Procalcitonin ratio as a predictor of successful surgical treatment of severe necrotizing soft tissue infections

Biomarkers to predict mortality in patients with Fournier's gangrene admitted to the intensive care unit after surgery in South Korea

BACKGROUND

The use of biomarkers to predict patient outcomes may be crucial for patients admitted to the intensive care unit (ICU) following surgery because biomarkers guide clinicians in tailoring treatment plans accordingly. Therefore, we aimed to identify potential biomarkers to predict the prognosis of patients with Fournier's gangrene (FG) admitted to the ICU after surgery.

METHODS

We enrolled patients with FG admitted to our Hospital between January 2013 and December 2022. We retrospectively analyzed patient characteristics, factors related to management, scores known to be associated with the prognosis of FG, and laboratory data.

RESULTS

The study population included 28 survivors and 13 nonsurvivors. The initial serum lactate level taken in the emergency department; white blood cell, neutrophil, and platelet counts; delta neutrophil index and international normalized ratio; albumin, glucose, HCO3, and postoperative lactate levels; and the laboratory risk indicator for necrotizing fasciitis differed between survivors and nonsurvivors. Postoperative lactate and initial albumin levels were independent predictors of mortality in patients with FG. In the receiver operating characteristic curve analysis, the postoperative lactate level was the best indicator of mortality (area under the curve, 0.877; 95% confidence interval, 0.711-1.000). The optimal cutoff postoperative lactate level for predicting mortality was 3.0 mmol/L (sensitivity, 80.0%; specificity, 95.0%).

CONCLUSIONS

Postoperative lactate and initial albumin levels could be potential predictors of mortality in patients with FG admitted to the ICU after surgery, and the optimal cutoff postoperative lactate and initial albumin levels to predict mortality were 3.0 mmol/L and 3.05 g/dl, respectively. Large-scale multicenter prospective studies are required to confirm our results.

Causative Micro-Organisms in Necrotizing Fasciitis and their Influence on Inflammatory Parameters and Clinical Outcome

Background: Necrotizing fasciitis (NF) is a potentially fatal soft tissue infection. Four types of pathogens can be distinguished in the pathogen spectrum, although there are strong regional differences with regard to the most common pathogens. Patients and Methods: All cases of NF between 2003 and 2021 with an identified causative agent were analyzed retrospectively. The cases were divided into three groups: polymicrobial, gram-positive and gram-negative. Demographic factors, localization of infection, inflammatory parameters, and clinical outcome were compared between the three groups. Results: A total of 95 cases were analyzed, 41% of which were caused by multiple pathogens. A gram-positive pathogen was reported in 40% of cases and a gram-negative pathogen in 19%. There were significant differences between the three groups with respect to age (with patients in the gram-negative group being on average the oldest) and intensive care unit admissions (which was most frequent in the polymicrobial group). Conclusions: The pathogen spectrum of NF has rarely been studied in a large patient population. Gram-positive pathogens account for the majority of monomicrobial infections in our study. Nevertheless, we recommend calculated broad-spectrum antibiotic therapy given the high number of polymicrobial infections and gram-negative infections. Gram-negative infections may be associated with increased mortality, elevated procalcitonin levels, and are relatively frequent in NF of the lower extremities.

Diagnostic and prognostic value of the Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) based on an 18 years' experience

BACKGROUND

Necrotising fasciitis (NF) represents a rare but often life-threatening condition. Early diagnosis and surgical treatment are of vital importance. The LRINEC score was developed to distinguish necrotising fasciitis from other soft tissue infections (STI) at initial evaluation using six laboratory values. In this retrospective study, we attempted to determine the diagnostic and prognostic value of the LRINEC score.

METHODS

A total of 125 patients, hospitalised in our clinic between 2003 and 2021 with a histologically confirmed diagnosis of necrotising fasciitis (NF group) and 319 patients with surgically treated soft tissue infections (STI group) were included in this study. Individual LRINEC scores were calculated and analysed retrospectively.

RESULTS

The sensitivity of the LRINEC score at the cut-off point of ≥ 6 was 59%, whereas the specificity was 82%. The positive and negative predictive values were 57% and 84%, respectively. The mean LRINEC score was significantly higher in the NF group than in the STI group (6.0 compared to 2.4, respectively). All clinical outcome parameters such as amputation and mortality rates (15% vs 1%) were found to be significantly higher in the NF group (p<0.001). Within the NF group, there was no statistically significant association between the LRINEC score and clinical outcomes except for the necessary number of operations.

CONCLUSION

In isolation, we found the LRINEC score not to be a reliable enough diagnostic tool for the differentiation between NF and other soft tissue infections, because of its low sensitivity. Although we cannot recommend it as a prognostic tool either, we do believe it can be a useful adjunct to the clinical suspicion of NF.

