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Ray GS, Streeter SS, Bateman LM, Elliott JT, Henderson ER. Real-time identification of life-threatening necrotizing soft-tissue infections using indocyanine green fluorescence imaging. JOURNAL OF BIOMEDICAL OPTICS 2024; 29:066003. [PMID: 38745983 PMCID: PMC11092151 DOI: 10.1117/1.jbo.29.6.066003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 04/02/2024] [Accepted: 04/25/2024] [Indexed: 05/16/2024]
Abstract
Significance Necrotizing soft-tissue infections (NSTIs) are life-threatening infections with a cumulative case fatality rate of 21%. The initial presentation of an NSTI is non-specific, frequently leading to misdiagnosis and delays in care. No current strategies yield an accurate, real-time diagnosis of an NSTI. Aim A first-in-kind, observational, clinical pilot study tested the hypothesis that measurable fluorescence signal voids occur in NSTI-affected tissues following intravenous administration and imaging of perfusion-based indocyanine green (ICG) fluorescence. This hypothesis is based on the established knowledge that NSTI is associated with local microvascular thrombosis. Approach Adult patients presenting to the Emergency Department of a tertiary care medical center at high risk for NSTI were prospectively enrolled and imaged with a commercial fluorescence imager. Single-frame fluorescence snapshot and first-pass perfusion kinetic parameters-ingress slope (IS), time-to-peak (TTP) intensity, and maximum fluorescence intensity (IMAX)-were quantified using a dynamic contrast-enhanced fluorescence imaging technique. Clinical variables (comorbidities, blood laboratory values), fluorescence parameters, and fluorescence signal-to-background ratios (SBRs) were compared to final infection diagnosis. Results Fourteen patients were enrolled and imaged (six NSTI, six cellulitis, one diabetes mellitus-associated gangrene, and one osteomyelitis). Clinical variables demonstrated no statistically significant differences between NSTI and non-NSTI patient groups (p -value ≥ 0.22 ). All NSTI cases exhibited prominent fluorescence signal voids in affected tissues, including tissue features not visible to the naked eye. All cellulitis cases exhibited a hyperemic response with increased fluorescence and no distinct signal voids. Median lesion-to-background tissue SBRs based on snapshot, IS, TTP, and IMAX parameter maps ranged from 3.2 to 9.1, 2.2 to 33.8, 1.0 to 7.5, and 1.5 to 12.7, respectively, for the NSTI patient group. All fluorescence parameters except TTP demonstrated statistically significant differences between NSTI and cellulitis patient groups (p -value < 0.05 ). Conclusions Real-time, accurate discrimination of NSTIs compared with non-necrotizing infections may be possible with perfusion-based ICG fluorescence imaging.
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Affiliation(s)
- Gabrielle S. Ray
- Dartmouth Health, Department of Orthopaedics, Lebanon, New Hampshire, United States
- Dartmouth College, Geisel School of Medicine, Hanover, New Hampshire, United States
| | - Samuel S. Streeter
- Dartmouth Health, Department of Orthopaedics, Lebanon, New Hampshire, United States
- Dartmouth College, Geisel School of Medicine, Hanover, New Hampshire, United States
| | - Logan M. Bateman
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire, United States
| | - Jonathan Thomas Elliott
- Dartmouth Health, Department of Orthopaedics, Lebanon, New Hampshire, United States
- Dartmouth College, Geisel School of Medicine, Hanover, New Hampshire, United States
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire, United States
| | - Eric R. Henderson
- Dartmouth Health, Department of Orthopaedics, Lebanon, New Hampshire, United States
- Dartmouth College, Geisel School of Medicine, Hanover, New Hampshire, United States
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire, United States
| | - NEFARIOUS Study Group
- Dartmouth Health, Department of Orthopaedics, Lebanon, New Hampshire, United States
- Dartmouth College, Geisel School of Medicine, Hanover, New Hampshire, United States
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire, United States
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Garrido-Hidalgo A, García-Coiradas J, Echevarría-Marín M, Llanos S, Valle-Cruz JA, Marco F. Understanding limb necrotizing infections: A comprehensive approach. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024:S1888-4415(24)00075-4. [PMID: 38642737 DOI: 10.1016/j.recot.2024.03.012] [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: 02/18/2024] [Revised: 03/24/2024] [Accepted: 03/30/2024] [Indexed: 04/22/2024] Open
Abstract
INTRODUCTION Necrotizing soft tissue infections (NSTI) are increasing, posing a significant risk of morbidity and mortality. Due to nonspecific symptoms, a high index of suspicion is crucial. Treatment involves a multidisciplinary approach, with broad-spectrum antibiotics, early surgical debridement, and life support. This study analyzes the characteristics, demographics, complications, and treatment of NSTI in a hospital in Madrid, Spain. METHODS A retrospective observational study was conducted, including all surgically treated NSTI patients at our center from January 2016 to December 2022, examining epidemiological and clinical data. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) was prospectively calculated for all patients. RESULTS Twenty-two patients (16 men, 6 women, mean age 54.8) were included. Median time from symptom onset to emergency room visit was 3.5 days. All reported severe treatment-resistant pain; sixteen had fever exceeding 37.8°C (72.7%). Skin lesions occurred in twelve (54.5%), and thirteen had hypotension and tachycardia (59.1%). Treatment involved resuscitative support, antibiotherapy, and radical debridement. Median time to surgery was 8.25h. Intraoperative cultures were positive in twenty patients: twelve Streptococcus pyogenes, four Staphylococcus aureus, one Escherichia coli, and four polymicrobial infection. In-hospital mortality rate was 22.73%. CONCLUSIONS We examined the correlation between our results, amputation rates and mortality with LRINEC score and time to surgery. However, we found no significant relationship unlike some other studies. Nevertheless, a multidisciplinary approach with radical debridement and antibiotic therapy remains the treatment cornerstone. Our hospital stays, outcomes and mortality rates align with our literature review, confirming high morbimortality despite early and appropriate intervention.
