1
|
Allaw F, Wehbe S, Kanj SS. Necrotizing fasciitis: an update on epidemiology, diagnostic methods, and treatment. Curr Opin Infect Dis 2024; 37:105-111. [PMID: 38037890 DOI: 10.1097/qco.0000000000000988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
PURPOSE OF REVIEW The aim of this review is to discuss the latest evidence of epidemiology, diagnostic methods, and treatment of necrotizing soft tissue infections (NSTIs) with a particular focus on necrotizing fasciitis (NF). RECENT FINDINGS NSTIs have been historically referred to as NF but encompass a broader range of infections, with variable rates ranging from 0.86 to 32.64 per 100 000 person-years, influenced by factors such as climate and seasonal variations. They have diverse microbiological profiles categorized into different types based on the involved pathogens, including polymicrobial or monomicrobial infections caused by organisms such as group A streptococcus (GAS), Staphylococcus aureus , some Gram-negative pathogens, and filamentous fungi following trauma and natural disasters. Diagnosis relies on clinical symptoms and signs, laboratory markers, and imaging. However, the gold standard for diagnosis remains intraoperative tissue culture. Treatment involves repeated surgical debridement of necrotic tissues in addition to intravenous antibiotics. Adjuvant therapies with intravenous immunoglobulin (IVIG) and hyperbaric oxygen therapy (HBOT) might have a role. Soft tissue reconstruction may be necessary following surgery. SUMMARY Prompt diagnosis and proper medical and surgical management of NSTI will improve outcomes.
Collapse
Affiliation(s)
- Fatima Allaw
- Division of Infectious Diseases, Department of Internal Medicine, American University of Beirut Medical Center
| | - Saliba Wehbe
- Division of Infectious Diseases, Department of Internal Medicine, American University of Beirut Medical Center
| | - Souha S Kanj
- Division of Infectious Diseases, Department of Internal Medicine, American University of Beirut Medical Center
- Center for Infectious Disease Research, American University of Beirut, Beirut, Lebanon
| |
Collapse
|
2
|
Burillo A, Pulido-Pérez A, Bouza E. Current challenges in acute bacterial skin infection management. Curr Opin Infect Dis 2024; 37:71-79. [PMID: 38179868 DOI: 10.1097/qco.0000000000000989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
PURPOSE OF REVIEW There are aspects of skin and soft tissue infections (SSTIs) that remain unresolved, such as current numbers, classification criteria, how best to define severity and predict the outcome, what diagnostic tests to perform, what new treatment options are available, or what the duration of antibiotic treatment should be. We have reviewed the literature over the last 18 months to clarify these issues and provide our opinion. RECENT FINDINGS SSTIs are common and among the top 10 most frequent infections worldwide. They represent a burden on the healthcare system and have a major impact on the quality of life of patients. Regarding classification, the Infectious Diseases Society of America (IDSA) provides a practical guide that distinguishes between uncomplicated and complicated infections, acute and chronic wound infections, and necrotising and nonnecrotizing infections based on skin extension and tissue necrosis. With new microbiological and imaging diagnostic techniques, SSTIs can now be better diagnosed. New PCR techniques are available, and mass spectrometry can be applied to samples collected in liquid transport media. Moreover, new treatment methods such as photodynamic therapy, reactive oxygen, and phages are emerging. SSTI patients can be treated with shorter antibiotic courses if they receive an active drug with good tissue penetration. Antibiotic treatment in necrotizing infections can be shortened to 48 h after the last debridement. SUMMARY SSTIs remain a challenge regarding rapid and accurate diagnosis and clinical management.
Collapse
Affiliation(s)
- Almudena Burillo
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón
- Medicine Department, School of Medicine, Universidad Complutense de Madrid
- Gregorio Marañón Health Research Institute, (IiSGM)
| | - Ana Pulido-Pérez
- Gregorio Marañón Health Research Institute, (IiSGM)
- Department of Dermatology, Hospital General Universitario Gregorio Marañón
| | - Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón
- Medicine Department, School of Medicine, Universidad Complutense de Madrid
- Gregorio Marañón Health Research Institute, (IiSGM)
- CIBER of Respiratory Diseases (CIBERES CB06/06/0058), Madrid, Spain
| |
Collapse
|
3
|
Destoop J, Vanhaecke C, Bani-Sadr F, Plenier Y, Viguier MA, Hentzien M. Significantly reduced duration of antibiotic prescription for erysipelas subsequent to the 2019 French guidelines on skin and soft tissue infection: A before-after study. Infect Dis Now 2024; 54:104887. [PMID: 38492802 DOI: 10.1016/j.idnow.2024.104887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 03/08/2024] [Accepted: 03/12/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND New skin and soft tissue infections (SSTI) guidelines were published in 2019 in France, changing the recommended duration for antibiotic treatment. The objective of the present study was to assess the impact of the publication of the 2019 French guidelines on SSTIs on the duration of antibiotic prescription for erysipelas. METHODS In a before-after study (a year before and a year after April 1st, 2019), we included all adult patients diagnosed with erysipelas in Reims University Hospital medical wards and the emergency department. We retrospectively retrieved antibiotic prescription duration in the patients' medical files. RESULTS Among 50 patients in the "before" and 39 in the "after" group, the mean duration of antibiotic prescription was significantly shorter in the "after" group (9.4 ± 2.8 vs. 12.4 ± 3.8 days, p = 0.0001). CONCLUSIONS A 25% decrease in the duration of antibiotic prescription for erysipelas was observed following the implementation of these guidelines, providing useful information for an antibiotic stewardship policy.
Collapse
Affiliation(s)
- Justin Destoop
- Department of Dermatology, Robert Debré University Hospital, Avenue du general Koenig, 51092 Reims Cedex, France.
| | - Clélia Vanhaecke
- Department of Dermatology, Robert Debré University Hospital, Avenue du general Koenig, 51092 Reims Cedex, France
| | - Firouzé Bani-Sadr
- Department of Internal Medicine, Infectious Diseases, and Clinical Immunology, Robert Debré University Hospital, Avenue du general Koenig, 51092 Reims Cedex, France
| | - Yannick Plenier
- Pediatric Emergency Department, American Memorial Hospital, 47 Rue Cognacq-Jay, 51100 Reims, France
| | - Manuelle-Anne Viguier
- Department of Dermatology, Robert Debré University Hospital, Avenue du general Koenig, 51092 Reims Cedex, France
| | - Maxime Hentzien
- Department of Internal Medicine, Infectious Diseases, and Clinical Immunology, Robert Debré University Hospital, Avenue du general Koenig, 51092 Reims Cedex, France; University of Reims Champagne-Ardenne, Reims, France
| |
Collapse
|
4
|
Peghin M, Graziano E, Grossi PA. Skin and soft tissue infections in solid organ transplants. Curr Opin Infect Dis 2024; 37:112-120. [PMID: 38050739 DOI: 10.1097/qco.0000000000000998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
PURPOSE OF REVIEW Skin and soft tissue infections (SSTI) in solid organ transplant (SOT) recipients may be a great challenge for clinicians caring for SOT due to the involvement of both common and opportunistic pathogens associated with a blunted immune response. The purpose of this review is to outline current literature and describe open issues on the management of SSTI in this special population. RECENT FINDINGS Clinical presentation in SOT recipients can manifest as isolated skin lesions after primary inoculation or be the sign of a disseminated infection. Tissue samples for microscopy and histopathology are crucial to making an accurate diagnosis given the nonspecific and heterogeneous appearance of skin lesions. Multidisciplinary teams are required for a comprehensive diagnosis and management. SUMMARY SSTI are frequent contributors to morbidity and mortality in SOT. Specific research focused on the clinical presentation, risk factors and management in this special population is needed.
Collapse
Affiliation(s)
- Maddalena Peghin
- Infectious and Tropical Diseases Unit, Department of Medicine and Surgery, University of Insubria, ASST-Sette Laghi, Varese, Italy
| | | | | |
Collapse
|
5
|
Suijker J, Pijpe A, Hoogerbrug D, Heymans MW, van Zuijlen PPM, Halm JA, Meij-de Vries A. IDENTIFICATION OF POTENTIALLY MODIFIABLE FACTORS TO IMPROVE RECOGNITION AND OUTCOME OF NECROTIZING SOFT-TISSUE INFECTIONS. Shock 2024; 61:585-591. [PMID: 38315508 DOI: 10.1097/shk.0000000000002325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
ABSTRACT Background : Necrotizing soft-tissue infections (NSTIs) present a surgical emergency of increasing incidence, which is often misdiagnosed and associated with substantial mortality and morbidity. A retrospective multicenter (11 hospitals) cohort study was initiated to identify the early predictors of misdiagnosis, mortality, and morbidity (skin defect size and amputation). Methods : Patients of all ages who presented with symptoms and were admitted for acute treatment of NSTIs between January 2013 and December 2017 were included. Generalized estimating equation analysis was used to identify early predictors (available before or during the first debridement surgery), with a significance level of P < 0.05. Results : The median age of the cohort (N = 216) was 59.5 (interquartile range = 23.6) years, of which 138 patients (63.9%) were male. Necrotizing soft-tissue infections most frequently originated in the legs (31.0%) and anogenital area (30.5%). More than half of the patients (n = 114, 54.3%) were initially misdiagnosed. Thirty-day mortality was 22.9%. Amputation of an extremity was performed in 26 patients (12.5%). Misdiagnosis was more likely in patients with a higher Charlson Comorbidity Index (β = 0.20, P = 0.001), and less likely when symptoms started in the anogenital area (β = -1.20, P = 0.003). Besides the established risk factors for mortality (septic shock and age), misdiagnosis was identified as an independent predictor of 30-day mortality (β = 1.03, P = 0.01). The strongest predictors of the final skin defect size were septic shock (β = 2.88, P < 0.001) and a skin-sparing approach to debridement (β = -1.79, P = 0.002). Conclusion : Recognition of the disease is essential for the survival of patients affected by NSTI, as is adequate treatment of septic shock. The application of a skin-sparing approach to surgical debridement may decrease morbidity.
Collapse
Affiliation(s)
| | | | | | - Martijn W Heymans
- Amsterdam, Department of Epidemiology and Data Science, Amsterdam, The Netherlands
| | | | - Jens A Halm
- Trauma Unit, Amsterdam UMC location AMC, Amsterdam, The Netherlands
| | | |
Collapse
|
6
|
Westgeest AC, Damstra RJ, Mook-Kanamori DO, Schippers EF. [Soft tissue infections]. Ned Tijdschr Geneeskd 2024; 168:D7934. [PMID: 38512230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
Soft tissue infections are common, but can be difficult to diagnose and manage. In this article, the classification of soft tissue infections is discussed, as well as the diagnostic possibilities and treatment options. Furthermore, the management of recurrent infections and necrotizing soft tissue infections are discussed. The added value of compression therapy is reviewed in more detail.