Delta neutrophil index as a prognostic factor for mortality in patients with Fournier's gangrene

OBJECTIVES

The delta neutrophil index represents the fraction of circulating immature granulocytes and is a marker of infection and sepsis. Our study aimed to evaluate the usefulness of the delta neutrophil index in predicting mortality in patients with Fournier's gangrene.

METHODS

We enrolled patients with Fournier's gangrene who were admitted to the Wonju Severance Christian Hospital (Wonju, Korea) between September 2010 and December 2021. We retrospectively analyzed the patients' characteristics, factors related to management, scoring systems such as the Fournier's Gangrene Severity Index, and laboratory data measured at initial presentation.

RESULTS

There were 58 (68.2%) survivors and 27 (31.8%) non-survivors. The initial levels of serum lactate, hemoglobin, delta neutrophil index, albumin, international normalized ratio, creatinine, Fournier's Gangrene Severity Index, Uludag Fournier's Gangrene Severity Index, and prognostic nutritional index differed between survivors and non-survivors. Age, international normalized ratio, and delta neutrophil index were independent predictors of mortality in Fournier's gangrene. In receiver operating characteristic curve analysis, delta neutrophil index on the day of admission was the best indicator of mortality (area under the curve, 0.804; 95% confidence interval [0.679-0.929]). The optimal cutoff for delta neutrophil index in predicting mortality was 11.25% (sensitivity, 74.1%; specificity, 91.4%). The initial delta neutrophil index was the best indicator of mortality (area under the curve, 0.804; 95% confidence interval 0.679-0.929).

CONCLUSION

The delta neutrophil index can be useful for predicting mortality in patients with Fournier's gangrene. A delta neutrophil index >11.25% at initial presentation is a reliable predictor of Fournier's gangrene.

The Diagnosis and Management of Life-threatening Urologic Infections

Genitourinary infections are commonly encountered and managed in inpatient, outpatient, and emergency settings. Fournier's gangrene, emphysematous pyelonephritis, and obstructive pyelonephritis represent the most serious urologic infections and have a high risk of mortality if not managed promptly. Due to the rarity of these infections, the evidence for specific treatment strategies is scattered. This review aims to provide comprehensive, evidence-based recommendations for the diagnosis and management of these life-threatening urologic infections.

Necrotizing Soft Tissue Infections in Intensive Care

Background:

Necrotizing soft tissue infections (NSTIs) are typically characterized by extensive soft tissue destruction with systemic signs of toxicity, ranging from sepsis to septic shock. Our aim was to analyze the clinical characteristics, microbiological results, laboratory data, therapies, and outcome of patients with NSTIs admitted to an intensive care unit (ICU).

Methods:

A monocentric observational study of patients admitted to the ICU of a university hospital between January 2009 and December 2017. The demographic characteristics, comorbidities, clinical features, microbiology and laboratory results, organ dysfunctions, therapies, and outcome were retrospectively analyzed.

Results:

There were 59 patients and 70% males. The mean age (± SD) was 55 ± 18; type II (monomicrobial) NSTI was present in 36 patients (61%); the most common isolated pathogen was Streptococcus pyogenes in 28 patients (48%). Septic shock was diagnosed in 41 patients (70%). The most common organ dysfunctions were circulatory and renal in 42 (71%) and 38 patients (64%). The mean value (± SD) of serum lactate at admission to the ICU was 4.22 ± 5.42 mmol/l, the median SOFA score and SAPS II were 7 (IQR 4 - 10) and 46 (IQR 30.5 - 53). ICU mortality rate was 25%. Both SOFA score and serum lactate demonstrated a good prognostic value regarding ICU outcome (OR 1.29, 95%CI 1.07-1.57, P < 0.007 and OR 1.53, 95%CI 1.19-1.98, P < 0.001). A cut-off value for serum lactate of 6.55 mmol/L positively predicted mortality with 67% sensitivity and 97% specificity.

Conclusion:

NSTIs carry a high risk of septic shock and multiple organ dysfunction syndrome and thus are still associated with high mortality. In our study, the value of serum lactate at admission to the ICU correlated well with mortality. This easy-to-measure parameter could play a role in the decision-making process regarding prognosis and continuation of care.

The role of procalcitonin in reducing antibiotics across the surgical pathway

Procalcitonin (PCT) is widely considered as a highly sensitive biomarker of bacterial infection, offering general and emergency surgeons a key tool in the management of surgical infections. A multidisciplinary task force of experts met in Bologna, Italy, on April 4, 2019, to clarify the key issues in the use of PCT across the surgical pathway. The panelists presented the statements developed for each of the main questions regarding the use of PCT across the surgical pathway. An agreement on the statements was reached by the Delphi method, and this document reports the executive summary of the final recommendations approved by the expert panel.

