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Dhanasekara CS, Marschke B, Morris E, Kahathuduwa CN, Dissanaike S. Regional Variations in Microbiology and Outcomes of Necrotizing Soft Tissue Infections: A Systematic Review and Meta-Analysis. Surg Infect (Larchmt) 2022; 23:634-644. [PMID: 35904966 DOI: 10.1089/sur.2022.142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Frequency, microbiology, and outcomes of necrotizing soft tissue infections (NSTIs) could vary across the United States because of differences in locoregional and environmental factors. We synthesized the literature from across the regions of the United States on NSTIs in a systematic review/meta-analysis. Methods: PubMed, ProQuest, Scopus, and Web of Science databases were systematically searched and screened. DerSimonian-Laird random-effects meta-analyses were performed using 'meta' package in R to determine pooled prevalences. Meta-regression analyses examined moderator effects of risk factors. Results: Twenty-seven studies (2,242 total patients) were included. Pooled prevalences of polymicrobial and monomicrobial infections were 52.2% and 39.9%, respectively. The prevalence of monomicrobial NSTIs increased over the last two decades (p = 0.018), whereas polymicrobial infections declined (p = 0.003). Meta-regression analysis showed that most polymicrobial NSTIs were Fournier gangrene (p < 0.001), whereas monomicrobial NSTIs mostly affected extremities (p < 0.001). Staphylococcus aureus was the most common organism isolated (predominantly in the South), followed by Bacteroides spp. (predominately in the East) and Streptococcus pyogenes. Methicillin-resistant Staphylococcus aureus (MRSA) accounted for 11.9% of NSTIs, mainly in the South. The overall mortality rate was 17.8% and declined over last two decades (p < 0.001), with the lowest rate reported in the last decade at 13% without any regional differences. Conclusions: Advancement in the management of NSTIs may have contributed to the observed decline in NSTI-related mortality in the United States. However, the proportion of monomicrobial NSTIs seems to be increasing, possibly because of increased comorbidities affecting extremities. Causative organisms varied by region. Multi-center observational studies are warranted to confirm our observations.
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Affiliation(s)
- Chathurika S Dhanasekara
- Department of Surgery, School of Health Professions, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Brianna Marschke
- Department of Surgery, School of Health Professions, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Erin Morris
- Department of Surgery, School of Health Professions, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Chanaka N Kahathuduwa
- Department of Psychiatry, School of Medicine, School of Health Professions, Texas Tech University Health Sciences Center, Lubbock, Texas, USA.,Department of Laboratory Sciences and Primary Care, School of Health Professions, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Sharmila Dissanaike
- Department of Surgery, School of Health Professions, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
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Dhanasekara CS, Marschke B, Morris E, Kahathuduwa CN, Dissanaike S. Global patterns of necrotizing soft tissue infections: A systematic review and meta-analysis. Surgery 2021; 170:1718-1726. [PMID: 34362585 DOI: 10.1016/j.surg.2021.06.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/29/2021] [Accepted: 06/21/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Frequency, microbiology, and outcomes of necrotizing soft tissue infections vary based on locoregional and environmental factors; however, there has been no global survey of these patterns. We performed a systematic review/meta-analysis on published reports of necrotizing soft tissue infections from across the globe. METHODS Peer-reviewed empirical studies examining rates of polymicrobial and monomicrobial necrotizing soft tissue infections with microbial isolation and overall mortality rate were extracted along with geographic location using PubMed, Scopus, ProQuest, and Web of Science. Random-effects meta-analyses and sensitivity analyses were performed, adjusting for publication bias. Meta-regression analyses examined moderator effects of risk factors. RESULTS One hundred and five studies (8,718 total patients) were included. Pooled prevalence of polymicrobial and monomicrobial infections were 53% and 37.9%, respectively. Truncal necrotizing soft tissue infections were commonly polymicrobial (P < .001), whereas monomicrobial infections prevailed in extremities (P = .008). Global prevalence of monomicrobial necrotizing soft tissue infections was observed to increase by 1.1% annually (P = .003). Staphylococcus aureus was the most common organism globally and in North America, Asia, the Middle East, and Africa, followed by Streptococcus pyogenes and Escherichia coli. Methicillin-resistant S. aureus accounted for 16% of necrotizing soft tissue infections globally. Overall mortality was 23.1%, observed to decline globally over the last decade (P = .020). No regional differences were noted for mortality. CONCLUSION Although polymicrobial infections remain predominant worldwide, the incidence of monomicrobial infections is increasing. The observed decline in necrotizing soft tissue infection-related mortality is encouraging and may reflect advances in management, despite major variations in available healthcare resources globally.
