2
|
Rodriguez C, Jary A, Hua C, Woerther PL, Bosc R, Desroches M, Sitterlé E, Gricourt G, De Prost N, Pawlotsky JM, Chosidow O, Sbidian E, Decousser JW. Pathogen identification by shotgun metagenomics of patients with necrotizing soft-tissue infections. Br J Dermatol 2019; 183:105-113. [PMID: 31610037 DOI: 10.1111/bjd.18611] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Necrotizing soft-tissue infections (NSTIs) are life threatening, requiring broad-spectrum antibiotics. Their aetiological diagnosis can be limited by poor performance of cultures and administration of antibiotics before surgery. OBJECTIVES We aimed (i) to compare 16S-targeted metagenomics (TM) and unbiased semiquantitative panmicroorganism DNA- and RNA-based shotgun metagenomics (SM) with cultures, (ii) to identify patients who would best benefit from metagenomics approaches and (iii) to detect the microbial pathogens in surrounding non-necrotic 'healthy' tissues by SM-based methods. METHODS A prospective observational study was performed to assess the analytical performance of standard cultures, TM and SM on tissues from 34 patients with NSTIs. Pathogen identification obtained with these three methods was compared. RESULTS Thirty-four necrotic and 10 healthy tissues were collected from 34 patients. The performance of TM was inferior to that of the other methods (P < 0·05), whereas SM performed better than standard culture, although the result was not statistically significant (P = 0·08). SM was significantly more sensitive than TM for the detection of all bacteria (P = 0·02) and more sensitive than standard culture for the detection of anaerobic bacteria (P < 0·01). There was a strong correlation (r = 0·71, Spearman correlation coefficient) between the semiquantitative abundance of bacteria in the culture and the bacteria-to-human sequence ratio in SM. Low amounts of bacterial DNA were found in healthy tissues, suggesting a bacterial continuum between macroscopically 'healthy' and necrotic tissue. CONCLUSIONS SM showed a significantly better ability to detect a broader range of pathogens than TM and identify strict anaerobes than standard culture. Patients with diabetes with NSTIs appeared to benefit most from SM. Finally, our results suggest a bacterial continuum between macroscopically 'healthy' non-necrotic areas and necrotic tissues. What's already known about this topic? Necrotizing soft-tissue infections (NSTIs) are characterized by rapidly progressive necrosis of subcutaneous tissues and high mortality, despite surgical debridement combined with broad-spectrum antibiotics. The spectrum of potentially involved pathogens is very large, and identification is often limited by the poor performance of standard cultures, which may be impaired by previous antibiotic intake. Metagenomics-based approaches show promise for better identification of the pathogens that cause these infections, but they have not been evaluated in this medical context. What does this study add? Shotgun metagenomics (SM) showed higher sensitivity than 16S rRNA gene sequencing and a better ability than culture to detect anaerobic bacteria. As a result, a significant proportion of infections with bacteria, such as Pasteurella multocida or Clostridium perfringens, were detected only by SM. SM bacterial quantification enabled better detection of low amounts of bacterial DNA from macroscopically 'healthy' tissue, suggesting a subclinical infectious extension. What is the translational message? The high analytical performance of SM shown in this study should allow its future implementation for the diagnosis of necrotizing fasciitis, complementing or replacing routine methods. The large amount of data, including additional information on antimicrobial resistance, virulence profiles and metabolic adaptation of the pathogens, will improve microbiological documentation. Our results will improve our understanding of infectious pathophysiology in the future, leading to potentially better medical care.