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Affiliation(s)
- A Garrido-Hidalgo
- Department of Traumatology and Orthopaedic Surgery, Clínico San Carlos Hospital, Profesor Martín Lagos s/n Street, 28040 Madrid, Spain.
| | - J García-Coiradas
- Department of Traumatology and Orthopaedic Surgery, Clínico San Carlos Hospital, Profesor Martín Lagos s/n Street, 28040 Madrid, Spain
| | - M Echevarría-Marín
- Department of Traumatology and Orthopaedic Surgery, Clínico San Carlos Hospital, Profesor Martín Lagos s/n Street, 28040 Madrid, Spain
| | - S Llanos
- Department of Traumatology and Orthopaedic Surgery, Clínico San Carlos Hospital, Profesor Martín Lagos s/n Street, 28040 Madrid, Spain
| | - J A Valle-Cruz
- Department of Traumatology and Orthopaedic Surgery, Clínico San Carlos Hospital, Profesor Martín Lagos s/n Street, 28040 Madrid, Spain
| | - F Marco
- Department of Traumatology and Orthopaedic Surgery, Clínico San Carlos Hospital, Profesor Martín Lagos s/n Street, 28040 Madrid, Spain; Surgery Department, Complutense University, Madrid, Spain
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Afzal H, Dawson E, Fonseca R, Canas M, Diaz L, Filippis AD, Mazuski J, Bochicchio KM, Bochicchio GV. Negative Pressure Wound Therapy With and Without Instillation in Necrotizing Soft Tissue Infections. Surg Infect (Larchmt) 2024; 25:199-205. [PMID: 38417035 DOI: 10.1089/sur.2023.299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2024] Open
Abstract
Background: Necrotizing soft tissue infections (NSTIs) are rare but deadly infections that require early and often extensive surgical debridement. After debridement, patients frequently have substantial morbidity because of large, open wounds. Hypothesis: Negative pressure wound therapy with instillation (NPWTi) results in higher wound closure rates compared with traditional negative pressure wound therapy (NPWT) or wet to dry dressings (moist wound care dressing). Patients and Methods: A prospectively maintained Acute and Critical Care Surgery database spanning 2008-2018 was queried for patients with a diagnosis of necrotizing fasciitis, Fournier gangrene, or gas gangrene. Data were collected on patient comorbidities, operative management, and clinical outcomes. Patients were stratified by use of moist wound care dressing, traditional NPWT, or NPWTi. Data were analyzed using analysis of variance (ANOVA), χ2, and logistic regression. Results: During the 10-year study period, patients were treated for NSTI; 173 were managed with moist wound care dressing, 150 with NPWT, and 48 with NPWTi. Patients were similar in terms of demographics, body mass index (BMI), diabetes mellitus, and smoking rates. Overall, complication rates were not substantially different, but mortality was higher in the moist wound care dressing group (16.2% vs. 10.7% NPWT vs. 2.1% NPWTi; p = 0.02). In the moist wound care dressing group, 81.5% of patients had an open wound at discharge compared with 52.7% of the NPWT group and only 14.6% of the NPWTi group (p < 0.001). On multivariable regression, NPWTi was associated with closure rates five times higher than the NPWT group (odds ratio [OR], 5.28; 95% confidence interval [CI], 2.40-11.61; p < 0.001) after controlling for smoking status, intravenous drug use, number of operations, and involvement of the most common region of the body. Conclusions: Negative pressure wound therapy with instillation is associated with higher rates of wound closure without increasing complication rates in patients with NSTI compared with traditional NPWT or moist wound care dressing. Although prospective studies are needed, this indicates the potential to improve patient quality of life through reduced pain and outpatient home health needs.
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Affiliation(s)
- Hussain Afzal
- Acute and Critical Care Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Erin Dawson
- Trauma and Surgical Critical Care, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Ricardo Fonseca
- Acute and Critical Care Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Melissa Canas
- Acute and Critical Care Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Leonardo Diaz
- Acute and Critical Care Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | | | - John Mazuski
- Acute and Critical Care Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Kelly M Bochicchio
- Acute and Critical Care Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Grant V Bochicchio
- Acute and Critical Care Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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Montravers P, Soussan R, Tanaka S. Identifying patients with difficult-to-treat acute bacterial skin infections. Curr Opin Infect Dis 2024; 37:87-94. [PMID: 38037891 DOI: 10.1097/qco.0000000000000991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
PURPOSE OF REVIEW The early recognition of acute bacterial skin infections (ABSIs) and their swift and adequate care are the major determinants of success. The features that can hamper or delay surgical and medical management can lead to 'difficult-to-treat' ABSIs. RECENT FINDINGS Delayed diagnosis and belated management are the key obstacles to be overcome. Clinicians should be careful about underestimating the severity of ABSIs and overlooking comorbidities, especially immunosuppression. Many conditions can lead to delayed source control, including a misdiagnosis, interhospital transfers, delayed re-exploration, or extensive injuries. Difficult therapeutic issues can occur, including rapidly destructive infections from highly pathogenic microorganisms (Group-A-streptococci, Vibrio spp., Clostridium spp. and Staphylococcus aureus ) or inadequate antibiotic therapy resulting from multidrug-resistant bacteria. Impaired pharmacokinetic capacities of antibiotic agents should also be considered as a source of clinical failure due to insufficient antimicrobial activity at the site of infection. SUMMARY Microbiological samples should be used for guiding antimicrobial therapy. Risk factors for multidrug-resistant bacteria should be considered, including local epidemiology and comorbidities. The optimization of antibiotic therapy should be achieved. Optimized care should be achieved through multidisciplinary management involving professionals with sufficient and appropriate training.
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Affiliation(s)
- Philippe Montravers
- Université Paris Cité
- AP-HP Nord, Anaesthesiology and Intensive Care Department, Bichat-Claude Bernard University Hospital
- PHERE, Physiopathology and Epidemiology of Respiratory Diseases, French Institute of Health and Medical Research (INSERM) U1152, Paris
| | - Romy Soussan
- Université Paris Cité
- AP-HP Nord, Anaesthesiology and Intensive Care Department, Bichat-Claude Bernard University Hospital
| | - Sébastien Tanaka
- AP-HP Nord, Anaesthesiology and Intensive Care Department, Bichat-Claude Bernard University Hospital
- DéTROI, Institute of Health and Medical Research (INSERM) U1188, Saint-Pierre, Reunion Island, France
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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] [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.