Usefulness of a risk scale based on procalcitonin for early discrimination between necrotising fasciitis and cellulitis of the extremities

BACKGROUND AND OBJECTIVE

To assess the usefulness of a risk scale based on serum procalcitonin (PCT) compared to the Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) scale in the early discrimination between necrotising fasciitis (NF) and cellulitis of the extremities.

MATERIALS AND METHODS

Retrospective study of consecutive patients with confirmed diagnosis of NF in one limb (n=11). This study group was compared with 23 consecutive patients with a diagnosis of severe limbs cellulitis during the same period. The clinical data and laboratory parameters were analysed, the main variable was the serum level of PCT upon admission. The capacity for NF diagnosis of the two methods, PCT level and LRINEC scale score, were evaluated by ROC curve and determined by the calculation of the area under the curve (AUC).

RESULTS

The AUC was significantly higher with PCT measurement, both as a continuous variable and when the risk was categorised. The cut-off point for the PCT level with the highest AUC under the curve was from 0.87ng/ml (sensitivity 90.9%, specificity 82.6%), whereas it was a score of 5 on the LRINEC scale (sensitivity 72.7%, specificity 82.6%).

CONCLUSION

PCT measurement was a more effective method than the LRINEC score for early discrimination between NF and cellulitis of the extremities. A low level of PCT, associated with the patient's clinical status and physical examination is especially useful to rule out an early diagnosis of NF.

Necrotizing fasciitis and the midterm outcomes after survival

Background and Aims:

Radical surgical intervention is necessary to save patients’ lives in cases of necrotizing fasciitis. This leads to persistent disabilities and most likely to a deteriorated quality of life. The purpose of this study was to evaluate the midterm outcomes after survival of necrotizing fasciitis.

Materials and Methods:

A retrospective analysis of 69 patients, treated for necrotizing fasciitis between 2003 and 2012. The patients were identified using the International Classification of Diseases (10th Revision) code M 72.6. Of the 50 survivors, 22 patients completed the Short Form 36 and Short Musculoskeletal Function Assessment questionnaires as a postal survey. The follow-up averaged 59 months (range: 6–128 months).

Results:

The average age at the time of necrotizing fasciitis was 60.0 years. The body mass index average was 29.7. The patients had a significantly decreased physical component summary score of 33.3 compared to a normative group (p < 0.001) (Short Form 36). They further showed a significantly decreased dysfunction and bother indices (Short Musculoskeletal Function Assessment) (p < 0.001). An increased age (⩾70 years) was associated with an inferior role emotional (p = 0.048) and physical functioning (p = 0.011) as well as social functioning (p = 0.038) (Short Form 36). The majority of patients (16, 72.7%) complained of pain at the final follow-up and 50% of patients required an assistive device on a regular basis.

Conclusion:

Patients who survived necrotizing fasciitis suffer from functional impairment and changed body appearance. Assistive devices or pain medication are often required, and the patients present with significantly decreased physical, social, and emotional functioning at the midterm follow-up. The patient’s age is a critical factor regarding functional or mental outcome parameters. Further research on the post-hospital course and long-term multidisciplinary care is required to improve the outcomes of these patients.

2018 WSES/SIS-E consensus conference: recommendations for the management of skin and soft-tissue infections

Skin and soft-tissue infections (SSTIs) encompass a variety of pathological conditions that involve the skin and underlying subcutaneous tissue, fascia, or muscle, ranging from simple superficial infections to severe necrotizing infections. SSTIs are a frequent clinical problem in surgical departments. In order to clarify key issues in the management of SSTIs, a task force of experts met in Bertinoro, Italy, on June 28, 2018, for a specialist multidisciplinary consensus conference under the auspices of the World Society of Emergency Surgery (WSES) and the Surgical Infection Society Europe (SIS-E). The multifaceted nature of these infections has led to a collaboration among general and emergency surgeons, intensivists, and infectious disease specialists, who have shared these clinical practice recommendations.

Procalcitonin kinetics after burn injury and burn surgery in septic and non-septic patients - a retrospective observational study

BACKGROUND

Early sepsis diagnosis is crucial for the correct management of burn patients, and it clearly influences outcomes. The systemic inflammatory response triggered by burns mimics sepsis presentation and complicates early sepsis diagnosis. Biomarkers were advocated to aid the diagnosis of early sepsis. Serum procalcitonin (PCT) exhibits fair accuracy and good correlation with sepsis severity, being used in diverse clinical settings. However, few studies have evaluated perioperative changes in PCT levels in burn patients. The present study evaluated PCT kinetics during the first days after burn injury and subsequent surgical interventions to assess PCT utility in distinguishing septic from non-septic inflammatory responses.