Collapse
Affiliation(s)
- C Rodriguez
- Department of Microbiology, AP-HP, Henri Mondor University Hospital, Université Paris-Est, Créteil, France.,INSERM U955, AP-HP, Henri Mondor University Hospital, Université Paris-Est, Créteil, France.,NGS Platform, IMRB Institute, AP-HP, Henri Mondor University Hospital, Université Paris-Est, Créteil, France
| | - A Jary
- Department of Microbiology, AP-HP, Henri Mondor University Hospital, Université Paris-Est, Créteil, France
| | - C Hua
- Department of Dermatology, AP-HP, Henri Mondor University Hospital, Université Paris-Est, Créteil, France
| | - P-L Woerther
- Department of Microbiology, AP-HP, Henri Mondor University Hospital, Université Paris-Est, Créteil, France
| | - R Bosc
- Department of Plastic Surgery, AP-HP, Henri Mondor University Hospital, Université Paris-Est, Créteil, France
| | - M Desroches
- Department of Microbiology, AP-HP, Henri Mondor University Hospital, Université Paris-Est, Créteil, France
| | - E Sitterlé
- Unité de Parasitologie-Mycologie, Service de Microbiologie Clinique, Hôpital Necker-Enfants-Malades, AP-HP, Paris, France
| | - G Gricourt
- NGS Platform, IMRB Institute, AP-HP, Henri Mondor University Hospital, Université Paris-Est, Créteil, France
| | - N De Prost
- Department of Microbiology, AP-HP, Henri Mondor University Hospital, Université Paris-Est, Créteil, France.,INSERM U955, AP-HP, Henri Mondor University Hospital, Université Paris-Est, Créteil, France
| | - J-M Pawlotsky
- Department of Microbiology, AP-HP, Henri Mondor University Hospital, Université Paris-Est, Créteil, France.,INSERM U955, AP-HP, Henri Mondor University Hospital, Université Paris-Est, Créteil, France
| | - O Chosidow
- Department of Dermatology, AP-HP, Henri Mondor University Hospital, Université Paris-Est, Créteil, France.,EA 7379 EpiDermE (Epidémiologie en Dermatologie et Evaluation des Thérapeutiques) and INSERM CIC 1430, Université Paris-Est, Créteil, and Université Pierre et Marie Curie, Paris, France
| | - E Sbidian
- Department of Dermatology, AP-HP, Henri Mondor University Hospital, Université Paris-Est, Créteil, France.,EA 7379 EpiDermE (Epidémiologie en Dermatologie et Evaluation des Thérapeutiques) and INSERM CIC 1430, Université Paris-Est, Créteil, and Université Pierre et Marie Curie, Paris, France
| | - J-W Decousser
- Department of Microbiology, AP-HP, Henri Mondor University Hospital, Université Paris-Est, Créteil, France
| | | |
Collapse
|
3
|
Brengard-Bresler T, De Runz A, Bourhis F, Mezzine H, Khairallah G, Younes M, Brix M, Simon E. [Postoperative quality of life of patients with a bacterial necrotizing dermis-hypodermitis or necrotizing fasciitis, a ten-year study]. ANN CHIR PLAST ESTH 2018; 62:31-44. [PMID: 26946930 DOI: 10.1016/j.anplas.2016.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 02/02/2016] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Bacterial necrotizing dermis-hypodermitis and necrotizing fasciitis (BNDH-NF) are serious life-threatening soft-tissue infections. The object is to evaluate the quality of life (QOL) of patients who have been operated in our plastic surgery departement. PATIENTS AND METHODS This is a retrospective study of cases who have been treated at Nancy University Hospital between 2005 and 2014. We analyzed the perioperative data (demographic, clinical, bacteriological), the surgical data (excision, reconstruction) and the follow up data (consequences, mortality). The quality of life was assessed by the Short-Form 36 score, and the patients' satisfaction was assessed by a four-level scale. RESULTS We analyzed 23 patients with an average age of 60 years (28-84 years). The main comorbidities were diabetes (43 %) and obesity (39 %). The average number of surgical excision was about 1.9 (1-5) and the average excised body surface area was about 5 % (1-16 %). The short-term mortality was about 17 %. The mortality rate has been statistically correlated with the surgically excised body surface area (short-term 95 days: P=0.02; and long-term: P=0.003). The statistical analysis has shown a strong relative linear relationship between number of surgical excision and the physical score of QOL (P<0.001), between number of surgical excision and mental score of QOL (P=0.032), and between age and physical score of QOL (P≤0.021). The statistical analysis has also shown a strong relative linear relationship between E. coli infections and physical score of QOL (P=0.01). The percentage of patients' satisfaction in our study was evaluated at 86 %. CONCLUSION We have found that multiple surgical excisions, an advanced age of patients and E. coli infections have been associated with poor QOL. The mortality rate increased in relation with the importance of excised body surface. In spite of the gravity of these infections, our patients were satisfied of their treatment.