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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
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Rajack F, Medford S, Naab T. Necrotizing fasciitis and fatal septic shock associated with Streptococcus constellatus. Autops Case Rep 2024; 13:e2023467. [PMID: 38213877 PMCID: PMC10782520 DOI: 10.4322/acr.2023.467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 12/14/2023] [Indexed: 01/13/2024]
Abstract
Streptococcus constellatus is usually a benign, commensal bacteria but has increased incidence in blood cultures and abscesses. This pathogenic involvement is most prevalent in individuals with underlying medical conditions, such as solid tumors and type 2 diabetes mellitus, as well as in cases of community-acquired infections. We report a 43-year-old male with a right medial thigh ulcer and necrotic scrotal skin. The wound culture from surgical debridement grew Streptococcus constellatus, and histology was consistent with stage III necrotizing fasciitis. Regardless of etiology, the mortality rate of patients with necrotizing fasciitis is greatly decreased with early intervention and thorough surgical debridement.
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Affiliation(s)
- Fareed Rajack
- Howard University Hospital, Department of Pathology and Laboratory Medicine, Washington, D.C., United States of America
| | - Shawn Medford
- Howard University College of Medicine, Washington, D.C., United States of America
| | - Tammey Naab
- Howard University Hospital, Department of Pathology and Laboratory Medicine, Washington, D.C., United States of America
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Soedjana H, Christine S, Sisca F. Treating necrotizing fasciitis patients at the topmost referral hospital in West Java, Indonesia: 6 years experience. Int Wound J 2024; 21:e14355. [PMID: 37596791 PMCID: PMC10781591 DOI: 10.1111/iwj.14355] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 08/03/2023] [Accepted: 08/04/2023] [Indexed: 08/20/2023] Open
Abstract
Necrotizing fasciitis is a progressive and rare disease, with high potential to be life-threatening because of its potential for systemic toxicity. Characterized by fascial infection, it is often followed by systemic toxicity, such as septic shock and multi-organ failure. The aim of this study is to establish reliable data on the treatment of necrotizing fasciitis patients at the topmost referral hospital in West Java, Indonesia. We collected medical record data from January 2015 to December 2021 at Rumah Sakit Umum Pusat Dr. Hasan Sadikin (RSHS), Bandung, Indonesia. We recorded the infection region, bacterial isolates, empirical antibiotics, waiting time for the first surgery, surgical management, length of stay and we analysed the pattern of bacterial isolates, antibiotic use, waiting time for the first surgery, length of stay and mortality. A total of 90 patients' medical records were analysed. We found that the infection was most found in the genitalia and inguinal region (37%). Eighty-five percent of all samples containing gram-negative bacteria. The most used empirical antibiotics were from Cephalosporin class (31%), most of them combined with nitroimidazole (metronidazole) and with quinolones (levofloxacin, ciprofloxacin). Overall mortality rate was 13.3%. Highest mortality rate came from gram-negative bacteria group (14.2%-11 out of 77 patients), patients receiving Ceftriaxone-Metronidazole as empirical antibiotics (28.57%-4 out of 14 patients), patients with no surgery group (37%-3 out of 8 patients), with no mortality came from patients, which were performed debridement followed by fasciotomy/skin graft/flap and amputation. We conclude that the most found bacterial aetiology was Acinetobacter baumanii though it has no significant relation to mortality. We highly recommend early aggressive surgical intervention in reducing mortality rate due to necrotizing fasciitis for source control accompanied by deliberate defect closure and early administration of empirical antibiotics with more susceptibility for gram-negative bacteria, such as Meropenem.
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Affiliation(s)
- Hardisiswo Soedjana
- Division of Plastic and Reconstructive Surgery, Department of SurgeryRumah Sakit Umum Pusat Dr. Hasan Sadikin/Universitas PadjadjaranKota BandungIndonesia
| | - Sitha Christine
- Division of Plastic and Reconstructive Surgery, Department of SurgeryRumah Sakit Umum Pusat Dr. Hasan Sadikin/Universitas PadjadjaranKota BandungIndonesia
| | - Fransisca Sisca
- Division of Plastic and Reconstructive Surgery, Department of SurgeryRumah Sakit Umum Pusat Dr. Hasan Sadikin/Universitas PadjadjaranKota BandungIndonesia
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Adhil I, Dahal S, Gyawali S, Neupane P, Kharel A, Neupane P, Pachhai P, Khadka R, Khatiwada RD, Shrestha JM. Evaluation of laboratory risk indicator for necrotizing fasciitis score as an early diagnostic tool for necrotizing fasciitis: a prospective observational study. Ann Med Surg (Lond) 2023; 85:5874-5878. [PMID: 38098577 PMCID: PMC10718372 DOI: 10.1097/ms9.0000000000001447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 10/18/2023] [Indexed: 12/17/2023] Open
Abstract
Introduction From its historical identification to modern times with advancements in management modalities globally, the mortality of necrotizing fasciitis (NF) is high ranging from 19 to 30% for all affected sites. Although many diagnostic adjuncts have been developed to assist with the prompt and accurate diagnosis of NF, the primary diagnosis is still based on high clinical suspicion. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was developed as a tool for distinguishing NF from other soft tissue infections. The main objective of this study is to evaluate LRINEC as a tool for early diagnosis of NF and differentiating it from other soft tissue infections like cellulitis. Methods This is a single-centered, prospective observational study. Patients presenting with soft tissue infections of the limbs to the emergency department from November 2020 to October 2021 were included in this study. The clinical findings and blood parameters for the LRINEC score were collected and the score was calculated. Based on clinical suspicion of NF, patients underwent debridement and had a tissue biopsy to confirm the diagnosis. The data obtained was analyzed using SPSS version 24 and MS Excel. The AUC curve was used to calculate a cutoff, sensitivity, specificity, positive predictive value, and negative predictive values for the LRINEC score based on our study. Results Forty-five patients with 28 males and 17 females were included. The average age was 53.667 years within a range of 19-79 years. Among them 44.4% of the patients had NF and 66.6% had other minor forms of soft tissue infections. The ROC curve obtained a cutoff value of greater than or equal to 6, with an AUC of 0.751. At this cut of value study showed a sensitivity of 85% with a specificity of 52%. Similarly, positive predictive value was found to be 58.62%, negative predictive values of 81.25%, and overall accuracy of 66.67% in early diagnosis of NF. Conclusion In conclusion, our study showed that the LRINEC score can be a reliable tool for the early diagnosis of NF in an ED setting. This scoring system is best to be used to rule out NF.