METHODS

This study was a retrospective observational study of all burn patients admitted to the Coimbra Burns Unit (Portugal) between January 2011 and December 2014 who presented with a total burn surface area ≥ 15% and who underwent subsequent surgery. PCT kinetics were investigated a) during the first five days after burn injury and b) preoperatively during the five days after surgery in three subsets of patients, including those with no preoperative and no postoperative sepsis (NN), no preoperative but postoperative sepsis (NS), and preoperative and postoperative sepsis (SS). A total of 145 patients met the selection criteria and were included in the analysis.

RESULTS

PCT levels in the first five days after burn injury were significantly higher in patients who developed at least one sepsis episode (n = 85) compared with patients who did not develop sepsis (n = 60). PCT values > 1.00 ng/mL were clearly associated with sepsis. Study participants (n = 145) underwent a total of 283 surgical interventions. Their distribution by preoperative/postoperative sepsis status was 142 (50.2%) in NN; 62 (21.9%) in NS; and 79 (27.9%) in SS. PCT values exhibited a parallel course in the three groups that peaked on the second postoperative day and returned to preoperative levels on the third day or later. The lowest PCT values were found in NN, and the highest values were observed in SS; the NS values were intermediate.

CONCLUSIONS

PCT kinetics coupled with a clinical examination may be helpful for sepsis diagnosis during the first days after burn injury and burn surgery.

Diagnosing Necrotizing Fasciitis Using Procalcitonin and a Laboratory Risk Indicator: Brief Overview

Necrotizing fasciitis is a progressive inflammatory disease that requires an early diagnosis to avoid limb salvage and other deadly manifestations. The current protocol is the microbiological and histopathological sampling of the tissue. Once the diagnosis is made, it should be managed with antimicrobial therapy, debridement, and surgical interventions. Such interventions can be invasive and increase the time to treat, which may increase morbidity. Our article discusses procalcitonin, C-reactive protein, and other markers, such as "pain out of proportion," lactate, creatinine, and creatine kinase, to make a quicker diagnosis before proceeding with invasive procedures. We discussed a similar non-invasive approach called the "Laboratory Risk Indicator for Necrotizing Fasciitis" scoring system that can aid in the early diagnosis of necrotizing fasciitis, which can prompt rapid empiric therapy, reducing the chances of morbidity. This scoring system comprises C-reactive protein, white blood cell count, hemoglobin level, creatinine, sodium, and glucose. Such non-invasive, bedside, and quick tests can help in reducing the time required to make the diagnosis and can affect the course of the disease, hence, improving patient outcomes.

Procalcitonin: Usefulness in Acute Care Surgery and Trauma

BACKGROUND

Procalcitonin (PCT) is a serum biomarker currently suggested by the Surviving Sepsis Campaign to aid in determination of the appropriate duration of therapy in sepsis patients. We review the use of procalcitonin in patients after trauma or acute care surgery.

METHOD

A MEDLINE search via PubMed was performed using the combination of "procalcitonin" and "humans" and "injuries, trauma," "wounds and injuries," or "wounds." Studies of burn patients, children, other biomarkers, and non-acute care surgery were excluded.

RESULTS

Procalcitonin may be useful in identifying infection in trauma and post-operative acute care surgery. However, heterogenity exists among patients, and surgery and trauma alone elevate PCT even in the absence of infection.

CONCLUSIONS

Although trends in PCT concentrations may offer insight, no standard approach can be recommended currently.

Procalcitonin: A Powerful Rescuer on Surgical Floors

Necrotizing fasciitis (NF) is a rare but life-threatening medical and surgical emergency. It is characterized by necrosis of the soft tissue leaving the overlying tissue unaffected, which delays the diagnosis and treatment. Delay in recognition of the severity of necrotizing fasciitis might lead to serious morbidity and mortality. Diagnosis of NF relies on strong clinical judgment, predictable by severe pain, erythema, and a presence of air under the skin, but all of them are not always present. Management of NF is prompt surgical intervention and antimicrobial therapy. The effectiveness depends on the timely diagnosis of NF because it rapidly spreads and may cause irreversible damage.

Various investigations for necrotizing fasciitis have been proposed. However, misdiagnosis is not infrequent and more work is needed to identify the different presentations across the spectrum. We consider changing it to discuss the role of procalcitonin in the diagnosis of necrotizing fasciitis.There is scarce literature about its clinical role in necrotizing fasciitis although it has evolved not only as a prognostic marker but also as a way of differentiating between cellulitis and necrotizing fasciitis. It can also predict the future consequences of septic shock.