Collapse
Affiliation(s)
| | - Robert J Damstra
- Nij Smellinghe, Expertisecentrum Lymfovasculaire geneeskunde, afd. Dermatologie, Drachten
| | | | | |
Collapse
|
7
|
Senneville É, Albalawi Z, van Asten SA, Abbas ZG, Allison G, Aragón-Sánchez J, Embil JM, Lavery LA, Alhasan M, Oz O, Uçkay I, Urbančič-Rovan V, Xu ZR, Peters EJG. Diagnosis of infection in the foot of patients with diabetes: A systematic review. Diabetes Metab Res Rev 2024; 40:e3723. [PMID: 37715722 DOI: 10.1002/dmrr.3723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 08/29/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND Securing an early accurate diagnosis of diabetic foot infections and assessment of their severity are of paramount importance since these infections can cause great morbidity and potential mortality and present formidable challenges in surgical and antimicrobial treatment. METHODS In June 2022, we searched the literature using PubMed and EMBASE for published studies on the diagnosis of diabetic foot infection (DFI). On the basis of pre-determined criteria, we reviewed prospective controlled, as well as non-controlled, studies in English. We then developed evidence statements based on the included papers. RESULTS We selected a total of 64 papers that met our inclusion criteria. The certainty of the majority of the evidence statements was low because of the weak methodology of nearly all of the studies. The available data suggest that diagnosing diabetic foot infections on the basis of clinical signs and symptoms and classified according to the International Working Group of the Diabetic Foot/Infectious Diseases Society of America scheme correlates with the patient's likelihood of the need for hospitalisation, lower extremity amputation, and risk of death. Elevated levels of selected serum inflammatory markers such as erythrocyte sedimentation rate (ESR), C-reactive protein and procalcitonin are supportive, but not diagnostic, of soft tissue infection. Culturing tissue samples of soft tissues or bone, when care is taken to avoid contamination, provides more accurate microbiological information than culturing superficial (swab) samples. Although non-culture techniques, especially next-generation sequencing, are likely to identify more bacteria from tissue samples including bone than standard cultures, no studies have established a significant impact on the management of patients with DFIs. In patients with suspected diabetic foot osteomyelitis, the combination of a positive probe-to-bone test and elevated ESR supports this diagnosis. Plain X-ray remains the first-line imaging examination when there is suspicion of diabetic foot osteomyelitis (DFO), but advanced imaging methods including magnetic resonance imaging (MRI) and nuclear imaging when MRI is not feasible help in cases when either the diagnosis or the localisation of infection is uncertain. Intra-operative or non-per-wound percutaneous biopsy is the best method to accurately identify bone pathogens in case of a suspicion of a DFO. Bedside percutaneous biopsies are effective and safe and are an option to obtain bone culture data when conventional (i.e. surgical or radiological) procedures are not feasible. CONCLUSIONS The results of this systematic review of the diagnosis of diabetic foot infections provide some guidance for clinicians, but there is still a need for more prospective controlled studies of high quality.
Collapse
Affiliation(s)
- Éric Senneville
- Department of Infectious Diseases, Gustave Dron Hospital, Tourcoing, France
- Univ-Lille, Lille, France
| | - Zaina Albalawi
- Department of Medicine, Division of Endocrinology, Memorial University, St. John's, Newfoundland, Canada
| | - Suzanne A van Asten
- Department of Medical Microbiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Zulfiqarali G Abbas
- Abbas Medical Centre, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Geneve Allison
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - John M Embil
- Alberta Public Laboratories, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Lawrence A Lavery
- Department of Plastic Surgery, Southwestern Medical Center, Dallas, Texas, USA
| | - Majdi Alhasan
- Department of Medicine, Prisma Health-Midlands, Columbia, South Carolina, USA
| | - Orhan Oz
- Department of Plastic Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Ilker Uçkay
- Department of Infectious Diseases, Balgrist University Hospital, Zurich, Switzerland
| | - Vilma Urbančič-Rovan
- Faculty of Medicine, University Medical Centre, University of Ljubljana, Ljubljana, Slovenia
| | - Zhang-Rong Xu
- Diabetes Centre, The 306th Hospital of PLA, Beijing, China
| | - Edgar J G Peters
- Section of Infectious Diseases, Department of Internal Medicine, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, The Netherlands
- Amsterdam Infection & Immunity, Infectious Diseases, Amsterdam, The Netherlands
| |
Collapse
|
8
|
Stallwood-Hall C, Binu V, Rajendran RK, Hiremath BV. Validating the laboratory risk indicator for necrotizing fasciitis (LRINEC) score: a prospective cohort study in a resource limited setting. ANZ J Surg 2024; 94:457-460. [PMID: 38197526 DOI: 10.1111/ans.18855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/20/2023] [Accepted: 12/23/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND Necrotising fasciitis is a rare and fulminant soft tissue infection. Prompt surgical debridement of the involved soft tissues and necrotic fascia is its definitive treatment, with any delay associated with increased mortality. The LRINEC score is a scoring system initially designed to aid in early diagnosis of necrotising fasciitis to facilitate early surgical intervention. This score utilizes common biochemical tests to produce a score of 0-13, stratifying patients into risk categories. METHODS A prospective cohort study was designed including all patients presenting with severe soft tissue infection from June 2011 to January 2014. Exclusion criteria included: less than 15 years or above 90 years, antibiotics within 48 h of presentation or prior debridement of their soft tissue infection. All patients underwent routine blood investigations, required for calculation of the LRINEC score. RESULTS The positive predictive value of the LRINEC score was 95.42%, whilst the negative predictive value was 81.16%. There was a statistically significant correlation between white cell count, serum creatinine, blood glucose level and positive histopathology. The mortality rate for patients with histopathologically-confirmed necrotising fasciitis was 10%. CONCLUSION The LRINEC score is a clinical adjunct to risk stratify patients presenting to the emergency department with soft tissue infections. It utilizes common blood tests commonly to calculate a score, which risk stratifies patients. The use of this scoring system can facilitate better allocation of resources and aids in the decision to transfer patients in rural or regional settings, which are often complicated by being a resource limited environment.
Collapse
Affiliation(s)
- Catrin Stallwood-Hall
- Department of Plastic and Reconstructive Surgery, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Vineet Binu
- Department of Paediatric Surgery, Rajagiri Hospital, Kochi, India
| | | | - Bharati V Hiremath
- Department of General Surgery, M S Ramaiah Medical College, Bangalore, India
| |
Collapse
|
9
|
Levy M, Blondé R, Naudin J, Dauger S. [Pediatric necrotizing soft-tissue infections]. Rev Prat 2024; 74:311-317. [PMID: 38551879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
PEDIATRIC NECROTIZING SOFT-TISSUE INFECTIONS. Necrotizing soft-tissue infections (NSTI) include necrotizing forms of fasciitis, myositis, and cellulitis. In children, these are extremely rare conditions with an estimated annual incidence of less than 0.1/100,000 patients aged 0-18 years in France. Nevertheless, the evolution can be very serious (6% mortality, higher than the mortality observed in paediatric intensive care units [PICU]), whereas the initial local symptoms are poor and can be falsely reassuring. The monitoring of a skin infection must be close in order not to ignore the evolution towards a NSTI. In this case, prompt transfer to a PICU with all the necessary technical facilities and used to the management of these rare conditions must be done. Early initiation of antibiotic treatment and aggressive haemodynamic resuscitation according to the latest Surviving Sepsis Campaign guidelines should be a priority. The paediatric surgeon should be called upon as soon as clinical suspicion arises and participate in the frequent clinical reassessment to determine the optimal time to perform the surgical treatment.
Collapse
Affiliation(s)
- Michaël Levy
- Service de médecine intensive et réanimation pédiatriques, hôpital universitaire Robert-Debré, AP-HP, Paris, France. Université Paris-Cité, Paris, France
| | - Renaud Blondé
- Service de réanimation pédiatrique, centre hospitalouniversitaire de Saint-Denis, La Réunion, France
| | - Jérôme Naudin
- Service de médecine intensive et réanimation pédiatriques, hôpital universitaire Robert-Debré, AP-HP, Paris, France
| | - Stéphane Dauger
- Service de médecine intensive et réanimation pédiatriques, hôpital universitaire Robert-Debré, AP-HP, Paris, France. Université Paris-Cité, Paris, France
| |
Collapse
|
10
|
Gundersen IM, Bruun T, Almeland SK, Skutlaberg DH, Nedrebø T, Rath E, Oppegaard O, Guttormsen AB, Norrby-Teglund A, Mosevoll KA, Skrede S. Necrotising soft tissue infections. Tidsskr Nor Laegeforen 2024; 144:23-0720. [PMID: 38415568 DOI: 10.4045/tidsskr.23.0720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024] Open
Abstract
Necrotising soft tissue infections can affect the skin, subcutaneous tissue, superficial fascia, deep fascia and musculature. The infections are severe, they spread quickly and can result in extensive tissue loss. Although rare, morbidity and mortality rates are high. Early clinical identification is crucial for the outcome, and rapid infection control through surgery and targeted antibiotic treatment is needed to save lives. Few prospective clinical trials have been conducted for the treatment of this type of infection. Specific challenges include rapid identification of the condition and the uncertain efficacy of the various treatment options. In this clinical review article, we describe clinical characteristics, diagnostics and treatment.
Collapse
Affiliation(s)
- Ingunn Margareetta Gundersen
- Seksjon for infeksjonssjukdommar, Medisinsk klinikk, Haukeland universitetssjukehus, og, Klinisk institutt 2, Det medisinske fakultet, Universitetet i Bergen
| | - Trond Bruun
- Seksjon for infeksjonssjukdommar, Medisinsk klinikk, Haukeland universitetssjukehus, og, Klinisk institutt 2, Det medisinske fakultet, Universitetet i Bergen
| | - Stian Kreken Almeland
- Avdeling for plastikk-, hand- og rekonstruktiv kirurgi, og, Brannskadeavdelinga, Haukeland universitetssjukehus, og, Klinisk institutt 1, Det medisinske fakultet, Universitetet i Bergen
| | | | - Torbjørn Nedrebø
- Seksjon for hyperbarmedisin, Yrkesmedisinsk avdeling, og, Kirurgisk serviceklinikk, Haukeland universitetssjukehus
| | - Eivind Rath
- Seksjon for infeksjonssjukdommar, Medisinsk klinikk, og, Mottaksklinikken, Haukeland universitetssjukehus
| | - Oddvar Oppegaard
- Seksjon for infeksjonssjukdommar, Medisinsk klinikk, Haukeland universitetssjukehus, og, Klinisk institutt 2, Det medisinske fakultet, Universitetet i Bergen
| | - Anne Berit Guttormsen
- Klinisk institutt 1, Det medisinske fakultet, Universitetet i Bergen, og, Kirurgisk serviceklinikk, Haukeland universitetssjukehus
| | - Anna Norrby-Teglund
- Center for infektionsmedicin, Karolinska Institutet, Karolinska Universitetssjukhuset
| | - Knut Anders Mosevoll
- Seksjon for infeksjonssjukdommar, Medisinsk klinikk, Haukeland universitetssjukehus, og, Klinisk institutt 2, Det medisinske fakultet, Universitetet i Bergen
| | - Steinar Skrede
- Seksjon for infeksjonssjukdommar, Medisinsk klinikk, Haukeland universitetssjukehus, og, Klinisk institutt 2, Det medisinske fakultet, Universitetet i Bergen
| |
Collapse
|
11
|
Carreras X, Salcedo AS, Ponce-Rosas L, Gonzales-Zamora JA, Diaz N, Alave J. Lemierre-like syndrome after soft tissue infection due to methicillin-resistant Staphylococcus aureus: A case report and literature review. Medicine (Baltimore) 2024; 103:e37006. [PMID: 38363930 PMCID: PMC10869080 DOI: 10.1097/md.0000000000037006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 12/29/2023] [Indexed: 02/18/2024] Open
Abstract
RATIONALE Lemierre-like syndrome (LLS) is characterized by bacteremia, septic thrombophlebitis of the internal jugular vein, and metastatic abscesses. In contrast to classic Lemierre syndrome, sources of infection are not related to oropharyngeal infections, as are frequent soft tissue infections. In recent years, Staphylococcus aureus has been identified as an emergent pathogen that causes this syndrome. The mortality rate of LLS caused by this pathogen is approximately 16%. Timely diagnosis, antibiotic treatment, and infection control are the cornerstones to treat LLS. Anticoagulant therapy as adjuvant treatment remains controversial. PATIENT CONCERNS A 31-year-old woman from California, United States (US), was admitted to the emergency room with a history of 2 days of fever and severe throbbing pain in the left cervical region. Thorax and neck CT tomography revealed confluent cavities suggestive of septic embolism in the lungs and a filiform thrombus in the lumen of the left internal jugular vein, with moderate swelling of the soft and muscular tissues. Methicillin-resistant Staphylococcus aureus (MRSA) was isolated from the blood culture. DIAGNOSIS The thrombus in the internal jugular vein associated with cellulitis in the neck and multiple cavitary lesions in the lungs support the diagnosis of LLS caused by MRSA with septic embolization. INTERVENTIONS During treatment, the patient received vancomycin IV for 25 days and returned to the US with linezolid orally. In addition, assisted video-thoracoscopy and bilateral mini-thoracotomy with pleural decortication were performed for infectious source control, where 1700cc of purulent pleural fluid was drained. OUTCOMES The patient was discharged with optimal evolution. LESSONS LLS should be suspected in patients with skin and soft tissue infections who develop thrombosis or metastatic infections. MRSA infections should be considered in patients from areas where this pathogen is prevalent.