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Affiliation(s)
| | | | | | | | - Ashok Kharel
- Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu
| | | | | | | | - Raj D. Khatiwada
- Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu
| | - Jayan M. Shrestha
- Department of Plastic Surgery and Burns, Tribhuvan University Teaching Hospital, Institute of Medicine
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Molasy B, Frydrych M. Necrotizing fasciitis - two case reports and literature review. POLISH JOURNAL OF SURGERY 2023; 96:103-108. [PMID: 38348986 DOI: 10.5604/01.3001.0053.9501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
<b><br>Introduction:</b> Necrotizing fasciitis (NF) is a rare, rapidly progressing infection of the skin and subcutaneous tissue. NF can lead to massive tissue necrosis, resulting in sepsis, septic shock and death. In this disease, it is important to quickly diagnose and implement appropriate treatment.</br> <b><br>Aim:</b> Analysis of the diagnostic and therapeutic process in two clinical cases and a review of the literature on the methods of diagnosis and treatment of necrotizing fasciitis.</br> <b><br>Material and methods:</b> The medical data of two patients hospitalized in the St Alexander Hospital in Kielce from December 2022 to June 2023 due to necrotizing fasciitis were analyzed. Also literature search across PubMed, Medline and Research Gate databases from 2000 up to 2023 was performed. We reviewed English literature according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. The following keywords were used: necrotizing fasciitis, etiopathogenesis, pathophysiology, management.</br> <b><br>Results:</b> The research group consisted of two male patients with NF after trauma, in different parts of the body. Based on the clinical examination, the results of laboratory and imaging tests, a diagnosis was made and appropriate treatment was initiated. Despite the applied treatment, one patient died as a result of progressive multiple organ failure.</br> <b><br>Conclusions:</b> Despite advances in diagnosis and treatment, including universal access to antibiotics, necrotizing fasciitis still cause high mortality. The microbiological complexity of the majority of cases and non-specific symptoms make the diagnostic and therapeutic process difficult. Taking into account necrotizing fasciitis each time in the differential diagnosis of inflammation of the skin and subcutaneous tissue, especially based on trauma, will allow to reduce morbidity and mortality in this disease.</br>.
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Affiliation(s)
- Bartosz Molasy
- Jan Kochanowski University Medical College, Department of General Surgery, St. Alexander Hospital in Kielce, Kielce, Poland
| | - Mateusz Frydrych
- Department of General Surgery, St. Alexander Hospital in Kielce, Kielce, Poland
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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] [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.
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Wladis EJ, Tomlinson LA, Moorjani S, Rothschild MI. Serologic Evaluations in the Distinction Between Sinusitis-Related Orbital Cellulitis and Periorbital Necrotizing Fasciitis. Ophthalmic Plast Reconstr Surg 2023; 39:599-601. [PMID: 37338341 DOI: 10.1097/iop.0000000000002437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
PURPOSE While sinusitis-related orbital cellulitis (SROC) and periorbital necrotizing fasciitis (PNF) share similar clinical presentations, they are managed differently, making rapid recognition of the appropriate clinical entity critical to optimal outcomes. This study was performed to assess whether serologic testing might help clinicians to distinguish between SROC and PNF. METHODS A retrospective review analysis was used to compare initial complete blood counts and comprehensive metabolic panels among adult patients with SROC and PNF. Statistical evaluations were used to determine the significance of differences between the groups. RESULTS Thirteen patients with PNF and 14 patients with SROC were identified. The 2 groups were similar in age, gender, and likelihood of immunosuppression ( p > 0.05 for each metric). Mean leukocyte counts were 18.52 (standard deviation = 7.02) and 10.31 (standard deviation = 5.77) for PNF and SROC, respectively ( p = 0.0057). White blood cell levels were above normal limits for 12 patients with PNF (92.3%) and 7 patients with SROC (50%) ( p = 0.017). No other laboratory test was significantly different between the 2 groups. CONCLUSIONS While the majority of serologic testing was quite similar in patients with either SROC or PNF, leukocyte levels may represent an important clue to distinguish between the two diseases. Clinical evaluation remains the gold standard to make the proper diagnosis, but markedly elevated white blood cell counts should prompt clinicians to at least consider a diagnosis of PNF.
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Affiliation(s)
- Edward J Wladis
- Ophthalmic Plastic Surgery, Lions Eye Institute, Department of Ophthalmology, Albany Medical College, Slingerlands, New York, U.S.A
- Department of Otolaryngology, Albany Medical College, Slingerlands, New York, U.S.A
| | - Lauren A Tomlinson
- Ophthalmic Plastic Surgery, Lions Eye Institute, Department of Ophthalmology, Albany Medical College, Slingerlands, New York, U.S.A
| | - Smriti Moorjani
- Ophthalmic Plastic Surgery, Lions Eye Institute, Department of Ophthalmology, Albany Medical College, Slingerlands, New York, U.S.A
| | - Michael I Rothschild
- Ophthalmic Plastic Surgery, Lions Eye Institute, Department of Ophthalmology, Albany Medical College, Slingerlands, New York, U.S.A
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12
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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] [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.