Procalcitonin as a Biomarker for Predicting Amputation Level in Lower Extremity Infections

Inflammatory markers are essential tools in the decision-making process for lower extremity infections. When coupled with objective findings, clinicians can more accurately diagnose and treat these entities. Typically, markers such as the white blood cell count, erythrocyte sedimentation rate, and C-reactive protein are used to initially assess these patients or monitor the progression of medical or surgical therapy. Procalcitonin is a newer inflammatory marker that is specific for an infectious process. Originally, procalcitonin was used to monitor antibiotic therapy and sepsis for patients in the intensive care setting, but it has now been expanded to other facets of medicine. The utility of procalcitonin has been described for diagnosing infection or osteomyelitis in diabetic foot ulcers. However, limited research has compared inflammatory marker levels and the level of amputation. A retrospective inpatient medical record review was performed of 156 consecutive patient occurrences during 25 months in which surgical intervention was required for a lower extremity infection and an initial procalcitonin level had been obtained. This initial procalcitonin value was then compared with the level of amputation at the final surgical intervention. A highly statistically significant difference was found when comparing those who underwent a below-the-knee or above-the-knee amputation (median procalcitonin 1.72 ng/mL) and those who did not (median procalcitonin 0.105 ng/mL; p < .001). Therefore, patients with higher initial procalcitonin values were more likely to undergo below-the-knee or above-the-knee amputation or require aggressive surgical intervention. Thus, the procalcitonin level can provide valuable initial information to the clinician.

Procalcitonin-guided diagnosis and antibiotic stewardship revisited

Several controlled clinical studies have evaluated the potential of the infection biomarker procalcitonin (PCT) to improve the diagnostic work-up of patients with bacterial infections and its influence on decisions regarding antibiotic therapy. Most research has focused on lower respiratory tract infections and critically ill sepsis patients. A clinical utility for PCT has also been found for patients with urinary tract infections, postoperative infections, meningitis, and patients with acute heart failure with possible superinfection (i.e., pneumonia). In these indications, PCT levels measured on hospital admission were found to substantially reduce the initiation of antibiotic treatment in low-risk situations (i.e., bronchitis, chronic obstructive pulmonary disease exacerbation). For more severe infections (i.e., pneumonia, sepsis), antibiotic stewardship by monitoring of PCT kinetics resulted in shorter antibiotic treatment durations with early cessation of therapy. Importantly, these strategies appear to be safe without increasing the risk for mortality, recurrent infections, or treatment failures. PCT kinetics also proved to have prognostic value correlating with disease severity (i.e., pancreatitis, abdominal infection) and resolution of illness (i.e., sepsis). Although promising findings have been published in these different types of infections, there are a number of limitations regarding PCT, including suboptimal sensitivity and/or specificity, which makes a careful interpretation of PCT in the clinical context mandatory. This narrative review aims to update clinicians on the strengths and limitations of PCT for patient management, focusing on research conducted within the last 4 years.

Procalcitonin Levels in Survivors and Nonsurvivors of Sepsis: Systematic Review and Meta-Analysis

Procalcitonin (PCT) is an acute-phase reactant that has been used to diagnose and potentially track the treatment of sepsis. Procalcitonin values rise initially as the infection sets in and eventually fall with resolution. Its level has been reported to be significantly higher in potential nonsurvivors of a septic episode than among survivors. However, there is also a significant amount of evidence against this. We thus conducted a meta-analysis to pool data from all the available studies regarding PCT levels in survivors and nonsurvivors of sepsis. An extensive literature search was conducted using the key words "procalcitonin," "sepsis," and "prognosis." The references of the relevant studies were also scanned. The data from the eligible studies were extracted and analyzed for any significant pooled mean difference between survivors and nonsurvivors both on days 1 and 3. The mean difference in the day 1 PCT values between survivors and nonsurvivors was found to be statistically significant (P = 0.02). The mean difference on day 3 was also statistically significant (P = 0.002). However, in a subgroup consisting of studies on patients with severe sepsis and septic shock, day 1 difference was not found to be significant (P = 0.62). We found heterogeneity of 90% in our study population, which decreased to 62% after exclusion of studies conducted in emergency department patients. Procalcitonin levels in early stages of sepsis are significantly lower among survivors as compared with nonsurvivors of sepsis.

Pentraxin-3 as a marker of disease severity and risk of death in patients with necrotizing soft tissue infections: a nationwide, prospective, observational study

BACKGROUND

New biomarkers are needed to assess the severity of necrotizing soft tissue infection (NSTI) at an early stage and to individualize treatment strategies. We assessed pentraxin-3 (PTX3) as a marker of disease severity and risk of death in patients with NSTI.

METHODS

We conducted a prospective, observational study in the intensive care unit at Copenhagen University Hospital, where treatment of NSTI is centralized at a national level. We compared PTX3, procalcitonin and C-reactive protein in septic shock versus nonshock patients and in amputated versus nonamputated patients using the Mann-Whitney U test. The prognostic value of the markers for 180-day mortality was assessed using Cox regression analyses.