Collapse
Affiliation(s)
- Xosse Carreras
- School of Medicine, Universidad Peruana de Ciencias Aplicadas, Lima, Peru
| | - Andrea S. Salcedo
- School of Medicine, Universidad Peruana de Ciencias Aplicadas, Lima, Peru
| | - Linda Ponce-Rosas
- Department of Medicine, Hamilton Medical Center, Dalton, GA 30720
- Peruvian American Medical Society, Albuquerque, NM
| | - Jose A. Gonzales-Zamora
- Peruvian American Medical Society, Albuquerque, NM
- Division of Infectious Diseases, Department of Medicine, University of Miami, Miller School of Medicine, FL 33136
| | - Nelson Diaz
- School of Medicine, Universidad Peruana Union, Lima, Peru
- Department of Internal Medicine, Clínica Good Hope, Lima, Peru
| | - Jorge Alave
- School of Medicine, Universidad Peruana Union, Lima, Peru
- Department of Internal Medicine, Clínica Good Hope, Lima, Peru
| |
Collapse
|
12
|
Moran Viacava F, Bandres MV, Mishkin A. A case of skin and soft tissue infection in a lung transplant recipient. Transpl Infect Dis 2024; 26:e14210. [PMID: 38041498 DOI: 10.1111/tid.14210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 11/16/2023] [Accepted: 11/24/2023] [Indexed: 12/03/2023]
Affiliation(s)
- Flavia Moran Viacava
- Department of Internal Medicine at Temple University Hospital, Philadelphia, Pennsylvania, USA
| | | | - Aaron Mishkin
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| |
Collapse
|
13
|
Maher E, Anokhin A. Bacterial Skin and Soft Tissue Infections in Older Adults. Clin Geriatr Med 2024; 40:117-130. [PMID: 38000856 DOI: 10.1016/j.cger.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Abstract
This article focuses on bacterial infections that commonly affect geriatric patients. The elderly population is at a higher risk of contracting bacterial infections due to weakened immune systems and comorbidities. The article explores the cause, pathogenesis, clinical manifestations, and treatment options of these infections. Additionally, antibiotic resistance is a growing concern in the treatment of bacterial infections. The article highlights the importance of preventing these infections through proper hygiene and wound care. This article aims to provide an understanding of bacterial infections in geriatric patients and inform health-care providers on the most effective ways to manage and prevent these infections.
Collapse
Affiliation(s)
- Eamonn Maher
- Department of Dermatology, University of Minnesota, Phillips-Wangensteen Building, 516 Delaware Street SE, Suite 1-400, Minneapolis, MN 55455, USA.
| | - Anya Anokhin
- University of Missouri, Phillips-Wangensteen Building, 516 Delaware Street SE, Suite 1-400, Minneapolis, MN 55455, USA
| |
Collapse
|
14
|
Rhoads JLW, Christensen L, Westerdahl S, Stevens V, Chapman WW, Conway M. Automatic Extraction of Skin and Soft Tissue Infection Status from Clinical Notes. Stud Health Technol Inform 2024; 310:579-583. [PMID: 38269875 DOI: 10.3233/shti231031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
The reliable identification of skin and soft tissue infections (SSTIs) from electronic health records is important for a number of applications, including quality improvement, clinical guideline construction, and epidemiological analysis. However, in the United States, types of SSTIs (e.g. is the infection purulent or non-purulent?) are not captured reliably in structured clinical data. With this work, we trained and evaluated a rule-based clinical natural language processing system using 6,576 manually annotated clinical notes derived from the United States Veterans Health Administration (VA) with the goal of automatically extracting and classifying SSTI subtypes from clinical notes. The trained system achieved mention- and document-level performance metrics of the range 0.39 to 0.80 for mention level classification and 0.49 to 0.98 for document level classification.
Collapse
Affiliation(s)
- Jamie L W Rhoads
- Dept. Dermatology, University of Utah, Salt Lake City, UT, USA
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Lee Christensen
- Dept. Biomedical Informatics, University of Utah, Salt Lake City, UT, USA
| | | | - Vanessa Stevens
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Div. Epidemiology, University of Utah, Salt Lake City, UT, USA
| | - Wendy W Chapman
- Centre for Digital Transformation of Health, University of Melbourne, VIC, Australia
| | - Mike Conway
- Centre for Digital Transformation of Health, University of Melbourne, VIC, Australia
| |
Collapse
|
15
|
Abeshouse M, Lopez-May M, Bernik S, Balija T. Necrotising cellulitis of the breast associated with a fungating mucinous adenocarcinoma. BMJ Case Rep 2024; 17:e258609. [PMID: 38216158 PMCID: PMC10806865 DOI: 10.1136/bcr-2023-258609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2024] Open
Abstract
Breast necrotising soft tissue infections (NSTIs) are rare surgical emergencies with limited cases described in the literature. Here, we discuss a unique case of a woman in her 70s who presented with newly diagnosed diabetes and a neglected right breast cancer associated with breast erythema, skin necrosis, crepitus on examination and breast soft tissue gas seen on CT requiring emergent total mastectomy with partial pectoralis muscle excision. Pathology revealed a 15 cm invasive mucinous adenocarcinoma and necrotising polymicrobial cellulitis with a large abscess cavity. She recovered from her surgery with strict glycaemic control and a 10-day course of antibiotics. Multidisciplinary tumour board recommended adjuvant anastrozole, abemaciclib and postmastectomy radiation to complete her oncological treatment. Although exceedingly rare, it is important that clinicians be aware of, promptly recognise and properly treat NSTIs of the breast, as correct care can be life-saving from both infection and malignancy.
Collapse
Affiliation(s)
- Marnie Abeshouse
- Breast Surgery, The Mount Sinai Hospital, New York, New York, USA
| | | | - Stephanie Bernik
- Breast Surgery, The Mount Sinai Hospital, New York, New York, USA
| | - Tara Balija
- Breast Surgery, The Mount Sinai Hospital, New York, New York, USA
| |
Collapse
|
16
|
Hansen SUB, Jespersen FVB, Markvart M, Hyldegaard O, Plaschke CC, Bjarnsholt T, Nielsen CH, Jensen SS. Characterization of patients with odontogenic necrotizing soft tissue infections in the head and neck area. A retrospective analysis. Acta Odontol Scand 2024; 82:40-47. [PMID: 37688516 DOI: 10.1080/00016357.2023.2254389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 08/13/2023] [Accepted: 08/27/2023] [Indexed: 09/11/2023]
Abstract
OBJECTIVE Necrotizing soft-tissue infection (NSTI) in the head and neck area may develop from odontogenic infections. The aim of this study was to characterize patients with NSTI in the head and neck with odontogenic origin in a well-defined prospectively collected cohort. MATERIAL AND METHODS Patients with NSTI in the head and neck, hospitalized between 2013 and 2017 at Copenhagen University Hospital and registered in the Scandinavian INFECT database were included. Medical records of identified patients and from the INFECT database were screened for a defined set of data including the primary focus of infection, comorbidities, predisposing factors, clinical and radiographic diagnostics, course of treatment, and treatment outcome. RESULTS Thirty-five patients with NSTI in the head and neck area were included in the study. A total of 54% had odontogenic origin, primarily from mandibular molars, and 94% had radiographic signs of infectious oral conditions. Overall, comorbidities were reported in 51% with cardiovascular disease being the most prevalent. In 20%, no comorbidities or predisposing conditions could be identified. The overall 30-day mortality rate was 9%. CONCLUSIONS More than half of NSTI cases in the head and neck region had an odontogenic origin, and special attention should be paid to infections related to mandibular molars.
Collapse
Affiliation(s)
| | | | - Merete Markvart
- Department of Odontology, University of Copenhagen, Copenhagen, Denmark
| | - Ole Hyldegaard
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christina Caroline Plaschke
- Department of Otorhinolaryngology Head and Neck Surgery and Audiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Thomas Bjarnsholt
- Department of Clinical Microbiology, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Immunology and Microbiology, Costerton Biofilm Center, University of Copenhagen, Copenhagen, Denmark
| | - Claus Henrik Nielsen
- Department of Odontology, University of Copenhagen, Copenhagen, Denmark
- Institute for Inflammation Research, Copenhagen University Hospital, Copenhagen, Denmark
| | - Simon Storgård Jensen
- Department of Odontology, University of Copenhagen, Copenhagen, Denmark
- Deparment of Oral & Maxillofacial Surgery, Copenhagen University Hospital, Copenhagen, Denmark
| |
Collapse
|
17
|
Castater C, Bishop E, Santos A, Freedberg M, Kim P, Sciarretta C. Diabetic Soft Tissue Infections. Surg Clin North Am 2023; 103:1191-1216. [PMID: 37838463 DOI: 10.1016/j.suc.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
Diabetes is a systemic illness that can cause a broad range of physiologic effects. Infection rates and wound healing are both affected through multiple mechanisms. Other physiologic changes increase risk for wounds as well as complex soft tissue infections ranging from simple cellulitis to necrotizing soft tissue infections. Clinicians and surgeons need to have a low index of suspicion for severe infection in a patient presenting with diabetes, and even more so in patients with uncontrolled diabetes.
Collapse
Affiliation(s)
- Christine Castater
- Morehouse School of Medicine, Grady Memorial Hospital 1C-144, 80 Jesse Hill Jr Drive Southeast, Atlanta, GA 30303, USA.
| | - Elliot Bishop
- Emory University, Grady Memorial Hospital Glenn Building 69 Jesse Hill Jr Drive Southeast, Atlanta, GA 30303, USA
| | - Adora Santos
- Emory University, Grady Memorial Hospital Glenn Building 69 Jesse Hill Jr Drive Southeast, Atlanta, GA 30303, USA
| | - Mari Freedberg
- Emory University, Grady Memorial Hospital Glenn Building 69 Jesse Hill Jr Drive Southeast, Atlanta, GA 30303, USA
| | - Phillip Kim
- Emory University, Grady Memorial Hospital Glenn Building 69 Jesse Hill Jr Drive Southeast, Atlanta, GA 30303, USA
| | - Christopher Sciarretta
- University of Tennessee, University of Tennessee College of Medicine, 975 3rd Avenue, Chattanooga, TN 37403, USA
| |
Collapse
|
18
|
Friederichs J, Gerl B, Schneidmüller D, Hungerer S. Severe necrotizing soft tissue infections-Is wound microbiology a prognostic factor for clinical outcome? Int Wound J 2023; 20:4235-4243. [PMID: 37646330 PMCID: PMC10681420 DOI: 10.1111/iwj.14325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 07/11/2023] [Indexed: 09/01/2023] Open
Abstract
Necrotizing soft tissue infections (NSTIs) represent similar pathophysiological features, but the clinical course might range from subacute to a rapidly progressive, fulminant sepsis. Initial wound microbiology is the base for the Guiliano classification. The timeline of microbiological colonization has not been described during the clinical course. The role of the different microbiological pathogens on the outcome and mortality is unclear. One hundred eighty patients were included with septic inflammation response syndrome on admission. Initial wound microbiology and the changes in wound microbiology were analysed during the clinical course and correlated with outcome and risk indicators. Overall mortality was 35%. Higher age, a high Charlson Comorbidity Index or ASA score and truncal infections were highly prognostic for a lethal outcome. Microbiological findings revealed significant differences in the persistence of bacteria during the course of disease. Streptococci were only detectable within the first 5 days, whereas other bacteria persisted over a longer period of time. Initial microbiological findings correlated with better prognosis when no causative agent was identified and for gram-negative rods. Varying survival rates were observed for different Streptococci, Staphylococci, Enterococci and other bacteria. The highest odds ratio for a lethal outcome was observed for Enterococci and fungi. Microbiological colonization changes during the clinical course of NSTIs and some microbiologic pathogens are predictive for worsening the outcome and survival. Streptococcus pyogenes is only detectable in the very early phase of NSTI and after 6 days not anymore detectable. Later Enterococci and fungi showed the highest odds ratios for a lethal outcome. Enterococci bacteria and fungi have yet not been considered of clinical relevance in NSTI or even as indicator for worsening the outcome.