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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
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Tazeoglu D, Benli S, Colak T. Temperature-Neutrophils-Multiple Organ Failure Grading as a Prognostic Indicator in Fournier Gangrene. Surg Infect (Larchmt) 2023; 24:749-754. [PMID: 37768832 DOI: 10.1089/sur.2023.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023] Open
Abstract
Background: Severity scoring systems are used widely to predict prognosis in managing various diseases and to tailor the treatment of patients in a personalized way, not in a general concept, by making a risk assessment. This study examines the importance of the Temperature-Neutrophils-Multiple Organ Failure (TNM) scoring system, a new scoring system, in evaluating the prognosis in patients with Fournier gangrene (FG). Patients and Methods: Patients who were operated on with the diagnosis of FG in our clinic between 2012 and 2022 were analyzed with a single-center cross-sectional retrospective study design. Demographic data (age, gender), pre-operative evaluation, body temperature, neutrophil ratio, presence of multiple organ failure, TNM score, and post-operative survival data were recorded. The patients were grouped as those with post-operative hospital mortality (group 1) and without (group 2). Results: The study included 167 patients. Twenty-two (13.2%) of the patients were in group 1 and 145 (86.8%) were in group 2. According to the TNM score, the frequency of stage 3-4 was higher in group 1 than in group 2 (p < 0.001). Patients ≥65 years of age had a 4.80 (95% confidence interval [CI], 1.87-12.29) times greater mortality risk than patients <65. Patients with comorbid disease had a 4.56 (95% CI, 1.47-14.14) times greater risk of mortality than patients without. Patients with TNM scores 3-4 had a 9.38 (95% CI, 3.01-29.28) times greater risk of exit than patients with scores 1-2. Conclusions: The TNM system is a new scoring system that is created quickly using simple laboratory and clinical data in patients with FG and is useful in predicting mortality. Therefore, its clinical use will benefit FG and other deep soft tissue infections.
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Affiliation(s)
- Deniz Tazeoglu
- Department of General Surgery, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Sami Benli
- Department of General Surgery, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Tahsin Colak
- Department of General Surgery, Faculty of Medicine, Mersin University, Mersin, Turkey
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14
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Keten T, Ozercan AY, Eroglu U, Basboga S, Tatlici K, Senel C, Guzel O, Tuncel A. Can HALP score, a new prognostic tool, take the place of traditional scoring systems in Fournier's gangrene? Int Urol Nephrol 2023; 55:2389-2395. [PMID: 37410304 DOI: 10.1007/s11255-023-03695-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 06/25/2023] [Indexed: 07/07/2023]
Abstract
PURPOSE Fournier's Gangrene (FG) is a fatal condition, therefore prognosis prediction is a crucial step before treatment planning. We aimed to investigate the predictive value of Hemoglobin, Albumin, Lymphocyte and Platelet (HALP) score which is frequently employed in vascular disorders and malignancies, on disease severity and survival in FG patients and to compare HALP score with well-known scoring systems on this aspect. MATERIALS AND METHODS Eighty-seven men who had surgical debridement for FG between December 2006 and January 2022 were included in this study. Their symptoms, physical examination findings, laboratory tests, medical histories, vital signs, extent and timing of the surgical debridement and antimicrobial therapies were noted. The HALP score, Age-adjusted Charlson Comorbidity Index (ACCI) and Fournier's Gangrene Severity Index (FGSI) were evaluated for their predictive values for survival. RESULTS FG patients were grouped as survivors (Group 1, n = 71) and non-survivors (Group 2, n = 16) and the results were compared. The mean ages of survivors (59 ± 12.55 years) and non-survivors (64.5 ± 14.6 years) were similar (p = 0.114). The median size of necrotized body surface area was 3% in Group 1 and 4.8% in Group 2 (p = 0.013). On admission, hemoglobin, albumin and serum urea levels and white blood cell counts were significantly different in two study groups. Two study groups were similar for HALP scores. However, ACCI and FGSI scores were greater significantly in non-survivors. CONCLUSIONS Our results indicated that HALP score does not predict a survival successfully in FG. However, FGSI and ACCI are successful outcome predictors in FG.
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Affiliation(s)
- Tanju Keten
- Department of Urology, University of Health Sciences, Ankara Bilkent City Hospital, Cankaya, 06800, Ankara, Turkey.
| | - Ali Yasin Ozercan
- Department of Urology, University of Health Sciences, Ankara Bilkent City Hospital, Cankaya, 06800, Ankara, Turkey
| | - Unsal Eroglu
- Department of Urology, University of Health Sciences, Ankara Bilkent City Hospital, Cankaya, 06800, Ankara, Turkey
| | - Serdar Basboga
- Department of Urology, University of Health Sciences, Ankara Bilkent City Hospital, Cankaya, 06800, Ankara, Turkey
| | - Koray Tatlici
- Department of Urology, University of Health Sciences, Ankara Bilkent City Hospital, Cankaya, 06800, Ankara, Turkey
| | - Cagdas Senel
- School of Medicine, Department of Urology, Balıkesir University, Balıkesir, Turkey
| | - Ozer Guzel
- Department of Urology, University of Health Sciences, Ankara Bilkent City Hospital, Cankaya, 06800, Ankara, Turkey
| | - Altug Tuncel
- Department of Urology, University of Health Sciences, Ankara Bilkent City Hospital, Cankaya, 06800, Ankara, Turkey
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Bitar ZI, Maadarani OS, Elzoueiry MM, Alfarhan A, Elhabibi ME. Necrotizing fasciitis following gastrostomy tube placement, detected by point-of-care ultrasound, case report. Int J Surg Case Rep 2023; 111:108889. [PMID: 37812958 PMCID: PMC10563042 DOI: 10.1016/j.ijscr.2023.108889] [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: 08/05/2023] [Revised: 09/24/2023] [Accepted: 09/27/2023] [Indexed: 10/11/2023] Open
Abstract
INTRODUCTION Necrotizing fasciitis is a recognized rare complication of gastrostomy tube replacement, but if it occurs and is not discovered early, a lethal outcome is possible. CASE PRESENTATION We present a woman in her 80s who was known to have chronic atrial fibrillation with ischemic heart disease. She was fed through percutaneous endoscopic gastrostomy after brain injury. Erythema was observed around the stoma of the gastrostomy tube, which was later removed, and erythema extended to the left anterior abdomen. The patient was diagnosed with cellulitis. Point-of-care ultrasound examination suspected necrotizing fasciitis and, confirmed later by computerized tomography of the abdomen. The case was managed surgically. DISCUSSION Patients with a high clinical suspicion of necrotizing fasciitis should undergo early surgical debridement with antibiotic administration. Necrotizing fasciitis starts with a clinical picture indistinguishable from other skin infections, such as cellulitis, and imaging modalities are important for confirmation and early diagnosis. We present a case of necrotizing fasciitis after gastrostomy tube replacement for which point-of-care ultrasound played a pivotal role in confirming the diagnosis early. CONCLUSION Point-of-care ultrasound is a useful adjunct tool for clinical evaluation and assessment in diagnosing early critically ill patients with life-threatening necrotizing infections.