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Affiliation(s)
| | - Brianna Marschke
- Department of Surgery, Texas Tech University Health Science Center, Lubbock, TX
| | - Erin Morris
- Department of Surgery, Texas Tech University Health Science Center, Lubbock, TX
| | - Chanaka N Kahathuduwa
- Department of Psychiatry, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX; Department of Laboratory Sciences and Primary Care, School of Health Professions, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Science Center, Lubbock, TX.
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Schroder̈ A, Gerin A, Firth GB, Hoffmann KS, Grieve A, von Sochaczewski CO. A systematic review of necrotising fasciitis in children from its first description in 1930 to 2018. BMC Infect Dis 2019; 19:317. [PMID: 30975101 PMCID: PMC6458701 DOI: 10.1186/s12879-019-3941-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 03/28/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Necrotising fasciitis is a rapidly progressing soft-tissue infection with a low incidence that carries a relevant risk of morbidity and mortality. Although necrotising fasciitis is often fatal in adults, its case fatality rate seems to be lower in children. A highly variable clinical presentation makes the diagnosis challenging, which often results in misdiagnosis and time-delay to therapy. METHODS We conducted a protocol-based systematic review to identify specific features of necrotising fasciitis in children aged one month to 17 years. We searched 'PubMed', 'Web of Science' and 'SCOPUS' for relevant literature. Primary outcomes were incidence and case fatality rates in population-based studies, and skin symptoms on presentation. We also assessed signs of systemic illness, causative organisms, predisposing factors, and reconstructive procedures as secondary outcomes. RESULTS We included five studies reporting incidence and case fatality rates, two case-control studies, and 298 cases from 195 reports. Incidence rates varied between 0.022 and 0.843 per 100,000 children per year with a case-fatality rate ranging from 0% to 14.3%. The most frequent skin symptoms were erythema (58.7%; 175/298) and swelling (48%; 143/298), whereas all other symptoms occurred in less than 50% of cases. The majority of cases had fever (76.7%; 188/245), but other signs of systemic illness were present in less than half of the cohort. Group-A streptococci accounted for 44.8% (132/298) followed by Gram-negative rods in 29.8% (88/295), while polymicrobial infections occurred in 17.3% (51/295). Extremities were affected in 45.6% (136/298), of which 73.5% (100/136) occurred in the lower extremities. Skin grafts were necessary in 51.6% (84/162) of the pooled cases, while flaps were seldom used (10.5%; 17/162). The vast majority of included reports originate from developed countries. CONCLUSIONS Clinical suspicion remains the key to diagnose necrotising fasciitis. A combination of swelling, pain, erythema, and a systemic inflammatory response syndrome might indicate necrotising fasciitis. Incidence and case-fatality rates in children are much smaller than in adults, although there seems to be a relevant risk of morbidity indicated by the high percentage of skin grafts. Systematic multi-institutional research efforts are necessary to improve early diagnosis on necrotising fasciits.
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Affiliation(s)
- Arne Schroder̈
- Klinik für Anästhesiologie und Intensivmedizin, Marienkrankenhaus Bergisch-Gladbach, Dr.-Robert-Koch-Straße 18, Bergisch-Gladbach, D-51465 Germany
| | - Aurelié Gerin
- Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, 26 Chris Hani Road, Johannesburg, ZA-1860 South Africa
| | - Gregory B. Firth
- Department of Orthopaedic Surgery, Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, 26 Chris Hani Road, Johannesburg, ZA-1860 South Africa
| | - Kelly S. Hoffmann
- Department of Paediatric Surgery, Universitair Medisch Centrum Groningen, Hanzeplein 1, Groningen, NL-9713 The Netherlands
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, 26 Chris Hani Road, Johannesburg, ZA-1860 South Africa
| | - Andrew Grieve
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, 26 Chris Hani Road, Johannesburg, ZA-1860 South Africa
| | - Christina Oetzmann von Sochaczewski
- Department of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, 26 Chris Hani Road, Johannesburg, ZA-1860 South Africa
- Klinik und Poliklinik für Kinderchirurgie, Universitätsmedizin Mainz, Langenbeckstraße 1, Mainz, D-55131 Germany
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Necrotizing Soft Tissue Infections in the Vasculopathic Patient: Review of Literature. Int Surg 2019. [DOI: 10.9738/intsurg-d-19-00019.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background:
Necrotizing soft tissue infection is a surgical emergency associated with high mortality. Its presence in patients with risk factors for peripheral arterial disease such as diabetes mellitus is consistently associated with significantly poorer outcomes. Though it has been over a century since it was initially described in the literature, mortality rates remain high and treatment regimens are not standardized.