Collapse
Affiliation(s)
- Jan Friederichs
- Trauma and Orthopedic SurgeryBG Unfallklinik MurnauMurnauGermany
| | - Benedikt Gerl
- Trauma and Orthopedic SurgeryBG Unfallklinik MurnauMurnauGermany
| | - D. Schneidmüller
- Trauma and Orthopedic SurgeryBG Unfallklinik MurnauMurnauGermany
| | - Sven Hungerer
- Trauma and Orthopedic SurgeryBG Unfallklinik MurnauMurnauGermany
- Institute for BiomechanicsParacelsus Medical UniversitySalzburgAustria
| |
Collapse
|
19
|
Agarwal N, Ashutosh, Sharma A, Gupta A. A prospective study on skin and soft tissue infections: a fact-finding mission from a tertiary centre in north India. J Wound Care 2023; 32:S4-S13. [PMID: 37907364 DOI: 10.12968/jowc.2023.32.sup11.s4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
OBJECTIVE Despite the high prevalence and poor outcome of skin and soft tissue infections (SSTIs), very few studies from India have dealt with the subject. We planned a prospective study of inpatients with SSTIs to study the aetiology, clinical presentation (severity) and outcome of patients with SSTIs in our facility. METHOD Patients with SSTIs involving >5% body surface area (BSA) and/or systemic signs were admitted to the surgery department of a teaching tertiary level hospital in Delhi, India, and were clinically classified into cellulitis, necrotising soft tissue infections (NSTIs), pyomyositis, and abscess. Demographic and clinical variables such as: age; sex; occupation; history of trauma/insect or animal bites; duration of illness; presenting symptoms and signs; comorbid conditions; predisposing factors such as lymphoedema or venous disease; hospital course; treatment instituted; complications; hospital outcome; presence of crepitus, bullae, gangrene, muscle necrosis and compartment syndrome were recorded. The chief outcome parameters were death and length of hospital stay; others, such as abscess drainage, the need for plastic surgical procedures and amputations were also noted. RESULTS Out of 250 patients enrolled in the study, 145 (58%) had NSTIs, 64 (26%) had abscesses, 15 (6%) had cellulitis and 26 (10%) had pyomyositis. Mortality was observed with NSTIs (27/145, 19%) and with pyomyositis (3/26, 11.5%). Factors affecting mortality by univariate analysis in the NSTI group were: abnormal pulse; hypotension; tachypnea; bullae; increased blood urea and serum creatinine; inotrope or ventilator support (all with p<0.001); local tenderness, gangrene, dialysis support and BSA (9.33±6.44 versus 5.12±3.62; p<0.05 for the last four). No factor was found to be significant on multivariate analysis. Variables associated with hospital stay >12 days were immunocompromise, pus discharge, ulceration or gangrene, and after interventions such as blood transfusion, drainage or skin grafting. CONCLUSION High prevalence of NSTI and pyomyositis with high mortality was observed in our SSTI patients, often in immunocompetent young individuals. Epidemiological studies focused on virulent strains of Staphylococcus aureus may be required to identify the cause, since Staphylococcal toxins have been implicated in other infections.
Collapse
Affiliation(s)
- Nitin Agarwal
- Formerly at Department of Surgery, University College of Medical Sciences (UCMS) and Guru Tegh Bahadur Hospital (GTBH), Delhi, India
- Department of Surgery and Transplant, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital (RMLH), Delhi, India
| | - Ashutosh
- Formerly at Department of Surgery, University College of Medical Sciences (UCMS) and Guru Tegh Bahadur Hospital (GTBH), Delhi, India
| | - Ashish Sharma
- Formerly at Department of Surgery, University College of Medical Sciences (UCMS) and Guru Tegh Bahadur Hospital (GTBH), Delhi, India
| | - Arun Gupta
- Formerly at Department of Surgery, University College of Medical Sciences (UCMS) and Guru Tegh Bahadur Hospital (GTBH), Delhi, India
| |
Collapse
|
20
|
Sunderkötter C, Michl C. [Practicability of the German guidelines on skin and soft tissue infections]. Dermatologie (Heidelb) 2023; 74:858-863. [PMID: 37851090 DOI: 10.1007/s00105-023-05229-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 10/19/2023]
Abstract
The guidelines on calculated parenteral initial treatment of bacterial infections in adults from 2018 were the first German language S2k guidelines for these infections. This article summarizes the experiences with respect to their practicality in the clinical routine and the resulting supplementations and comments. In view of the many different terms for soft tissue infections, the guidelines had to first establish some definitions and diagnostic criteria. Among others, the guidelines introduced the provisional term limited phlegmons (phlegmons are usually termed cellulitis in Angloamerican literature) for the frequent initially superficial soft tissue infections with Staphylococcus aureus, which do not always extend to the fascia, in order to differentiate them from erysipelas caused by Streptoccocus, which in contrast to phlegmons always respond to penicillin. The general symptoms present in erysipela are a practical differential criterion. Somewhat more complex are the definitions and recommendations for the severe forms of phlegmon, which involve the fascia and are accompanied by necrosis, so that here the practicality of the guidelines needs to prove its worth over time. The guidelines also give recommendations how to proceed in case of alleged or confirmed hypersensitivity to beta-lactam antibiotics. Currently, relevant guidelines recommend, and it is correspondingly here elaborated, that in acute cases a beta-lactam antibiotic with side chains other than those in the suspected drug may present an alternative without prior testing. Therefore, cefazolin, that does not share any side chains with other beta-lactam antibiotics, could be administered under appropriate precautionary measures. The term cellulitis is avoided in the guidelines. Since it is used frequently, and also for non-infectious dermatoses, the various meanings are discussed and distinguished from each other.
Collapse
Affiliation(s)
- Cord Sunderkötter
- Universitätsklinik und Poliklinik für Dermatologie und Venerologie, Universitätsklinikum Halle (Saale), Martin-Luther-Universität Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Deutschland.
| | - Christiane Michl
- Universitätsklinik und Poliklinik für Dermatologie und Venerologie, Universitätsklinikum Halle (Saale), Martin-Luther-Universität Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Deutschland
| |
Collapse
|
21
|
Desai V, Vokey S, Vaughan S, Somayaji R. Necrotizing Soft-Tissue Infections: A Case-Based Review. Adv Skin Wound Care 2023; 36:571-577. [PMID: 37861662 DOI: 10.1097/asw.0000000000000060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
GENERAL PURPOSE To review the assessment and management of necrotizing fasciitis. TARGET AUDIENCE This continuing-education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES After participating in this educational activity, the participant will:1. Identify the etiologic pathogens for necrotizing fasciitis.2. Summarize assessment guidelines for patients who present with signs of necrotizing fasciitis.3. Explain recommended treatment protocols for patients who have necrotizing fasciitis.
Collapse
|
22
|
Coye TL, Suludere MA, Kang GE, Crisologo PA, Malone M, Rogers LC, Lavery LA. The infected diabetes-related foot: Comparison of erythrocyte sedementation rate/albumin and C-reactive protein/albumin ratios with erythrocyte sedimentation rate and C-reactive protein to differentiate bone and soft tissue infections. Wound Repair Regen 2023; 31:738-744. [PMID: 37843834 DOI: 10.1111/wrr.13121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/17/2023] [Accepted: 09/22/2023] [Indexed: 10/17/2023]
Abstract
The objective of this study was to evaluate the effectiveness of C-reactive protein (CRP)/albumin, erythrocyte sedimentation rate (ESR)/albumin ratio, ESR, CRP and albumin to differentiate bone and soft tissue infection in persons with diabetes. We retrospectively evaluated 242 individuals admitted to hospital with diabetes-related foot infections (DFI). We categorised DFI cases as either bone (OM) or soft tissue infection based on bone culture and/or histology. We evaluated the diagnostic accuracy of CRP, ESR, albumin, CRP/albumin and ESR/albumin as biomarkers to diagnose OM in persons with diabetes. The median age was 53 years (74% male). There were 224 diabetes-related patients of which 125 had been diagnosed with osteomyelitis. The ESR/albumin and CRP/albumin ratios cut-points were >17.84 and >1.83, respectively. ESR/albumin and CRP/albumin ratios had similar diagnostic parameters: AUC (0.71, 0.71), sensitivity (70.0%, 57.0%), specificity (62.0%, 75.0%), positive predictive value (67.0%, 71.0%) and negative predictive value (66.0% and 71.0%). In contrast diagnostic efficiency of CRP and ESR were AUC 0.71 and 0.71, sensitivity (45.6%, 71.2%), specificity (85.5%, 60.7%), positive predictive value (70.0%, 65.9%) and negative predictive value (59.5%, 66.4%), respectively. When comparing area under the curves, the results showed that ESR/albumin was not significantly different to ESR alone (Delong test pvs ESR >0.1). Similarly, CRP/albumin was not significantly different to CRP alone (Delong test pvs CRP >0.1). In conclusion, ESR/albumin and CRP/albumin ratios provided comparable results as using ESR and CRP alone.
Collapse
Affiliation(s)
- Tyler L Coye
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mehmet A Suludere
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Gu Eon Kang
- Department of Bioengineering, University of Texas at Dallas, Richardson, Texas, USA
| | - P Andrew Crisologo
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Matthew Malone
- Limb Preservation and Wound Research Academic Unit, Liverpool Hospital, Southwestern Sydney LHD, Sydney, Australia
| | - Lee C Rogers
- Depart6ment of Orthopedic Surgery, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
23
|
Necrotizing Soft-Tissue Infections: A Case-Based Review. Adv Skin Wound Care 2023; 36:1. [PMID: 37861667 DOI: 10.1097/ASW.0000000000000058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
|
24
|
Yekta Aydın S, Ercan A, Ercan D. Investigation of the effects of clinical parameters on mortality in patients with necrotizing fasciitis. ULUS TRAVMA ACIL CER 2023; 29:1150-1157. [PMID: 37791443 PMCID: PMC10644092 DOI: 10.14744/tjtes.2023.31024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 07/21/2023] [Accepted: 08/04/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Necrotizing fasciitis is a rapidly progressing, potentially fatal soft-tissue infection that spreads through the fascia. Due to the late onset of diagnostic signs during the disease's advanced stage and its rapid progression, it can be challenging to make a prompt diagnosis. However, with a rapid and accurate diagnosis, the progression of the disease can be halted through appropriate early surgical intervention. Even with correct and timely treatment, the mortality rate for necrotizing fasciitis is higher compared to other soft-tissue infections. This study aims to investigate the effects of clinical parameters in patients with necrotizing fasciitis on mortality. METHODS The study included 37 patients with a necrotizing fasciitis diagnosis between 2009 and 2018. Demographic characteristics of the patients (age, gender, comorbid conditions), duration from diabetes diagnosis if present, blood glucose level at the time of diagnosis, microorganisms isolated from wound cultures, presence of positive blood cultures, administered antibiotic therapy, laboratory risk indicator for necrotizing fasciitis (LRINEC) score at presentation, number and types of surgical procedures performed, length of hospital stay, and mortality rates were retrospectively recorded. Statistical analysis of dependent and independent variables was conducted using t-tests, Mann-Whitney U test, Chi-square test, and Fisher's exact test. RESULTS Age was found to be an average of 70 in the mortality group, and it is significantly higher compared to the non-mortality group. A high LRINEC score, the presence of comorbidity, and a positive blood culture were also found to be significant in the mortal-ity group. The low number of surgical procedures performed is significantly lower in the mortality group. CONCLUSION This study highlights the conditions associated with high mortality in patients with necrotizing fasciitis, which is a treatable disease through timely and accurate diagnosis followed by appropriate antibiotic therapy and surgical intervention. It emphasizes the importance of updating the approach for high-risk group patients and aims to provide information that will help lower the threshold for diagnosing necrotizing fasciitis.