RESULTS

Patients with NSTI (n = 135) were included over 25 months with up to 2.5-year follow-up; 71% had septic shock, amputation was undertaken in 20% and the 180-day mortality was 27%. Baseline plasma PTX3 level was significantly higher in patients with septic shock (67.3 versus 24.6 ng/mL, p < 0.0001) and in patients who underwent amputation (118.6 versus 43.6 ng/mL, p = 0.019). No significant differences in baseline procalcitonin or C-reactive protein levels were found according to amputation (25.2 versus 7.0 μg/L, p = 0.060 and 202 versus 225 mg/L, p = 0.123), respectively. Baseline PTX3 level above the median was associated with death (p = 0.009, log-rank test) and the univariate Cox regression analysis revealed a significant association between PTX3 level upon admission and 180-day mortality (hazard ratio 2.60 (95% confidence interval 1.28-5.29), p = 0.008). When adjusted for age, sex, chronic disease and Simplified Acute Physiology Score II, no significant association was found.

CONCLUSIONS

High PTX3 level is associated with septic shock, amputation and risk of death in patients with NSTI, but it is not an independent predictor of 180-day mortality in this patient group.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02180906. Date of registration: June 29, 2014.

The Prediction Predicament: Rethinking Necrotizing Soft Tissue Infections Mortality

BACKGROUND

Our study sought to identify independent risk factors predisposing patients with necrotizing soft tissue infections (NSTIs) to mortality from among laboratory values, demographic data, and microbiologic findings in a small population. To this end, a retrospective review was conducted of the medical records of all patients with NSTI who had been treated at our institution from 2003 to 2012 (n=134).

METHODS

Baseline demographics and comorbidities, clinical and laboratory values, hospital course, and the microbiologic characteristics of surgical incision cultures were recorded. Each variable was tested for association with survival status and all associated variables with p<0.15 were included in a logistic regression model to seek factors associated independently with mortality.

RESULTS

Surprisingly, no demographic or pre-existing condition proved to be a predictor of mortality. Two laboratory values had an inverse correlation to mortality: High C-reactive protein (CRP) and highest recorded CRP. Of surgical incisions that grew bacteria in culture, 33.6% were polymicrobial. Mortality rates were highest with Enterococcus-containing polymicrobial infections (50%), followed by those containing Pseudomonas (40%), and Streptococcus spp. (27%). Understanding why so many studies across the literature, now including our own, find such disparate results for correlation of NSTI mortality with patient data may lie in the fundamentally dynamic nature of the organisms involved.

CONCLUSIONS

This study suggests that no single factor present on admission is a robust predictor of outcome; it is likely that survival in NSTI is predicated upon a complex interaction of multiple host and microbial factors that do not lend themselves to reduction into a simple formula. It is also abundantly clear that the well-established principles of NSTI surgery should continue to be followed in all cases, with an emphasis on early debridement, irrespective of apparent severity of initial presentation.

Procalcitonin-guided antibiotic therapy for septic patients in the surgical intensive care unit

In critically ill patients, elucidating those patients with the systemic inflammatory response syndrome (SIRS) from an infectious source (sepsis), versus those who have SIRS without infection, can be challenging since the clinical features are the same.

Even with strict monitoring and testing, 39–98 % of patients with SIRS will never have bacteriological confirmation of an infection, and 6–17 % of patients with a documented infection will not show signs of SIRS. Due to this overlap, an extensive amount of research has been performed to investigate ways of determining and separating SIRS from infection, compared to SIRS due to trauma, surgical stress, or other non-infectious causes. This review article will discuss the recommended and peer-approved use of procalcitonin in septic patients in the intensive care unit and its use as a guide to antibiotic initiation and termination. The article will focus on the prospective randomized trials (Level 1 evidence) that have been conducted, and lesser levels of evidence will be referenced as needed to substantiate a conclusion.

The literature documents multiple benefits of using procalcitonin as a guide to cost savings and appropriate termination of antibiotics by its use as a new objective marker of bacteremia that was previously not available. This article will show that antibiotics should be terminated when the procalcitonin level falls below 0.5 ng/mL.

Procalcitonin ratio and on-demand relaparotomy for septic peritonitis: validation of the focus index (FI)

PURPOSE

Secondary peritonitis remains challenging to manage and some recent evidence suggests that on-demand relaparotomy is more appropriate than planned relaparotomy. This study was designed to validate the predictive power of postoperative procalcitonin (PCT) changes in relation to elimination of the septic abdominal focus.

METHODS

In this prospective trial, postoperative PCT serum levels were monitored in 234 surgical patients with secondary peritonitis. The PCT ratio on postoperative days (PODs) 1 and 2 (focus index; FI) was calculated and correlated with the success of the operation.