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Affiliation(s)
- Zouheir Ibrahim Bitar
- Critical Care Unit, Ahmadi Hospital, Kuwait Oil Company, POBOx 46468, Postal code 64015 Fahahil, Kuwait.
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Jung HC, Kim YU. Fournier's gangrene after insertion of thermo-expandable prostatic stent for benign prostatic hyperplasia: A case report. World J Clin Cases 2023; 11:6498-6504. [PMID: 37900218 PMCID: PMC10601010 DOI: 10.12998/wjcc.v11.i27.6498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 08/15/2023] [Accepted: 08/29/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Thermo-expandable urethral stent (Memokath 028) implantation is an alternative treatment for older patients with lower urinary tract symptoms and benign prostatic obstruction. Following prostatic urethral stent implantation, minor complications such as urinary tract infection, irritative symptoms, gross hematuria, and urethral pain have been observed; however, there are no reports of life-threatening events. Herein, we report a critical case of Fournier's gangrene that occurred 7 years after prostatic stenting. CASE SUMMARY An 81-years-old man with benign prostatic hyperplasia (volume, 126 ccs; as measured by transrectal ultrasound) had undergone insertion of a thermo-expandable urethral stent (Memokath 028) as he was unfit for surgery under general anesthesia. However, the patient had undergone a suprapubic cystostomy for recurrent acute urinary retention 4 years after the insertion of prostatic stent (Memokath 028). We had planned to remove the Memokath 028; however, the patient was lost to follow-up. The patient presented to the emergency department 3 years after the suprapubic cystostomy with necrotic changes from the right scrotum to the right inguinal area. In digital rectal examination, tenderness and heat of prostate was identified. Also, the black skin color change with foul-smelling from right scrotum to right inguinal area was identified. In computed tomography finding, subcutaneous emphysema was identified to same area. He was diagnosed with Fournier's gangrene based on the physical examination and computed tomography findings. In emergency room, Fournier's gangrene severity index value is seven points. Therefore, he underwent emergent extended surgical debridement and removal of the Memokath 028. Broad-spectrum intravenous antibiotics were administered and additional necrotic tissue debridement was performed. However, the patient died 14 days after surgery due to multiorgan failure. CONCLUSION If Memokath 028 for benign prostatic hyperplasia is not working in older patients, its rapid removal may help prevent severe complications.
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Affiliation(s)
- Hee Chang Jung
- Department of Urology, Yeungnam University College of Medicine, Daegu 42415, South Korea
| | - Yeong Uk Kim
- Department of Urology, Yeungnam University College of Medicine, Daegu 42415, South Korea
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Kuo YT, Hsiao CT, Wu PH, Wu KH, Chang CP. Comparison of National Early Warning Score with shock index in patients with necrotizing fasciitis. Medicine (Baltimore) 2023; 102:e34651. [PMID: 37682200 PMCID: PMC10489463 DOI: 10.1097/md.0000000000034651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/18/2023] [Indexed: 09/09/2023] Open
Abstract
Shock index (SI) and national early warning score (NEWS) are more frequently used as assessment tools in acute illnesses, patient disposition and early identification of critical condition. Both they are consisted of common vital signs and parameters including heart rate, systolic blood pressure, respiratory rate, oxygen saturation and level of conscious, which made it easy to evaluate in medical facilities. Its ability to predict mortality in patients with necrotizing fasciitis (NF) in the emergency department remains unclear. This study was conducted to compare the predictive capability of the risk scores among NF patients. A retrospective cohort study of hospitalized patients with NF was conducted in 2 tertiary teaching hospitals in Taiwan between January 2013 and March 2015. We investigated the association of NEWS and SI with mortality in NF patients. Of the 395 NF patients, 32 (8.1%) died in the hospital. For mortality, the area under the receiver curve value of NEWS (0.81, 95% confidence interval 0.76-0.86) was significantly higher than SI (0.76, 95% confidence interval 0.73-0.79, P = .016). The sensitivities of NEWS of 3, 4, and 5 for mortality were 98.1%, 95.6%, and 92.3%. On the contrast, the sensitivities of SI of 0.5, 0.6, and 0.7 for mortality were 87.8%, 84.7%, and 81.5%. NEWS had advantage in better discriminative performance of mortality in NF patients. The NEWS may be used to identify relative low risk patients among NF patients.
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Affiliation(s)
- Yen-Ting Kuo
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Cheng-Ting Hsiao
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
- Department of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Po-Han Wu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Kai-Hsiang Wu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Chia-Peng Chang
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
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18
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Riha GM, Englehart MS, Carter BT, Pathak M, Thompson SJ. Outcomes in necrotizing soft tissue infections are worse in rural versus urban Montana: a 10-year single center retrospective review. INTERNATIONAL JOURNAL OF BURNS AND TRAUMA 2023; 13:173-181. [PMID: 37736030 PMCID: PMC10509540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 07/05/2023] [Indexed: 09/23/2023]
Abstract
Time to definitive surgical debridement has been recognized as a predictor for morbidity and mortality in necrotizing soft-tissue infections (NSTI). Rural patients are at particular risk due to limited local resources, decreased access to care, and prolonged transport times. The aim of the current study was to examine the outcomes of NSTI requiring surgical treatment in a previously non-described setting. This retrospective study (2010-2020) from a single tertiary care center in Montana reviewed patients ≥18 years old with a NSTI via ICD9/10 codes. Rural-Urban Continuum Codes (RUCC; characterizing counties by population size) were used to distinguish urban versus rural counties. Race (White and American Indian/Alaskan Native (AI/AN)) was self-described. Qualitative and quantitative comparisons between groups were determined using the appropriate two-tailed statistical tests. An aggregate of 177 patients was identified. Mean age in AI/AN was significantly lower (P<0.0001) compared to White patients with no preexisting condition delineation. NSTI demonstrated an elevated incidence in both rural areas and AI/AN patients. Diabetes was also significantly higher (P=0.0073) in rural versus urban patients. Both rural and AI/AN patients faced extended travel distance for treatment. AI/AN patients had a significantly different infection location than White. Furthermore, polymicrobial species were significantly more prevalent in AI/AN patients. Morbidities (defined as septic shock and/or amputation) were significantly higher in AI/AN patients and rural environments (P<0.01). There was no significant difference in all-cause mortality between respective groups. The state of Montana presents unique challenges to optimizing NSTI treatment due to excessive distances to regional tertiary care facilities. This delay in treatment can lead to increased morbidity.