Collapse
Affiliation(s)
- Servet Yekta Aydın
- Department of Plastic, Reconstructive and Aesthetic Surgery, İstanbul University-Cerrahpasa Cerrahpasa Faculty of Medicine, İstanbul-Türkiye
| | - Alp Ercan
- Department of Plastic, Reconstructive and Aesthetic Surgery, İstanbul University-Cerrahpasa Cerrahpasa Faculty of Medicine, İstanbul-Türkiye
| | - Damla Ercan
- Department of General Surgery Clinic, Sultan 2. Abdulhamid Han Research and Training Hospital, İstanbul-Türkiye
| |
Collapse
|
25
|
Salle R, Skayem C, Hua C, Chosidow O, Duong TA. Reply to the comment of Gallardo et al to "Challenges and limitations of teledermatology for skin and soft-tissue infections: A real-world study of an expert center". J Am Acad Dermatol 2023; 89:e151-e152. [PMID: 36948299 DOI: 10.1016/j.jaad.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/11/2023] [Indexed: 03/24/2023]
Affiliation(s)
- Romain Salle
- Assistance Publique des Hôpitaux de Paris (AP-HP), Dermatology Department, Henri Mondor Hospital, Créteil, France.
| | - Charbel Skayem
- Assistance Publique des Hôpitaux de Paris (AP-HP), Dermatology Department, Henri Mondor Hospital, Créteil, France; Faculty of Medicine, Sorbonne University, Paris, France
| | - Camille Hua
- Assistance Publique des Hôpitaux de Paris (AP-HP), Dermatology Department, Henri Mondor Hospital, Créteil, France; EpiDermE, Université Paris Est Créteil, Créteil, France
| | - Olivier Chosidow
- Assistance Publique des Hôpitaux de Paris (AP-HP), Dermatology Department, Henri Mondor Hospital, Créteil, France; Faculté de Santé de Créteil, École nationale vétérinaire d'Alfort, USC ANSES, Université Paris-Est Créteil, Créteil, France
| | - Tu-Anh Duong
- Assistance Publique des Hôpitaux de Paris (AP-HP), Dermatology Department, Henri Mondor Hospital, Créteil, France; UF Telemedecine, GHU Paris Saclay, Boulogne-Billancourt, France; Chaire Avenir Santé numérique, Équipe 8 IMRB U955 INSERM, Créteil, France; Research Group Dynamyc, EA7380, Créteil, France
| |
Collapse
|
26
|
Brunner S, Hummels M, Bruns CJ. [62/m-Unclear soft tissue infection of the left thorax with rapid progression and subsequent sepsis : Preparation for the medical specialist examination: part 48]. Chirurgie (Heidelb) 2023; 94:93-97. [PMID: 37530781 DOI: 10.1007/s00104-023-01924-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/12/2023] [Indexed: 08/03/2023]
Affiliation(s)
- Stefanie Brunner
- Klinik für Allgemein‑, Viszeral‑, Tumor- und Transplantationschirurgie, Universitätsklinik Köln, Kerpenerstr. 62, 50935, Köln, Deutschland
| | - Marielle Hummels
- Klinik für Allgemein‑, Viszeral‑, Tumor- und Transplantationschirurgie, Universitätsklinik Köln, Kerpenerstr. 62, 50935, Köln, Deutschland.
| | - Christiane J Bruns
- Klinik für Allgemein‑, Viszeral‑, Tumor- und Transplantationschirurgie, Universitätsklinik Köln, Kerpenerstr. 62, 50935, Köln, Deutschland
| |
Collapse
|
27
|
Ture Z, Unuvar GK, Esmaoglu A, Ulu-Kilic A, Coruh A, Doganay M. Severe and complicated soft tissue infections: a single-centre case series. J Wound Care 2023; 32:492-499. [PMID: 37572342 DOI: 10.12968/jowc.2023.32.8.492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/14/2023]
Abstract
OBJECTIVE To assess the demographic and clinical characteristics, laboratory findings, and economic burden of patients with a diagnosis of complicated skin and soft tissue infection (cSSTI). METHOD The demographic and clinical characteristics, laboratory findings, surgical interventions, cost of treatment, and outcome of patients diagnosed with cSSTIs between January 2017 and December 2019 were retrospectively analysed. RESULTS A total of 24 patients with cSSTIs were included in the study. The median age was 53 (22-85) years, and 14 (58%) were female. The most common comorbidity was diabetes (54%). On admission, 75% of patients presented with sepsis, and 70% had a high-grade Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score. The causative microorganism was isolated from 21 (87%) patients, and the multidrug resistance rate of Gram-negative bacteria was 50%. The median number of debridements was 3 (1-12). In all, 11 patients were followed up in the intensive care unit, and the mortality rate was 29%. The presence of confusion (p=0.025), causative Gram-negative microorganisms (p=0.009), hyponatraemia (p=0.034), the need for intensive care (p=0.001), anti-meticillin-resistant Staphylococcus aureus antibiotics (p=0.023) and the rate of antibiotic changes during treatment (p=0.019) were significantly higher in the non-survival patient group. Hyponatraemia was a significant independent risk factor for mortality (p=0.048). The median cost of per-patient treatment was $9453 USD in the non-surviving and $1536 in the surviving group. CONCLUSION It is important to know possible factors and local resistance rates at the beginning of empirical antibacterial and surgical treatment. The presence of hyponatraemia, sepsis and a high LRINEC score can be considered to be the mortality predictors.
Collapse
Affiliation(s)
- Zeynep Ture
- Department of Infectious Diseases, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Gamze Kalin Unuvar
- Department of Infectious Diseases, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Aliye Esmaoglu
- Department of Anesthesiology and Reanimation, Erciyes University Medical Faculty, Kayseri, Turkey
| | - Aysegul Ulu-Kilic
- Department of Infectious Diseases, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Atilla Coruh
- Department of Plastic & Reconstructive Surgery, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Mehmet Doganay
- Department of Infectious Diseases, Faculty of Medicine, Lokman Hekim University, Ankara, Turkey
| |
Collapse
|
28
|
Düzenli T. Prediagnosis of soft tissue infection that was finally diagnosed as pyoderma gangrenosum of ulcerative colitis. Rev Esp Enferm Dig 2023; 115:464. [PMID: 36412491 DOI: 10.17235/reed.2022.9332/2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Pyoderma gangrenosum is a rare disorder characterized by inflammatory and ulcerative skin lesions. In this case report, we aimed to present our patient who had a prediagnosis of soft tissue infection and skin ulcers, and was eventually diagnosed with ulcerative colitis-associated pyoderma gangrenosum. A 30-year-old female patient was admitted to the emergency department with skin lesions on her kneecap and lower neck. The patient's skin lesions were considered as infective ulcers, and the patient was admitted to the infectious diseases clinic. The patient had received antibiotics of meropenem and teicoplanin in the follow-up. Surgical debridement was performed but after debridement, the wound had progressed.
Collapse
Affiliation(s)
- Tolga Düzenli
- Gastroenterology, SBU Sancaktepe Şehit Prof. Dr. İlhan Varank Training and Research Hospital, Turkey
| |
Collapse
|
29
|
Gallardo MA, Yan A, Korman AM, Chung C, Kaffenberger BH. Unmet needs in the study of cellulitis: A response to Salle et al's "Challenges and limitations of teledermatology for skin and soft-tissue infections: A real-world study of an expert center". J Am Acad Dermatol 2023; 88:e307-e308. [PMID: 36871642 DOI: 10.1016/j.jaad.2023.02.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 02/16/2023] [Accepted: 02/20/2023] [Indexed: 03/06/2023]
Affiliation(s)
- Matthew A Gallardo
- College of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Allison Yan
- College of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Abraham M Korman
- Department of Dermatology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Catherine Chung
- Department of Dermatology, The Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | | |
Collapse
|
30
|
MacLeod CS, O’Neill HL, Shaalan R, Nagy J, Flett MM, Guthrie GJ, McLeod G, Suttie SA. Predicting necrotising soft tissue infections in people who inject drugs: poor performance of the Laboratory Risk Indicator for Necrotising Fasciitis score and development of a novel clinical predictive nomogram in a retrospective cohort with internal validation. Int J Surg 2023; 109:1561-1572. [PMID: 37042577 PMCID: PMC10389200 DOI: 10.1097/js9.0000000000000367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 03/13/2023] [Indexed: 04/13/2023]
Abstract
INTRODUCTION Necrotising soft tissue infections (NSTI) can threaten life and limb. Early identification and urgent surgical debridement are key for improved outcomes. NSTI can be insidious. Scoring systems, like the Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC), exist to aid diagnosis. People who inject drugs (PWID) are high risk for NSTI. This study aimed to assess the utility of the LRINEC in PWID with lower limb infections and develop a predictive nomogram. METHODS A retrospective database of all hospital admissions due to limb-related complications secondary to injecting drug use between December 2011 and December 2020 was compiled through discharge codes and a prospectively maintained Vascular Surgery database. All lower limb infections were extracted from this database, dichotomised by NSTI and non-NSTI with the LRINEC applied. Specialty management times were evaluated. Statistical analyses involved: chi-square; Analysis of "variance"; Kaplan-Meier, and receiver operating characteristic curves. Nomograms were developed to facilitate diagnosis and predict survival. RESULTS There were 557 admissions for 378 patients, with 124 (22.3%; 111 patients) NSTI. Time from admission to: theatre and computed tomography imaging respectively varied significantly between specialties ( P =0.001). Surgical specialties were faster than medical ( P =0.001). Vascular surgery received the most admissions and had the quickest time to theatre. During follow-up there were 79 (20.9%) deaths: 27 (24.3%) NSTI and 52 (19.5%) non-NSTI. LRINEC ≥6 had a positive predictive value of 33.3% and sensitivity of 74% for NSTI. LRINEC <6 had a negative predictive value of 90.7% and specificity of 63.2% for non-NSTI. Area under the curve was 0.697 (95% CI: 0.615-0.778). Nomogram models found age, C-reactive protein, and non-linear albumin to be significant predictors of NSTI, with age, white cell count, sodium, creatinine, C-reactive protein, and albumin being significant in predicting survival on discharge. CONCLUSION There was reduced performance of the LRINEC in this PWID cohort. Diagnosis may be enhanced through use of this predictive nomogram.
