTS

Initiating factors included boils (45%), i.v. cannula extravasations (22.5%), and blunt trauma (17.5%). Lesion (s) were predominantly on the lower limbs (35%) and trunk (25%). Twenty-two patients (55%) had <5% body surface area (BSA) involved. Severely deranged clinical and laboratory parameters were common. Ultrasound localized fluid collections. Pus cultures showed methicillin-resistant Staphylococcus aureus (52.5%), methicillin-sensitive S. aureus [27.5%], and polymicrobial growth (20%). Blood culture was positive in 24 patients (60%). Most isolates were sensitive to clindamycin and amoxy-clavulanate. Prognostic factors for mortality (n = 6; 15%) included categorization as "Sick," BSA involvement >10%, thrombocytopenia, raised serum creatinine, late debridement, and polymicrobial blood culture isolates. All six nonsurvivors had a LRINEC score of ≥8 and positive blood cultures. Six patients (20.7%) developed unsightly scars and 5 (17.24%) contractures across joints.

CONCLUSIONS

Pediatric NF has significant morbidity and mortality. Patients with adverse prognostic factors can benefit from early referral to a facility with a critical care unit. Adequate wound management is essential to minimize residual deformity.

Updates and Advances: Pediatric Musculoskeletal Infection Imaging Made Easier for Radiologists and Clinicians

Infants and children often present with a wide range of musculoskeletal (MSK) infections in daily clinical practice. This can vary from relatively benign superficial infections such as cellulitis to destructive osseous and articular infections and life-threatening deep soft tissue processes such as necrotizing fasciitis. Imaging evaluation plays an essential role for initial detection and follow-up evaluation of pediatric MSK infections. Therefore, a clear and up-to-date knowledge of imaging manifestations in MSK infections in infants and children is imperative for timely and accurate diagnosis that, in turn, can result in optimal patient management. This article reviews an up-to-date practical imaging techniques, the differences between pediatric and adult MSK infections, the spectrum of pediatric MSK infections, and mimics of pediatric MSK infections encountered in daily clinical practice by radiologists and clinicians.

Necrotizing Soft Tissue Infection: A Single-Center Retrospective Study of Treatment and Outcomes

Introduction

Necrotizing fasciitis is a severe inflammatory disease of the body's soft tissue characterized by spreading rapidly and high mortality. Rapid surgical intervention along with other supportive measures of treatment have a great impact on the outcome of treatment.

Material and methods

This study was conducted by a retrospective medical record review of all patients with a microbiologically and clinically confirmed diagnosis of necrotizing fasciitis who were admitted to the general surgery department at the General Hospital Novi Pazar, Serbia, during the period between 2017 and 2020. Demographic, clinical, laboratory, and microbiology data were analyzed.

Results

A total of 13 cases were identified, which represents 0.21% of the total number of patients treated at the surgical department during the period January 2017 to November 2020. The mean age of patients was 55 years, with a male/female ratio of 1:1.6. All of them had at least one comorbidity and more than half had three or more. Diabetes, cardiovascular diseases, and obesity were the most common comorbidities. The most common causes of infection were Klebsiella spp, Pseudomonas aeruginosa, S. pyogenes, and S. aureus. All patients received multiple surgical interventions (mean 2.3).

Conclusion

Treating necrotizing fasciitis requires a multidisciplinary approach. Early diagnosis and rapid clinical response allow for better disease outcomes. Getting to know more about necrotizing fasciitis will help doctors make better decisions when treating it.

Cultured Epidermal Autograft for Total Scalp Reconstruction in a Neonate Following Necrotizing Fasciitis

Necrotizing fasciitis in the pediatric population is a particularly difficult diagnostic and management challenge. Options for soft tissue reconstruction of wounds following surgical debridement have been historically limited, yet recent advancements in bioengineered tissue and matrices have introduced alternative methods of treatment for these patients. We present a case of neonatal necrotizing fasciitis of the scalp requiring full-thickness surgical debridement, which was successfully reconstructed using Epicel cultured epidermal autograft (CEA). A 4-day-old female neonate (gestational age 40 weeks) presented with scalp erythema, blistering, and sepsis following peripartum fetal scalp electrode monitoring. She underwent surgical excision of the scalp to healthy bleeding tissue resulting in a defect of approximately 97% of the scalp, measuring 18 × 19 cm including 4 × 3.5 cm of exposed bone at the occiput. Initial provisional coverage of the defect was obtained with Integra collagen matrix bilayer dressing to stimulate granulation over exposed bone. Concurrently, a 2 × 4-cm excisional biopsy of the left groin skin was obtained for CEA in vitro expansion over 21 days. Then, autograft sheets were applied to achieve total scalp coverage. Clinical assessments at 1 week, 1 month, and 2 months postoperatively exhibited, approximately, 60% take, 80% take, and 90% take, respectively. Scalp involvement in neonatal necrotizing infections is a notably rare presentation as surmised by our review of the literature, and to our knowledge, this is the first report on the use of Integra and CEA for near-total neonatal scalp coverage.