RESULTS

A cutoff value of 1.1 was calculated for the FI. Values below 1.1 indicated insufficient elimination of the focus and values above 1.1 correlated with effective treatment. The optimal time for first PCT sampling was found to be 12-24 h after the index operation. After the respective data cleanup, successful elimination of the intraabdominal focus could be confirmed, with a sensitivity of 93 % and a specificity of 71 %.

CONCLUSIONS

The FI is a single parameter-based reliable predictor of successful surgical eradication and strengthens the on-demand relaparotomy concept as the method of choice to treat secondary peritonitis.

Acute Phase Reactants in Infections: Evidence-Based Review and a Guide for Clinicians

There is increasing evidence to support the role of various acute phase reactants as an adjunct to clinical judgement in the management of various infections. Procalcitonin is more specific in diagnosing bacterial infections and has a wider role in the management of complex infections. Procalcitonin based antibiotic guidance is helpful in antibiotic management in patients with pneumonia and sepsis

Acute-phase reactants such as erythrocyte sedimentation rate and C-reactive protein have traditionally been used as markers for inflammation and as a measure of “sickness index” in infectious and noninfectious conditions. In the last decade, more data have become available on the wider and more specific role for these markers in the management of complex infections. This includes the potential role in early diagnosis, in differentiating infectious from noninfectious causes, as a prognostic marker, and in antibiotic guidance strategies. A better defined role for biological markers as a supplement to clinical assessment may lead to more judicious antibiotic prescriptions, and it has the potential for a long-term favorable impact on antimicrobial stewardship and antibiotic resistance. Procalcitonin as a biological marker has been of particular interest in this regard. This review examines the current published evidence and summarizes the role of various acute-phase markers in infections. A MEDLINE search of English-language articles on acute-phase reactants and infections published between 1986 and March 2015 was conducted. Additional articles were also identified through a search of references from the retrieved articles, published guidelines, systematic reviews, and meta-analyses.

Necrotizing soft tissue infections after injection therapy: Higher mortality and worse outcome compared to other entry mechanisms

OBJECTIVES

Necrotizing Soft Tissue Infections represent a rare entity of infection associated with a high mortality. The aim of this retrospective study was to analyze patients with an iatrogenic etiology of injection or infiltration to compare the outcome with other etiologies.

METHODS

The study group consisted of 21 patients treated with a Necrotizing Fasciitis caused by injection or infiltration. Risk factors and outcome were compared to 134 patients with a Necrotizing Fasciitis caused by other entry mechanisms.

RESULTS

Overall mortality in our study group was 14 of 21 (67%) with an amputation rate of 11 of 15 (73%) if an extremity was involved. The survival rate was significantly worse after injection or infiltration (p < 0.001) as was the amputation rate (p = 0.013), the percentage of patients requiring intensive care (100% vs. 83%, p = 0.038) and vasopressors (81% vs. 54%, p = 0.02). Injection or infiltration therapy proved to be the strongest prognostic factor (p = 0.003) besides the known risk factors obesity (0.007) and renal insufficiency (0.025).

CONCLUSIONS

Our results demonstrate that patients with a Necrotizing Soft Tissue Infection after injection or infiltration therapy have a significantly worse prognosis.

Pneumoretroperitoneum and Pneumomediastinum Revealing a Left Colon Perforation

Left colon perforation usually occurs in complicated diverticulitis or cancer. The most frequent signs are intraperitoneal abscess or peritonitis. In cases of retroperitoneal colonic perforation, diagnosis may be difficult. A 59-year-old woman presented with left thigh pain and with abdominal discomfort associated with mild dyspnea. Computed tomography scan showed air bubbles and purulent collection in the retroperitoneum, with subcutaneous emphysema extending from the left thigh to the neck. Computed tomography scan also revealed portal vein gas and thrombosis with multiple liver abscesses. An emergency laparotomy revealed a perforation of the proximal left colon. No masses were found. A left colectomy was performed. The retroperitoneum was drained and washed extensively. A negative pressure wound therapy was applied. A second-look laparotomy was performed 48 hours later. The retroperitoneum was drained and an end colostomy was performed. Intensive Care Unit postoperative stay was 9 days, and the patient was discharged on the 32nd postoperative day. Pneumoretroperitoneum and pneumomediastinum are rare signs of colonic retroperitoneal perforation. The diagnosis may be delayed, especially in the absence of peritoneal irritation. Clinical, laboratory, and especially radiologic parameters might be useful. Surgical treatment must be prompt to improve prognosis.

Necrotising soft tissue infection in a UK metropolitan population

INTRODUCTION

Necrotising soft tissue infection (NSTI) is a rare but life threatening diagnosis. Geographic, economic and social variances influence presentation and prognosis. As the current literature does not reflect a UK metropolitan population, we conducted a retrospective chart review to establish pertinent features relevant to our practice.