Collapse
Affiliation(s)
- Caitlin S. MacLeod
- East of Scotland Vascular Network, Department of Vascular Surgery
- School of Medicine, University of Dundee, Dundee, Scotland
| | | | - Ramy Shaalan
- East of Scotland Vascular Network, Department of Vascular Surgery
- Department of General Surgery, Ain Shams University, Cairo, Egypt
| | - John Nagy
- East of Scotland Vascular Network, Department of Vascular Surgery
| | - Murray M. Flett
- East of Scotland Vascular Network, Department of Vascular Surgery
| | | | - Graeme McLeod
- Department of Anaesthetics, Ninewells Hospital
- Department of General Surgery, Ain Shams University, Cairo, Egypt
| | - Stuart A. Suttie
- East of Scotland Vascular Network, Department of Vascular Surgery
| |
Collapse
|
31
|
Henry R, McGillen P, Nassiri N, Asanad K, Matsushima K, Inaba K, Clark D. Gluteal Necrotizing Soft Tissue Infection and Hip Osteomyelitis due to Candida Glabrata. Am Surg 2023; 89:2101-2104. [PMID: 34237237 DOI: 10.1177/00031348211031856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Necrotizing soft tissue infection (NSTI) is a rapidly progressive and often fatal infection of the soft tissue. Classically, it is attributed to bacterial infection and immunocompromised patients are particularly vulnerable. However, NSTI due to fungal infection rarely does occur, including from Candida species, and can pose a diagnostic challenge for unfamiliar providers. Expedient clinical recognition, surgical debridement, fungal tissue culture, and initiation of antifungal therapy are key. CASE PRESENTATION We report a 39-year-old obese male with long-standing history of poorly controlled diabetes who presented to a community hospital, noted to have NSTI of the sacrum, bilateral buttocks, and left hip, and was treated only with antibiotics. After transfer to an academic center, the patient underwent aggressive debridement and tissue diagnosis of Candida glabrata NSTI was made. He received broad-spectrum antibiotic and antifungal therapy for several months. Over the course of 4 months, his infection was cleared, and his large tissue defects were reconstructed with rotation flaps and the patient was discharged home. CONCLUSIONS Fungal NSTI is a rare entity, especially when due to Candida species. It can be exceedingly difficult to diagnose and manage, as these patients may suffer higher mortality than those with NSTI due to bacteria. A high index of suspicion for the entity, rapid debridement, intraoperative tissue culture, and treatment with appropriate antifungal therapy offers the greatest chance of survival.
Collapse
Affiliation(s)
- Reynold Henry
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA, USA
| | - Patrick McGillen
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA, USA
| | - Nima Nassiri
- Department of Urology, University of Southern California, Los Angeles, CA, USA
| | - Kian Asanad
- Department of Urology, University of Southern California, Los Angeles, CA, USA
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA, USA
| | - Kenji Inaba
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA, USA
| | - Damon Clark
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA, USA
| |
Collapse
|
32
|
Abstract
PURPOSE OF REVIEW Our purpose is to review the state-of-the-art on the management of skin and soft tissue infections (SSTI) in emergency departments (ED).Although the information is scarce, SSTI may account for 3-30% of all cases presenting to an ED, of which 25-40% require hospital admission.SSTI include very different entities in aetiology, location, pathogenesis, extension, and severity. Therefore, no single management can be applied to them all. A simple approach is to classify them as non-purulent, purulent, and necrotising, to which a severity scale based on their systemic repercussions (mild, moderate, and severe) must be added.The initial approach to many SSTIs often requires no other means than anamnesis and physical examination, but imaging tests are an indispensable complement in many other circumstances (ultrasound, computerized tomography, magnetic resonance imaging…). In our opinion, an attempt at etiological filiation should be made in severe cases or where there is suspicion of a causality other than the usual one, with tests based not only on cultures of the local lesion but also molecular tests and blood cultures. RECENT FINDINGS Recent contributions of interest include the value of bedside ultrasound and the potential usefulness of biomarkers such as thrombomodulin to differentiate in early stages the presence of necrotising lesions not yet explicit.New antimicrobials will allow the treatment of many of these infections, including severe ones, with oral drugs with good bioavailability and for shorter periods. SUMMARY The ED has an essential role in managing SSTIs, in their classification, in decisions on when and where to administer antimicrobial treatment, and in the rapid convening of multidisciplinary teams that can deal with the most complex situations.
Collapse
Affiliation(s)
- Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón
- Medicine Department, School of Medicine, Universidad Complutense de Madrid
- Gregorio Marañón Health Research Institute (IiSGM)
- CIBER of Respiratory Diseases (CIBERES CB06/06/0058), Madrid, Spain
| | - Almudena Burillo
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón
- Medicine Department, School of Medicine, Universidad Complutense de Madrid
- Gregorio Marañón Health Research Institute (IiSGM)
| | - Patricia Muñoz
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón
- Medicine Department, School of Medicine, Universidad Complutense de Madrid
- Gregorio Marañón Health Research Institute (IiSGM)
- CIBER of Respiratory Diseases (CIBERES CB06/06/0058), Madrid, Spain
| |
Collapse
|
33
|
Abstract
PURPOSE OF REVIEW To highlight the peculiarity of skin and soft tissue infections (SSTIs) in elderly patients and to provide useful elements for their optimal management. RECENT FINDINGS In the COVID-19 era, early discharge from the hospital and implementation of outpatient management is of key importance. SUMMARY Elderly patients are at high risk of SSTIs due to several factors, including presence of multiple comorbidities and skin factors predisposing to infections. Clinical presentation may be atypical and some signs of severity, such as fever and increase in C-reactive protein, may be absent or aspecific in this patients population. An appropriate diagnosis of SSTIs in the elderly is crucial to avoid antibiotic overtreatment. Further studies should explore factors associated with bacterial superinfections in patients with pressure ulcers or lower limb erythema. Since several risk factors for methicillin-resistant Staphylococcus aureus (MRSA) may coexist in elderly patients, these subjects should be carefully screened for MRSA risk factors and those with high risk of resistant etiology should receive early antibiotic therapy active against MRSA. Physicians should aim to several objectives, including clinical cure, patient safety, early discharge and return to community. SSTIs in the elderly may be managed using long-acting antibiotics, but clinical follow-up is needed.
Collapse
Affiliation(s)
- Marco Falcone
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | | |
Collapse
|
34
|
Sepulcri C, Vena A, Bassetti M. Skin and soft tissue infections due to rapidly growing mycobacteria. Curr Opin Infect Dis 2023; 36:74-80. [PMID: 36718980 DOI: 10.1097/qco.0000000000000905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE OF REVIEW The aim of this article is to review skin and soft tissue infections due to rapidly growing mycobacteria (RGM), with a particular focus on recently published literature (2021-2022). RECENT FINDINGS RGM are increasingly reported as a cause of skin and soft tissue infections, both in the community setting and as a cause of nosocomial outbreaks. Recent advances in molecular methods have expanded the number of species of RGM and resulted in increased diagnosis. New treatment options are under evaluation particularly for Mycobacterium abscessus , the most difficult-to-treat among RGM. SUMMARY RGM are an uncommon cause of skin and soft tissue infections and a high clinical suspicion together with advanced laboratory facilities are required for diagnosis. Species identification and antimicrobial susceptibility testing are essential to drive appropriate treatment, which combines surgical debridement with prolonged antimycobacterial combination therapy.
Collapse
Affiliation(s)
- Chiara Sepulcri
- Division of Infectious Diseases, Department of Health Sciences (DISSAL), University of Genova
| | - Antonio Vena
- Division of Infectious Diseases, Department of Health Sciences (DISSAL), University of Genova
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Matteo Bassetti
- Division of Infectious Diseases, Department of Health Sciences (DISSAL), University of Genova
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
| |
Collapse
|
35
|
Barbier F, Woerther PL, Timsit JF. Rapid diagnostics for skin and soft tissue infections: the current landscape and future potential. Curr Opin Infect Dis 2023; 36:57-66. [PMID: 36718917 DOI: 10.1097/qco.0000000000000901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE OF REVIEW Managing antimicrobial therapy in patients with complicated skin and soft tissue infections (SSTI) constitutes a growing challenge due to the wide spectrum of potential pathogens and resistance phenotypes. Today, microbiological documentation relies on cultural methods. This review summarizes the available evidence regarding the clinical input of rapid microbiological diagnostic tools (RMDT) and their impact on the management of antimicrobial therapy in SSTI. RECENT FINDINGS Accurate tools are already available for the early detection of methicillin-resistant Staphylococcus aureus (MRSA) in SSTI samples and may help avoiding or shortening empirical anti-MRSA coverage. Further research is necessary to develop and evaluate RMDT detecting group A streptococci (e.g., antigenic test) and Gram-negative pathogens (e.g., multiplex PCR assays), including through point-of-care utilization. Next-generation sequencing (NGS) methods could provide pivotal information for the stewardship of antimicrobial therapy, especially in case of polymicrobial or fungal SSTI and in the immunocompromised host; however, a shortening in the turnaround time and prospective data regarding their therapeutic input are needed to better appraise the clinical positioning of these promising approaches. SUMMARY The clinical input of RMDT in SSTI is currently limited due to the scarcity of available dedicated assays and the polymicrobial feature of certain cases. NGS appears as a relevant tool but requires further developments before its implementation in routine clinical practice.
Collapse
Affiliation(s)
- François Barbier
- Médecine Intensive - Réanimation, Centre Hospitalier Régional d'Orléans, Orléans
- CEPR/INSERM U1100, Université de Tours, Tours
| | - Paul-Louis Woerther
- Département de Microbiologie, Centre Hospitalier Universitaire Henri Mondor, Assistance Publique - Hôpitaux de Paris
- DYNAMYC/EA7380, Université Paris Est - Créteil, Créteil
| | - Jean-François Timsit
- Réanimation Médicale et des Maladies Infectieuses, Centre Hospitalier Universitaire Bichat - Claude Bernard, Assistance Publique - Hôpitaux de Paris
- DeSCID/IAME/INSERM U1137, Université Paris Cité, Paris, France
| |
Collapse
|
36
|
Huang CY, Hsieh ZY, Chang KC, Chang DH. Marjolin's ulcer in an ischial pressure sore presented with necrotizing soft tissue infection: A case report. Medicine (Baltimore) 2023; 102:e33450. [PMID: 37000064 PMCID: PMC10063310 DOI: 10.1097/md.0000000000033450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 03/15/2023] [Indexed: 04/01/2023] Open
Abstract
RATIONALE Marjolin's ulcer (MU) is a rare skin malignancy derived from a chronic wound. Pressure ulcer related MU possesses poor prognosis and high metastatic rate, and it is difficult to be differentiated, especially when superimposed infection. PATIENT CONCERNS Here we report a case with pressure ulcer related MU which presented as necrotizing soft tissue infection (NSTI) to demonstrate the manifestation, treatment, and prognosis of this rare disease. DIAGNOSES A 45-year-old male patient had spinal cord injury at age 2 years. He presented ischial pressure sore complicated with NSTI initially. After serial debridements and antibiotic treatment, the infection subsided. For the persistent verruca-like skin lesion, he underwent wide excision which revealed well-differentiated squamous cell carcinoma. Further image studies showed localized residual tumor without distant metastasis. INTERVENTIONS He then underwent hip disarticulation and anterior thigh fillet flap reconstruction. Local recurrence developed 3 months later, and re-wide excision and inguinal lymph node dissection were performed. No lymph node metastasis was noted and adjuvant radiotherapy was given. OUTCOMES He was followed for 34 months and no recurrence or metastasis was found. The patient can move with a wheelchair or a hip prosthesis, and is partially dependent for daily activities. LESSONS MU can masquerade as NSTI and one should be alert to its malignant potential. Due to its aggressive nature, limb sacrifice can be considered in circumstances of profound involvement. As for the reconstruction method, pedicled fillet flap provided good wound coverage.
Collapse
Affiliation(s)
- Ching-Yen Huang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Far Eastern Memorial Hosptial, New Taipei, Taiwan
| | - Zhoa-Yu Hsieh
- Division of Medical Imaging, Department of Radiology, Far Eastern Memorial Hospital, New Taipei, Taiwan
| | - Ke-Chung Chang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Far Eastern Memorial Hosptial, New Taipei, Taiwan
| | - Dun-Hao Chang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Far Eastern Memorial Hosptial, New Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| |
Collapse
|
37
|
Cantarella S, Casamassima A, Bussone DM, Baldini E, Kersik A, Boccia O, Gianotti C. A necrotising fasciitis: case report. J Ultrasound 2023; 26:147-150. [PMID: 36609958 PMCID: PMC10063729 DOI: 10.1007/s40477-022-00717-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/21/2022] [Indexed: 01/09/2023] Open
Abstract
Necrotizing fasciitis is one of the most common soft tissue infections, with a high risk of major amputation and a mortality ranging from 6 to 33% which has not changed in the past 20 years. Early surgical resection of necrotic tissue plays a key role in determining the prognosis. Nawijn et al. identified an optimal 6 hours window from presentation to surgery. Symptoms of necrotizing fasciitis mimic those of common skin infections, such as erysipelas and cellulitis, making rapid surgical management difficult. In this context, the aid of point-of-care-ultrasound is a valuable tool for early diagnosis, detecting the presence of subcutaneous thickening, gas and perifascial liquid. Other characteristic ultrasound findings include the "cobblestone" appearance of the subcutaneous soft tissues and reverberation artifacts due to hyperechoic outbreaks, defined as "snow globes" due to the presence of heterogeneous swirling material, and "dirty shadowing" due to the foggy shadow created by the gas.