Atypical Presentation of Severe Fungal Necrotizing Fasciitis in a Patient with X-Linked Agammaglobulinemia

X-linked agammaglobulinemia is a rare primary immunodeficiency due to a BTK mutation. The patients are characteristically deficient in peripheral B cells and serum immunoglobulins. While they are susceptible to infections caused by bacteria, enteroviruses, and parasites, fungal infections are uncommon in XLA patients. Here, we report a boy of Malay ethnicity who suffered from recurrent upper respiratory tract infections and severe progressive necrotizing fasciitis caused by Saksenaea erythrospora. Immunological tests showed a B cell deficiency and hypogammaglobulinemia. Whole-exome sequencing identified a dinucleotide deletion (c.1580_1581del) in BTK, confirmed by Sanger sequencing and predicted to be disease causing by in silico functional prediction tools (Varsome and MutationTaster2) but was absent in the gnomAD database. This mutation resulted in a frameshift and premature termination (p.C527fs), which disrupted the protein structure. The mother was heterozygous at the mutation site, confirming her carrier status. Flow cytometric analysis of monocyte BTK expression showed it to be absent in the patient and bimodal in the mother. This study describes a novel BTK mutation in a defined hotspot and an atypical fungal phenotype in XLA. Further studies are required to understand the pathogenesis of fungal infection in XLA.

Flap coverage for necrotising soft tissue infections: A systematic review

BACKGROUND

Necrotising soft tissue infections (NSTI) are destructive and often life-threatening infections of the skin and soft tissue, necessitating prompt recognition and aggressive medical and surgical treatment. After debridement, the aim of surgical closure and reconstruction is to minimize disability and optimize appearance. Although skin grafting may fulfil this role, techniques higher on the reconstructive ladder, including local, regional and free flaps, are sometimes undertaken. This systematic review sought to determine the circumstances when this is true, which flaps were most commonly employed, and for which anatomical areas.

METHODS

A systematic review of the literature was conducted utilising electronic databases (Medline, Embase, Cochrane Library). Full text studies of flaps used for the management of NSTI's (including Necrotising Fasciitis and Fournier Gangrene) were included. The web-based program 'Covidence' facilitated storage of references and data management. Data obtained in the search included reference details (journal, date and title), the study design, the purpose of the study, the study findings, number of patients with NSTI included, the anatomical areas of NSTI involved, the types of flaps used, and the complication rate.

RESULTS

After screening 4555 references, 501 full text manuscripts were assessed for eligibility after duplicates and irrelevant studies were excluded. 230 full text manuscripts discussed the use of 888 flap closures in the context of NSTI in 733 patients; the majority of these were case series published in the last 20 years in a large variety of journals. Reconstruction of the perineum following Fournier's gangrene accounted for the majority of the reported flaps (58.6%). Free flaps were used infrequently (8%), whereas loco-regional muscle flaps (18%) and loco-regional fasciocutaneous flaps (71%) were employed more often. The reported rate of partial or complete flap loss was 3.3%.

CONCLUSION

Complex skin and soft tissue defects from NSTIs, not amenable to skin grafting, can be more effectively and durably covered using a spectrum of flaps. This systematic review highlights the important contribution that the plastic surgeon makes as an integral member of multidisciplinary teams managing these patients.

Noma and Necrotizing Fasciitis of the Face and Neck

Necrotizing fasciitis (NF) is part of the class of necrotizing soft tissue infections characterized by rapid fascial spread and necrosis of the skin, subcutaneous tissue, and superficial fascia. If left untreated, NF can rapidly deteriorate into multiorgan shock and systemic failure. NF most commonly infects the trunk and lower extremities, although it can sometimes present in the head and neck region. This review provides an overview of NF as it relates specifically to the head and neck region, including its associated clinical features and options for treatment. Noma, a related but relatively unknown disease, is then described along with its relationship with severe poverty.

Necrotizing fasciitis, causative agents and management: a five-year retrospective study in two tertiary care hospitals in Central Malaysia

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.