METHODS

Patients with histologically confirmed diagnoses of NSTI presenting to two London teaching hospitals between January 2007 and July 2013 were included in the study. Features of presentation, surgical and medical management, microbiological findings and outcome were evaluated.

RESULTS

Twenty-four patients with histologically confirmed NSTI were included. Two age clusters were identified, with means of 46 years (standard deviation [SD]: 10 years) and 80 years (SD: 6 years). Pain, erythema and sepsis were common findings. Hypertension, hypercholesterolaemia and type II diabetes mellitus were common co-morbidities. A third of younger patients had human immunodeficiency virus or hepatitis C, with a quarter dependent on drugs and/or alcohol. The mean Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score was 5.8 (SD: 3.3). The lower extremities, groin and perineum were common sites of infection. Fourteen patients required inotropic support and seventeen required transfusions. The median number of surgical procedures was 5 (range: 1-17). Group A Streptococcus was the most frequently identified pathogen. Five patients died. Being elderly, female sex and failure to use clindamycin as a first-line antibiotic were associated with significantly higher mortality.

CONCLUSIONS

In contrast to other recent series, group A streptococcal monomicrobial NSTI remains the most common presentation in our population. Survival is anticipated in young patients, regardless of premorbid status. Elderly patients have a poor prognosis. The negative predictive value of the LRINEC score is questioned. Use of clindamycin as a first-line antibiotic is supported.

Necrotizing Soft-Tissue Infection of the Thumb: A Case Report

CASE

We present the case of a fifty-three-year-old man who presented with a necrotizing soft-tissue infection (NSTI) of the thumb, which tracked along the flexor pollicis longus tendon into the space of Parona. In this case report, we review the clinical and laboratory findings diagnostic of NSTI as well as the appropriate initial treatment for this challenging problem.

CONCLUSION

NSTI is a rare, life-threatening condition that must be identified and treated promptly for optimal results. In our patient, although we amputated the necrotic thumb, we were able to salvage the remaining hand and wrist despite more proximal involvement.

Update on procalcitonin measurements

Procalcitonin (PCT) is used as a biomarker for the diagnosis of sepsis, severe sepsis and septic shock. At the same time, PCT has also been used to guide antibiotic therapy. This review outlines the main indications for PCT measurement and points out possible pitfalls. The classic indications for PCT measurement are: (i) confirmation or exclusion of diagnosis of sepsis, severe sepsis, or septic shock, (ii) severity assessment and follow up of systemic inflammation mainly induced by microbial infection, and (iii) individual, patient adapted guide of antibiotic therapy and focus treatment. Using serially monitored PCT levels, the duration and need of antibiotic therapy can be better adapted to the individual requirements of the patient. This individualized approach has been evaluated in various studies, and it is recommended to be a part of an antibiotic stewardship program.

Procalcitonin as a predictor of sepsis and outcome in severe trauma patients: a prospective study

INTRODUCTION

Despite the advances in medical sciences, the morbidity and mortality due to sepsis in severe trauma patients remains high; hence the need for early and accurate diagnosis. Very few prospective studies are available in a country like India, which tried to analyze the prediction of sepsis using serum procalcitonin (PCT) in such a large scale among trauma patients. This study explores the role of the biomarker PCT in early diagnosis of sepsis and prediction of outcomes in severe trauma cases.

MATERIALS AND METHODS

We studied the patient population prospectively in two different groups. One with acute trauma but no clinical evidence of sepsis and the second group with clinical evidence of sepsis and are followed. Bronchoalveolar lavage, tracheal aspirates, pus, urine, body fluids from sterile body sites, etc., were collected including blood for culture and serum for PCT assays. Such assays were done on samples collected on days 1 and 4 and then compared. Additionally, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) levels were also tested. Antimicrobial sensitivity tests were carried out for all the isolates from the clinical samples and correlated with the clinically suspected cases of sepsis. Outcomes of the patients were noted.

RESULTS

Patients with high initial PCT levels (>2 ng/ml) in severe trauma cases had poor outcomes and risk of developing complications. Its correlation with severe outcomes was better marked as compared with CRP and ESR levels. The difference in PCT levels between days 1 and 4 in group two patients was statistically significant (P = 0.006) but were not statistically significant for CRP (P = 0.646) and ESR (P = 0.935). The study also shows that PCT levels fall in response to appropriate antimicrobial treatment.

CONCLUSION

PCT is a useful biomarker for early and accurate prediction of sepsis in severe trauma patients. If used in adjunct to clinical findings, it proves to be a good biomarker for early diagnosis, treatment and for monitoring response to therapy in confirmed cases of sepsis. It will prove to be a good supportive indicator of sepsis in early stages for the trauma patients in a low resource country like India.