Collapse
Affiliation(s)
- S Cantarella
- Chirurgia Generale, Ospedale di Melzo - ASST Melegnano e Martesana, Milan, Italy.
| | - A Casamassima
- Chirurgia Generale, Ospedale di Melzo - ASST Melegnano e Martesana, Milan, Italy
| | - Dott M Bussone
- Chirurgia Generale, Ospedale di Melzo - ASST Melegnano e Martesana, Milan, Italy
| | - E Baldini
- Chirurgia Generale, Ospedale di Melzo - ASST Melegnano e Martesana, Milan, Italy
| | - A Kersik
- Scuola di Specializzazione in Chirurgia Generale, Università degli Studi di Milano, Milan, Italy
| | - O Boccia
- Scuola di Specializzazione in Chirurgia Generale, Università degli Studi di Milano, Milan, Italy
| | - C Gianotti
- Scuola di Specializzazione in Chirurgia Generale, Università degli Studi di Milano, Milan, Italy
| |
Collapse
|
38
|
Dogra P, Singla N, Kaushik R, Singh S, Gupta V. Primary Cutaneous Mucormycosis: A Necrotising Soft Tissue Infection with Poor Prognosis. Infect Disord Drug Targets 2023; 23:e040523216523. [PMID: 37150984 DOI: 10.2174/1871526523666230504114801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 03/18/2023] [Accepted: 03/21/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND Cutaneous mucormycosis is an unusual fungal infection that continues to occur. It needs aggressive surgical debridement and timely administration of antifungals due to its high fatality rate. High clinical suspicion on the part of a surgeon is required to prevent the same. CASE PRESENTATION We present two cases of cutaneous mucormycosis in which the patients succumbed to death, highlighting the seriousness of the condition. One patient had a lower leg ulcer and was diabetic, and the other patient had a gluteal abscess following an intramuscular injection. Tissue samples grew Rhizopus arrhizus and Apophysomyces sp., respectively. Both patients were treated with amphotericin B, and extensive debridement was performed. DISCUSSION Cutaneous mucormycosis can be reported in immunocompetent people, and there is a need for early recognition of the entity as a differential diagnosis of any nonhealing necrotic ulcer. CONCLUSION Proper training and education of technical and clinical staff should be done at peripheral primary and secondary care centres so as not to miss out on cases of mucormycosis and for better prognosis in a cutaneous variety of mucormycosis in surgical patients.
Collapse
Affiliation(s)
- Poornima Dogra
- Department of General Surgery, Government Medical College and Hospital, Sector 32 Chandigarh, India
| | - Nidhi Singla
- Department of Microbiology, Government Medical College and Hospital, Sector 32 Chandigarh, India
| | - Robin Kaushik
- Department of General Surgery, Government Medical College and Hospital, Sector 32 Chandigarh, India
| | - Simrandeep Singh
- Department of General Surgery, Government Medical College and Hospital, Sector 32 Chandigarh, India
| | - Varsha Gupta
- Department of Microbiology, Government Medical College and Hospital, Sector 32 Chandigarh, India
| |
Collapse
|
39
|
Erickson BA, Miller AC, Warner HL, Drobish JN, Koeneman SH, Cavanaugh JE, Polgreen PM. Understanding the Prodromal Period of Necrotizing Soft Tissue Infections of the Genitalia (Fournier's Gangrene) and the Incidence, Duration, and Risk Factors Associated With Potential Missed Opportunities for an Earlier Diagnosis: A Population-based Longitudinal Study. J Urol 2022; 208:1259-1267. [PMID: 36006046 PMCID: PMC11005462 DOI: 10.1097/ju.0000000000002920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 07/22/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this paper was to investigate patterns of health care utilization leading up to diagnosis of necrotizing soft tissue infections of the genitalia and to identify risk factors associated with potential diagnostic delay. MATERIALS AND METHODS IBM MarketScan Research Databases (2001-2020) were used to identify index cases of necrotizing soft tissue infections of the genitalia. We identified health care visits for symptomatically similar diagnoses (eg, penile swelling, cellulitis) that occurred prior to necrotizing soft tissue infections of the genitalia diagnosis. A change-point analysis identified the window before diagnosis where diagnostic opportunities first appeared. A simulation model estimated the likelihood symptomatically similar diagnosis visits represented a missed opportunity for earlier diagnosis. Patient and provider characteristics were evaluated for their associations with delay. RESULTS We identified 8,098 patients with necrotizing soft tissue infections of the genitalia, in which 4,032 (50%) had a symptomatically similar diagnosis visit in the 21-day diagnostic window, most commonly for "non-infectious urologic abnormalities" (eg, genital swelling; 64%): 46% received antibiotics; 16% saw a urologist. Models estimated that 5,096 of the symptomatically similar diagnosis visits (63%) represented diagnostic delay (mean duration 6.2 days; mean missed opportunities 1.8). Risk factors for delay included urinary tract infection history (OR 2.1) and morbid obesity (OR 1.6). Visits to more than 1 health care provider/location in a 24-hour period significantly decreased delay risk. CONCLUSIONS Nearly 50% of insured patients who undergo debridement for, or die from, necrotizing soft tissue infections of the genitalia will present to a medical provider with a symptomatically similar diagnosis suggestive of early disease development. Many of these visits likely represent diagnostic delay. Efforts to minimize logistic and cognitive biases in this rare condition may lead to improved outcomes if they lead to earlier interventions.
Collapse
Affiliation(s)
- Bradley A. Erickson
- Department of Urology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Aaron C. Miller
- Department of Internal Medicine, Division of Infectious Diseases, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Hayden L. Warner
- Department of Urology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Justin N. Drobish
- Department of Urology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Scott H. Koeneman
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, Iowa
| | - Joseph E. Cavanaugh
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, Iowa
| | - Philip M. Polgreen
- Department of Internal Medicine, Division of Infectious Diseases, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| |
Collapse
|
40
|
Breidung D, Grieb G, Malsagova AT, Barth AA, Billner M, Hitzl W, Reichert B, Megas IF. Time Is Fascia: Laboratory and Anamnestic Risk Indicators for Necrotizing Fasciitis. Surg Infect (Larchmt) 2022; 23:747-753. [PMID: 36191292 DOI: 10.1089/sur.2022.222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023] Open
Abstract
Background: Necrotizing fasciitis is a potentially fatal soft tissue infection in which the timing of surgical intervention significantly affects clinical outcome. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, the Site other than the lower limb, Immunosuppression, Age <60 years, Renal impairment (creatinine >141), and Inflammatory markers (CRP ≥150, WCC >25) (SIARI) score, and procalcitonin levels are intended to aid in the decision-making process to differentiate between necrotizing fasciitis and soft tissue infections. Methods: A retrospective analysis of cases of necrotizing fasciitis and soft tissue infections treated at Klinikum Nürnberg was performed. The two scores as well as procalcitonin levels were tested for their diagnostic value and a new score, the Laboratory and Anamnestic Risk Indicator for Necrotizing Fasciitis (LARINF), was created based on the results. Results: Procalcitonin, LRINEC score, and SIARI score showed insufficient discriminatory ability in our study. The newly created LARINF score combined laboratory parameters of the LRINEC score (hemoglobin and C-reactive protein) with procalcitonin and three comorbidities, resulting in a sensitivity of 84% and a specificity of 75% and the highest area under the receiver operating characteristic (ROC) curve of 0.83. Conclusions: The LARINF score is a novel decision-supporting tool. The decision, in which cases surgical exploration should be initiated, remains a clinical one. However, the score seems to provide an improved basis for identifying a rare clinical picture.
Collapse
Affiliation(s)
- David Breidung
- Department of Plastic, Reconstructive and Hand Surgery, Center for Severe Burn Injuries, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany
| | - Gerrit Grieb
- Department of Plastic Surgery and Hand Surgery, Gemeinschaftskrankenhaus Havelhoehe, Berlin, Germany
- Burn Center, Department of Plastic Surgery and Hand Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Asja T Malsagova
- Department of Plastic, Reconstructive and Hand Surgery, Center for Severe Burn Injuries, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany
| | - Andrè A Barth
- Department of Plastic, Reconstructive and Hand Surgery, Center for Severe Burn Injuries, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany
| | - Moritz Billner
- Department of Plastic, Reconstructive and Hand Surgery, Center for Severe Burn Injuries, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany
| | - Wolfgang Hitzl
- Research and Innovation Management (RIM), Paracelsus Medical University Salzburg, Department of Ophthalmology and Optometry, Salzburg, Austria
- Department of Ophthalmology and Optometry, Paracelsus Medical University Salzburg, Salzburg, Austria
- Research Program Experimental Ophthalmology and Glaucoma Research, Paracelsus Medical University, Salzburg, Austria
| | - Bert Reichert
- Department of Plastic, Reconstructive and Hand Surgery, Center for Severe Burn Injuries, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany
| | - Ioannis-Fivos Megas
- Department of Plastic, Reconstructive and Hand Surgery, Center for Severe Burn Injuries, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany
| |
Collapse
|
41
|
Livshits D, Sokup B, Farrell R, Jeong J. Finger Test for the Diagnosis of a Critically Ill Patient with Necrotizing Fasciitis. J Emerg Med 2022; 63:102-105. [PMID: 35934649 DOI: 10.1016/j.jemermed.2022.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 03/08/2022] [Accepted: 04/23/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Necrotizing fasciitis is a life-threatening soft-tissue infection, often characterized by soft-tissue destruction, systemic toxicity, and high mortality. No single laboratory value can diagnose necrotizing fasciitis; ultimately, necrotizing fasciitis is a clinical diagnosis and therefore presents a diagnostic dilemma for many physicians. The finger probe test is useful in confirming the diagnosis when imaging studies are unobtainable or nondiagnostic. CASE REPORT We present the case of a 70-year-old woman presenting nonverbal and obtunded with a soft-tissue infection of the right lower extremity. The only pertinent positive vital sign was tachypnea with a respiratory rate of 22 breaths/min. Physical examination revealed nonpitting edema, cold-to-touch lower extremity, and Nikolsky-positive hemorrhagic bullae. Initial laboratory test results showed white blood cell count of 38 x 109/L and lactic acid of 8.2 mg/dL. Advanced imaging was unobtainable, given the patient's worsening clinical status, and the decision was made to perform the finger probe test, which revealed absence of bleeding and presence of friable tissue and "dishwater" discharge. Consequently, the general surgery team took the patient to the operating room and performed an above-the-knee amputation and surgical debridement. Postoperative report noted nonviable tissue consistent with necrotizing fasciitis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Necrotizing fasciitis is a life-threatening emergency that can destroy soft-tissue at a rate of 1 inch/h. When imaging is unobtainable or nondiagnostic, the finger probe test can be used in select patients to aid with diagnosis.