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Affiliation(s)
- Gordon M Riha
- Trauma & General Surgery, Billings ClinicBillings, MT, USA
| | | | - Benjamin T Carter
- Collaborative Science & Innovation, Billings ClinicBillings, MT, USA
| | - Manoj Pathak
- Department of Mathematics and Statistics, Murray State UniversityMurray, KY, USA
| | - Simon J Thompson
- Collaborative Science & Innovation, Billings ClinicBillings, MT, USA
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Othman RE, Allaw F, Kharsa A, Hallit S. Salmonella typhimurium necrotizing fasciitis: a case report. J Med Case Rep 2023; 17:345. [PMID: 37573427 PMCID: PMC10423414 DOI: 10.1186/s13256-023-04090-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 07/20/2023] [Indexed: 08/14/2023] Open
Abstract
BACKGROUND Necrotizing fasciitis is an aggressive disease that causes necrosis in the muscular fascia and subcutaneous tissues. The infection spreads rapidly along the fascia and perifascial planes, followed by extension of the infection to nearby soft tissues and muscles. Necrotizing fasciitis can be attributed to different pathogens, namely Staphylococcus aureus, group A streptococci, and Clostridium perfringes. Only a few cases of skin and soft tissue infections from Salmonella species have been reported to date. Herein we report a case of Salmonella non-typhi necrotizing fasciitis, an exceedingly rare entity. This case report may serve as a potential management plan in similar cases in light of the scarcity of evidence. CASE PRESENTATION A 20-year-old Caucasian male patient with congenital cardiac anomaly presented with diarrhea and unilateral lower extremity cellulitis causing septic shock. Cultures from blood and the bullae associated with the lower extremity cellulitis grew Salmonella typhimurium. Surgical debridement was performed. Intraoperative tissue cultures were positive for Salmonella typhimurium, and surgical pathology confirmed the diagnosis of necrotizing fasciitis. After a total of 6 weeks of appropriate antimicrobial therapy, another surgical debridement was executed for poor wound healing. New intraoperative cultures grew Fusarium species, and the patient received voriconazole with an adequate response. Immunologic studies showed humoral and cellular immunodeficiency. CONCLUSION It is important to maintain a high index of suspicion for rare entities that can cause skin and soft tissue infections, such as Salmonella non-typhi, in particular in immunosuppressed patients where a delay in diagnosis and management may have significant morbidity and mortality.
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Affiliation(s)
- Radwan El Othman
- Department of Internal Medicine, American University of Beirut Medical Center (AUBMC), Beirut, Lebanon
| | - Fatima Allaw
- Department of Internal Medicine, American University of Beirut Medical Center (AUBMC), Beirut, Lebanon
- Division of Infectious Diseases, American University of Beirut Medical Center (AUBMC), Beirut, Lebanon
| | - Antoine Kharsa
- Department of Internal Medicine, American University of Beirut Medical Center (AUBMC), Beirut, Lebanon
| | - Souheil Hallit
- School of Medicine and Medical Sciences, Holy Spirit University of Kaslik, P.O. Box 446, Jounieh, Lebanon
- Applied Science Research Center, Applied Science Private University, Amman, Jordan
- Research Department, Psychiatric Hospital of the Cross, Jal Eddib, Lebanon
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20
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Milano VR, Cabanilla MG. Under the Skin: A Case Series of Clostridium sordellii Necrotizing Soft Tissue Infections in Patients Who Inject Drugs. Cureus 2023; 15:e43870. [PMID: 37736428 PMCID: PMC10511237 DOI: 10.7759/cureus.43870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2023] [Indexed: 09/23/2023] Open
Abstract
Clostridium sordellii has been well-associated as a cause of obstetric infections but is a less commonly recognized organism of necrotizing skin and soft tissue infections (NSTI). C. sordelli infections are rare with only 14 cases reported in the literature to date. These infections are often associated with profound septic shock and the mortality rate remains high. We report four patients who presented with C. sordellii NSTI over a period of two years at an academic medical center. Notably, injection drug use was the main risk factor for infection in these patients. Appropriate management of C. sordellii NSTI necessitates a combination of antibiotics and emergent surgical intervention. However, despite these efforts, the mortality rate remains high, with three of the four patients dying. Clinicians should consider NSTI in the differential diagnosis when evaluating skin and soft tissue infections in people who inject drugs. Furthermore, it is imperative to educate patients who engage in injection drug use on the potential risks associated with NSTI and inform them of warning signs that warrant immediate medical attention. The devastating consequences of C. sordellii-associated NSTI in this vulnerable population can be mitigated by enhancing awareness and facilitating early intervention.
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Affiliation(s)
- Victoria R Milano
- Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, USA
| | - M Gabriela Cabanilla
- Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, USA
- Internal Medicine Division of Infectious Diseases, University of New Mexico Health Sciences Center, Albuquerque, USA
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21
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Samir S. Phages for treatment of Staphylococcus aureus infection. PROGRESS IN MOLECULAR BIOLOGY AND TRANSLATIONAL SCIENCE 2023; 200:275-302. [PMID: 37739558 DOI: 10.1016/bs.pmbts.2023.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
Abstract
Combating multi-drug resistant bacterial infections should be a universal urgency. The gram- positive Staphylococcus aureus (S. aureus) bacteria are generally harmless; healthy people frequently have them on their skin and nose. These bacteria, for the most part, produce no difficulties or only minor skin diseases. Antibiotics and cleansing of the affected region are usually the treatments of choice. S. aureus can become virulent causing serious infections that may lead to pustules to sepsis or death. Normally, it is thought that antibiotics may solve problems concerning bacterial infection; but unfortunately, Staphylococci have evolved mechanisms to resist drugs. Methicillin-Resistant Staphylococcus aureus (MRSA); both in hospitals and in the community, infections are evolving into dangerous pathogens. Health care practitioners may need to use antibiotics with more adverse effects to treat antibiotic-resistant S. aureus infections. Amid existing efforts to resolve this problem, phage therapy proposes a hopeful alternate to face Staphylococcal infections. When the majority of antibiotics have failed to treat infections caused by multidrug-resistant bacteria, such as methicillin- and vancomycin-resistant S. aureus, phage therapy may be an option. Here, we appraise the potential efficacy, current knowledge on bacteriophages for S. aureus, experimental research and information on their clinical application, and limitations of phage therapy for S. aureus infections.