Collapse
Affiliation(s)
- T Brengard-Bresler
- Service de chirurgie maxillofaciale, plastique, reconstructrice et esthétique, CHU de Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54000 Nancy, France; Faculté de médecine, université de Lorraine, 54000 Nancy, France.
| | - A De Runz
- Service de chirurgie maxillofaciale, plastique, reconstructrice et esthétique, CHU de Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54000 Nancy, France; Faculté de médecine, université de Lorraine, 54000 Nancy, France
| | - F Bourhis
- Mapi Group, Health Economics and Outcomes Research, 41, rue des Trois-Fontanot, 92000 Nanterre, France
| | - H Mezzine
- Service de chirurgie maxillofaciale, plastique, reconstructrice et esthétique, CHU de Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54000 Nancy, France; Faculté de médecine, université de Lorraine, 54000 Nancy, France
| | - G Khairallah
- Service de chirurgie maxillofaciale, plastique, reconstructrice et esthétique, CHR de Metz-Thionville, 1, allée du Château, 57085 Metz, France
| | - M Younes
- Service de chirurgie maxillofaciale, plastique, reconstructrice et esthétique, CHU de Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54000 Nancy, France; Faculté de médecine, université de Lorraine, 54000 Nancy, France
| | - M Brix
- Service de chirurgie maxillofaciale, plastique, reconstructrice et esthétique, CHU de Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54000 Nancy, France; Faculté de médecine, université de Lorraine, 54000 Nancy, France
| | - E Simon
- Service de chirurgie maxillofaciale, plastique, reconstructrice et esthétique, CHU de Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54000 Nancy, France; Faculté de médecine, université de Lorraine, 54000 Nancy, France
| |
Collapse
|
4
|
Niddam J, Bosc R, Hersant B, Bouhassira J, Meningaud JP. Surgical management of necrotizing cellulitis: Results of a survey conducted in French plastic surgery departments. Med Mal Infect 2016; 46:360-364. [PMID: 27292169 DOI: 10.1016/j.medmal.2016.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 01/21/2016] [Accepted: 05/12/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Necrotizing cellulitis (NC) is a severe infection of the skin and soft tissues, requiring an urgent multidisciplinary approach. We aimed to clarify the surgical management of NC in French plastic surgery departments. PATIENTS AND METHOD Thirty-two French plastic surgery departments were invited to complete a survey sent by email. Questions focused on diagnostic and therapeutic management of NC in France. RESULTS Twenty-five plastic surgery departments completed the survey (78%) and each center had a lead plastic surgeon. Overall, 88% of surgeons declared to have managed at least five NC patients within the year. The plastic surgeon was the lead surgical specialist for NC in 80% of cases. Conversely, 76% of interviewed facilities reported not to have any lead medical specialist. Time between surgical indication and surgical management was less than six hours in 92% of cases. Overall, 24% of responding facilities declared that access to the operating room never delayed management. Finally, 80% of facilities declared to be in favor of dedicated care pathways to improve the management of necrotizing cellulitis patients. CONCLUSION Our study results highlight the heterogeneity of necrotizing cellulitis management in France. The lack of a dedicated care pathway may lead to diagnostic and treatment delays.
Collapse
Affiliation(s)
- J Niddam
- Université Paris Est, Hôpital Henri-Mondor, Service de chirurgie plastique, reconstructrice et esthétique, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France.
| | - R Bosc
- Université Paris Est, Hôpital Henri-Mondor, Service de chirurgie plastique, reconstructrice et esthétique, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France
| | - B Hersant
- Université Paris Est, Hôpital Henri-Mondor, Service de chirurgie plastique, reconstructrice et esthétique, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France
| | - J Bouhassira
- Université Paris Est, Hôpital Henri-Mondor, Service de chirurgie plastique, reconstructrice et esthétique, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France
| | - J-P Meningaud
- Université Paris Est, Hôpital Henri-Mondor, Service de chirurgie plastique, reconstructrice et esthétique, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France
| |
Collapse
|