Necrotizing Fasciitis due to Candida Infection after Thyroid Surgery

Fatal Necrotizing Fasciitis Mediated by Escherichia coli After Parotidectomy and Neck Dissection: A Case Report and Review of the Literature

Necrotizing soft tissue infection (NSTI) is a rare, but life-threatening, complication of head and neck surgery. We present a 70-year-old male with a history of immunosuppression who presented with polymicrobial NSTI following parotidectomy and neck dissection for cutaneous squamous cell carcinoma. The objective of this report was to promote awareness for NSTI following parotidectomy and selective neck dissection and highlight the management measures that can optimize survival outcomes. We performed a database search that identified 1,025 citations, of which 5 articles described classified as craniocervical necrotizing fasciitis following major head and neck surgery. Consent was obtained from the patient for inclusion in the research study and Institutional Review Board approval was waived. Our literature review yielded 6 cases of craniocervical necrotizing fasciitis following major head and neck surgery. This NSTI, however-unlike the others previously reported-was predominantly mediated by Escherichia coli, a bacterium associated with elevated mortality rates. Despite immediate awake fiberoptic intubation, repeated surgical debridement, and empirical antibiotic therapy, he deteriorated rapidly and was withdrawn from life-support on postoperative day seven. Prophylactic antibiotics, airway management, prompt diagnosis, and surgical debridement are critical for limiting mortality in NSTI of the head and neck.

Penetration of echinocandins into wound secretion of critically ill patients

Purpose

Wound infections caused by Candida are life-threatening and difficult to treat. Echinocandins are highly effective against Candida species and recommended for treatment of invasive candidiasis. As penetration of echinocandins into wounds is largely unknown, we measured the concentrations of the echinocandins anidulafungin (AFG), micafungin (MFG), and caspofungin (CAS) in wound secretion (WS) and in plasma of critically ill patients.

Methods

We included critically ill adults with an indwelling wound drainage or undergoing vacuum-assisted closure therapy, who were treated with an echinocandin for suspected or proven invasive fungal infection. Concentrations were measured by liquid chromatography with UV (AFG and MFG) or tandem mass spectrometry detection (CAS).

Results

Twenty-one patients were enrolled. From eight patients, serial WS samples and simultaneous plasma samples were obtained within a dosage interval. AFG concentrations in WS amounted to < 0.025–2.25 mg/L, MFG concentrations were 0.025–2.53 mg/L, and CAS achieved concentrations of 0.18–4.04 mg/L. Concentrations in WS were significantly lower than the simultaneous plasma concentrations and below the MIC values of some relevant pathogens.

Conclusion

Echinocandin penetration into WS displays a high inter-individual variability. In WS of some of the patients, concentrations may be sub-therapeutic. However, the relevance of sub-therapeutic concentrations is unknown as no correlation has been established between concentration data and clinical outcome. Nevertheless, in the absence of clinical outcome studies, our data do not support the use of echinocandins at standard doses for the treatment of fungal wound infections, but underline the pivotal role of surgical debridement.

Supplementary Information

The online version contains supplementary material available at 10.1007/s15010-021-01604-x.