Materials and methods:
PubMed and Cochrane databases were searched for articles pertaining to necrotizing soft tissue infections. Articles were screened for relevance with the intent to compare outcomes in prospective studies of patients with diabetes mellitus or peripheral arterial disease. Patient demographics, clinical findings, mortality, rates of amputation, and morbidity were intended to be compared.
Results:
857 articles were identified, 165 duplicates were removed, and 6 prospective trials were identified for inclusion. Due to significant paucity of data, patient heterogeneity, and lack of standardization for surgical management, a descriptive review of the literature in relation to necrotizing soft tissue infections was pursued, with a focus on high-risk patients with peripheral arterial disease or diabetes mellitus.
Conclusions:
Early aggressive surgical intervention or major amputation may reduce mortality at the cost of increased disability and poorer quality of life in the long term, and may be appropriate in vasculopaths with poorly controlled diabetes and rapidly progressive fulminant infection. However, there is a deficiency in high-level evidence supporting surgical decision-making in this setting, with no standardized protocols for amputation. Future research will be needed to clarify the patient population who would benefit from radical amputation versus intention for limb salvage.
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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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Presenting features of extremity necrotizing fasciitis in the pediatric patient: a case-control analysis. J Pediatr Orthop B 2018; 27:461-466. [PMID: 28877051 DOI: 10.1097/bpb.0000000000000493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This analysis sought to develop a tool for early differentiation between pediatric necrotizing fasciitis (NF) of the extremity and more benign infection. All diagnoses of extremity NF, cellulitis, and abscess from a single institution from 2009 to 2015 were included. Vitals and laboratory values were compared between cohorts using analysis of variance and decision tree analysis. NF was associated with thrombocytopenia, hyperthermia, tachycardia, and tachypnea. Decision tree analysis identified C-reactive protein more than 7.0 to be 100% sensitive and 95.7% specific for differentiating NF from cellulitis or abscess. The results offer quantitative support for clinical suspicion of NF in the evaluation of pediatric extremity infection.
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Jauregui JJ, Bor N, Thakral R, Standard SC, Paley D, Herzenberg JE. Life- and limb-threatening infections following the use of an external fixator. Bone Joint J 2015; 97-B:1296-300. [PMID: 26330600 DOI: 10.1302/0301-620x.97b9.35626] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
External fixation is widely used in orthopaedic and trauma surgery. Infections around pin or wire sites, which are usually localised, non-invasive, and are easily managed, are common. Occasionally, more serious invasive complications such as necrotising fasciitis (NF) and toxic shock syndrome (TSS) may occur. We retrospectively reviewed all patients who underwent external fixation between 1997 and 2012 in our limb lengthening and reconstruction programme. A total of eight patients (seven female and one male) with a mean age of 20 years (5 to 45) in which pin/wire track infections became limb- or life-threatening were identified. Of these, four were due to TSS and four to NF. Their management is described. A satisfactory outcome was obtained with early diagnosis and aggressive medical and surgical treatment. Clinicians caring for patients who have external fixation and in whom infection has developed should be aware of the possibility of these more serious complications. Early diagnosis and aggressive treatment are required in order to obtain a satisfactory outcome.
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Affiliation(s)
- J J Jauregui
- Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - N Bor
- Emek Medical Center, Afula, Israel
| | - R Thakral
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - S C Standard
- Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - D Paley
- Paley Advanced Limb Lengthening Institute, West Palm Beach, Florida, USA
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