Collapse
Affiliation(s)
- Dimitri Livshits
- NYC Health + Hospitals/Coney Island, Coney Island Hospital, Brooklyn, New York
| | - Brenda Sokup
- NYC Health + Hospitals/Coney Island, Coney Island Hospital, Brooklyn, New York
| | - Robert Farrell
- NYC Health + Hospitals/Coney Island, Coney Island Hospital, Brooklyn, New York
| | - Jordan Jeong
- NYC Health + Hospitals/Coney Island, Coney Island Hospital, Brooklyn, New York
| |
Collapse
|
42
|
Lauterio M, Deck DH. Current Challenges in the Management of Skin and Soft Tissue Infections and Community-Acquired Pneumonia. J Fam Pract 2022; 71:S2-S9. [PMID: 35776861 DOI: 10.12788/jfp.0423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Skin and soft tissue infections (SSTI) and community-acquired pneumonia (CAP) are major public health problems that are commonly encountered in the primary care setting. Establishing the severity of disease is an important step in the diagnosis of SSTI and CAP, because this can affect decisions about optimal management, including level of care. Due to antibiotic resistance, allergies, and adverse effect profiles of current therapies, there is a need for new treatment options for both SSTI and CAP. Improved utilization of oral outpatient antibiotic treatments can also minimize the risk of serious adverse effects or nosocomial infections, leading to better patient outcomes. As these infections are mostly treated in outpatient settings, primary care clinicians are best suited to implement changes such as use of oral antibiotics, where appropriate, to reduce hospitalization, with its associated costs and risks to the patient.
Collapse
|
43
|
Pomerantz ML. Necrotizing Soft Tissue Infections of the Hand and Wrist. Orthop Clin North Am 2022; 53:57-67. [PMID: 34799023 DOI: 10.1016/j.ocl.2021.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Necrotizing soft tissue infections of the upper extremity threaten life and limb. Their presentation is often difficult to recognize and multiple factors contribute to the varied presentation, speed of spread, and morbidity of the disease process. The only treatment to be definitively shown to improve outcomes is prompt surgical treatment. It should be expected to perform multiple debridements as well as reconstructive procedures once the infection and necrosis has been arrested. The use of a multidisciplinary team is mandatory to optimize care for these patients. Despite advances in knowledge and treatment, these infections still have high mortality and morbidity.
Collapse
Affiliation(s)
- M Lucius Pomerantz
- Synergy Orthopedic Specialists, Inc., 955 Lane Ave, #200, Chula Vista, CA 91914, USA; Orthopedic Surgery, University of California San Diego, San Diego, CA, USA.
| |
Collapse
|
44
|
Ulrych J, Adámková V, Gürlich R, Kolář M, Lahoda-Brodská H, Třeška V, Veverková L. Diagnosis and treatment of surgical skin and soft tissue infections - current status. Rozhl Chir 2022; 101:300-311. [PMID: 36075692 DOI: 10.33699/pis.2022.101.7.300-311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Surgical skin and soft tissue infections (SSTIs) result from microbial invasion of the skin and underlying soft tissues, often requiring surgical treatment. SSTIs encompass a variety of pathological conditions, ranging from frequent simple superficial skin infections with very good outcomes to rare, rapidly progressive necrotizing infections associated with long-lasting morbidity and high mortality. The document summarizes current knowledge of the diagnosis and therapy of these diseases and provides clinicians with current standards of care of these patients based on international guidelines. Additionally, regional specific aspects are also reflected, and thus in all cases, this paper on diagnostic-therapeutic management of individual clinical forms respects the actual clinical practice and epidemiology in the Czech Republic. The document has been prepared based on multidisciplinary consensus of experts from universities all over the Czech Republic.
Collapse
|
45
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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.
| |
Collapse
|
46
|
Dong CT, Liveris A, Lewis ER, Mascharak S, Chao E, Reddy SH, Teperman SH, McNelis J, Stone ME. Do surgical emergencies stay at home? Observations from the first United States Coronavirus epicenter. J Trauma Acute Care Surg 2021; 91:241-246. [PMID: 34144567 PMCID: PMC8218982 DOI: 10.1097/ta.0000000000003202] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/06/2021] [Accepted: 02/24/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND During the coronavirus disease 2019 pandemic, New York instituted a statewide stay-at-home mandate to lower viral transmission. While public health guidelines advised continued provision of timely care for patients, disruption of safety-net health care and public fear have been proposed to be related to indirect deaths because of delays in presentation. We hypothesized that admissions for emergency general surgery (EGS) diagnoses would decrease during the pandemic and that mortality for these patients would increase. METHODS A multicenter observational study comparing EGS admissions from January to May 2020 to 2018 and 2019 across 11 NYC hospitals in the largest public health care system in the United States was performed. Emergency general surgery diagnoses were defined using International Classification Diseases, Tenth Revision, codes and grouped into seven common diagnosis categories: appendicitis, cholecystitis, small/large bowel, peptic ulcer disease, groin hernia, ventral hernia, and necrotizing soft tissue infection. Baseline demographics were compared including age, race/ethnicity, and payor status. Outcomes included coronavirus disease (COVID) status and mortality. RESULTS A total of 1,376 patients were admitted for EGS diagnoses from January to May 2020, a decrease compared with both 2018 (1,789) and 2019 (1,668) (p < 0.0001). This drop was most notable after the stay-at-home mandate (March 22, 2020; week 12). From March to May 2020, 3.3%, 19.2%, and 6.0% of EGS admissions were incidentally COVID positive, respectively. Mortality increased in March to May 2020 compared with 2019 (2.2% vs. 0.7%); this difference was statistically significant between April 2020 and April 2019 (4.1% vs. 0.9%, p = 0.045). CONCLUSION Supporting our hypothesis, the coronavirus disease 2019 pandemic and subsequent stay-at-home mandate resulted in decreased EGS admissions between March and May 2020 compared with prior years. During this time, there was also a statistically significant increase in mortality, which peaked at the height of COVID infection rates in our population. LEVEL OF EVIDENCE Epidemiological, level IV.
Collapse
|
47
|
Rodrigues MA, Caetano M, Amorim I, Selores M. [Non-Necrotizing Acute Dermo-Hypodermal Infections: Erysipela and Infectious Cellulitis]. ACTA MEDICA PORT 2021; 34:217-228. [PMID: 33971117 DOI: 10.20344/amp.12642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 01/24/2020] [Indexed: 11/20/2022]
Abstract
Non-necrotizing acute dermo-hypodermal infections are infectious processes that include erysipela and infectious cellulitis, and are mainly caused by group A β-haemolytic streptococcus. The lower limbs are affected in more than 80% of cases and the risk factors are disruption of cutaneous barrier, lymphoedema and obesity. Diagnosis is clinical and in a typical setting we observe an acute inflammatory plaque with fever, lymphangitis, adenopathy and leucocytosis. Bacteriology is usually not helpful because of low sensitivity or delayed positivity. In case of atypical presentations, erysipela must be distinguished from necrotizing fasciitis and acute vein thrombosis. Flucloxacillin and cefradine remain the first line of treatment. Recurrence is the main complication, so correct treatment of the risk factors is crucial.
Collapse
Affiliation(s)
| | - Mónica Caetano
- Serviço de Dermatovenereologia. Centro Hospitalar e Universitário do Porto. Porto. Departamento de Dermatovenereologia. Instituto de Ciências Biomédicas Abel Salazar. Porto. Portugal
| | - Isabel Amorim
- Serviço de Dermatovenereologia. Centro Hospitalar e Universitário do Porto. Porto. Portugal
| | - Manuela Selores
- Serviço de Dermatovenereologia. Centro Hospitalar e Universitário do Porto. Porto. Departamento de Dermatovenereologia. Instituto de Ciências Biomédicas Abel Salazar. Porto. Portugal
| |
Collapse
|
48
|
Abstract
BACKGROUND AND AIMS There are more than 463 million people living with diabetes with this number expected to increase to 700 million people by 2045. Diabetes is a risk factor for patients developing various comorbidities including, but not limited to, diabetic neuropathy, retinopathy, chronic kidney disease, vascular impediments, and infections. Due to the continuous invasiveness of monitoring and/or treatment of this disease, site for infections are elevated. METHODS Information was primarily gathered by employing various PubMed scholarly articles for real-world examples in addition to data extraction from supplementary manuscripts. Key search words employed were: diabetes, insulin site infection, lancing infections, insulin pump associated infections, and continuous glucose monitoring infections. RESULTS Diabetic care devices used for blood glucose monitoring and insulin administration are an integral part of the disease management and/or treatment in various settings including patient homes, assisted living facilities, community centers, and hospitals. These invasive devices leave a diabetic patient with a small open wound which may get infected or aid in blood borne pathogen transmission. Since diabetes itself has a morbidity and mortality burden, it is important to also study complications arising from the management of diabetes. CONCLUSION Although cases exist of infections, either by pathogen transmission or direct inoculation of the prick site, these are a very small percentage and thus should not undermine the confidence in diabetes management. This review highlights the instances of these infections and where they most often occur.
Collapse
Affiliation(s)
- Bansree Patel
- Massachusetts College of Pharmacy and Health Sciences University, Boston, MA, USA
| | - Ronny Priefer
- Massachusetts College of Pharmacy and Health Sciences University, Boston, MA, USA.
| |
Collapse
|
49
|
Schefte DF, Polzik PV. [Necrotising soft-tissue infections]. Ugeskr Laeger 2021; 183:V05200360. [PMID: 33491620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Necrotising soft-tissue infections (NSTI) is a new term for infections by bacteria, which cause ischaemia and necrosis of the affected tissue. Scientific advances during the past decade have expanded our knowledge of the epidemiology, pathophysiology, prognosis and treatment of NSTI. Early, correct diagnosis and elimination of delay to surgical debridement is crucial for survival. The recommended antimicrobial treatment has recently been updated. This review summarises the latest advances concerning NSTI, and it is important, that all Danish clinicians are up to date on these.
Collapse
|
50
|
Johnson LJ, Crisologo PA, Sivaganesan S, Caldwell CC, Henning J. Evaluation of the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score for detecting necrotizing soft tissue infections in patients with diabetes and lower extremity infection. Diabetes Res Clin Pract 2021; 171:108520. [PMID: 33096188 DOI: 10.1016/j.diabres.2020.108520] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 09/10/2020] [Accepted: 10/12/2020] [Indexed: 11/23/2022]
Abstract
AIMS The aim of this pilot study was to assess the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC), a scoring system for Necrotizing Soft Tissue Infections, to diagnose Necrotizing Soft Tissue Infections of the lower extremity in patients with diabetes. METHODS Sixty-nine patients with lower extremity infections were prospectively enrolled. The Laboratory Risk Indicator for Necrotizing Fasciitis was calculated and logistic regression was performed for each laboratory value. RESULTS The Laboratory Risk Indicator for Necrotizing Fasciitis was associated with Necrotizing Soft Tissue Infection diagnosis in patients with diabetes (p = 0.01). Sensitivity, specificity, positive predictive value, and negative predictive value were 100%, 69%, 16.6%, and 100% respectively. Elevated C-reactive protein (OR 1.01, p = 0.02, 95% CI [1.002-1.23]) and white blood cell count (OR 1.34, p < 0.01, 95% CI [1.1-1.7]) were associated with Necrotizing Soft Tissue Infection. CONCLUSIONS The Laboratory Risk Indicator for Necrotizing Fasciitis was useful as a negative predictor of Necrotizing Soft Tissue Infection while C- reactive protein and white blood cell count may have value as individual predictors. We recommend high clinical suspicion of Necrotizing Soft Tissue Infections in diabetics as laboratory evaluation may be non-specific.
Collapse
Affiliation(s)
- Lance J Johnson
- University of Cincinnati Medical Center, Cincinnati, OH, USA.
| | - Peter A Crisologo
- Division of Podiatric Surgery, Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Siva Sivaganesan
- Division of Statistics and Data Science, Department of Mathematical Sciences, University of Cincinnati, Cincinnati, OH, USA
| | - Charles C Caldwell
- Division of Research, Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Jordan Henning
- Division of Podiatric Surgery, Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH, USA; Podiatry Department, Cincinnati Veteran Affairs Medical Center, Cincinnati, OH, USA
| |
Collapse
|