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Affiliation(s)
- Safia Samir
- Department of Biochemistry and Molecular Biology, Theodor Bilharz Research Institute, Giza, Egypt.
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22
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Daniels M, Perbix W, Oberländer H, Schiefer J, Fuchs PC, Seyhan H. The performance of clinical risk scores in the diagnosis of necrotising fasciitis. J Wound Care 2023; 32:284-290. [PMID: 37094928 DOI: 10.12968/jowc.2023.32.5.284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
OBJECTIVE Necrotising fasciitis (NF) is a quickly progressing and potentially life-threatening infection, involving the fascia and subcutaneous tissues. The diagnosis of this disease is challenging, especially due to a lack of specific clinical signs. In order to ensure a better and quicker identification of NF patients, a laboratory risk indicator score has been developed for NF (LRINEC). A variant has widened this score by adding clinical parameters (modified LRINEC). This study shows current outcomes of NF and compares the two scoring systems. METHODS This study was conducted between 2011 and 2018, and included patient demographics, clinical presentations, sites of infection, comorbidities, microbiological and laboratory findings, antibiotic therapies and LRINEC as well as modified LRINEC scores. The primary outcome was in-hospital mortality. RESULTS A cohort of 36 patients, diagnosed with NF, were included in this study. The mean hospital stay was 56 days (±38.2 days). The mortality rate in the cohort was 25%. The sensitivity of the LRINEC score was 86%. Calculation of the modified LRINEC score showed an improvement of the sensitivity to 97%. The average LRINEC score and modified LRINEC score for patients who died and who survived were equal (7.4 versus 7.9 and 10.4 versus 10.0, respectively). CONCLUSION The mortality rate of NF remains high. The modified LRINEC score increased the sensitivity in our cohort to 97%, and this scoring system could be supportive in the diagnosis of NF for early surgical debridement.
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Affiliation(s)
- Marc Daniels
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Hospital Cologne Merheim, University of Witten-Herdecke, Germany
| | - Walter Perbix
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Hospital Cologne Merheim, University of Witten-Herdecke, Germany
| | - Henrik Oberländer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Hospital Cologne Merheim, University of Witten-Herdecke, Germany
| | - Jennifer Schiefer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Hospital Cologne Merheim, University of Witten-Herdecke, Germany
| | - Paul Christian Fuchs
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Hospital Cologne Merheim, University of Witten-Herdecke, Germany
| | - Harun Seyhan
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Hospital Cologne Merheim, University of Witten-Herdecke, Germany
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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] [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.
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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
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Patibandla S, Razzak S, Ansari AZ, Brown SF. From Fibroids to Fasciitis: A Rare Case of Necrotizing Fasciitis Post-Abdominal Hysterectomy. Cureus 2023; 15:e39758. [PMID: 37398754 PMCID: PMC10311281 DOI: 10.7759/cureus.39758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2023] [Indexed: 07/04/2023] Open
Abstract
Necrotizing fasciitis is a life-threatening bacterial infection characterized by rapid tissue destruction and systemic inflammation. Although it is rare, it can occur at surgical incision sites in procedures such as open abdominal hysterectomy. Prompt diagnosis and treatment are essential to prevent sepsis and multi-organ failure. We present a case of a 39-year-old morbidly obese African American woman with a history of type II diabetes that developed necrotizing fasciitis at a transverse incision site following an abdominal hysterectomy. The infection was complicated by a urinary tract infection caused by Proteus mirabilis. Surgical debridement and antibiotic therapy were successfully employed to treat the infection. This case emphasizes the importance of clinical suspicion, early intervention, and appropriate antimicrobial therapy in managing necrotizing fasciitis at incision sites, particularly in patients with additional risk factors.
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Affiliation(s)
- Srihita Patibandla
- Obstetrics and Gynecology, William Carey University College of Osteopathic Medicine, Hattiesburg, USA
| | - Sania Razzak
- Obstetrics and Gynecology, William Carey University College of Osteopathic Medicine, Hattiesburg, USA
| | - Ali Z Ansari
- Obstetrics and Gynecology, William Carey University College of Osteopathic Medicine, Hattiesburg, USA
| | - Samuel F Brown
- Obstetrics and Gynecology, Merit Health Central, Jackson, USA
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Kaba E, Kayaoglu AT, Hacibey I. Retroperitoneal Necrotizing Fasciitis: A Rare Surgical Emergency. Indian J Surg 2023. [DOI: 10.1007/s12262-023-03757-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
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Sebastian A, Sebastian N, Arulthasan M, Simon R, Nicastro JM. Necrotizing Soft Tissue Infection Secondary to Streptococcus constellatus, Actinomyces odontolyticus, and Gemella morbillorum in an Intravenous Drug User: A Case Report and Literature Review. Cureus 2023; 15:e37314. [PMID: 37181983 PMCID: PMC10167094 DOI: 10.7759/cureus.37314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2023] [Indexed: 05/16/2023] Open
Abstract
A 53-year-old male with active IV heroin use presented with left upper extremity pain, erythema, swelling, and purulent foul-smelling drainage. Rapid diagnosis of necrotizing soft tissue infection (NSTI) was made based on clinical and radiologic findings. He was taken to the operating room for wound washouts and surgical debridements. The early microbiologic diagnosis was made based on intraoperative cultures. Successful treatment of NSTI in the setting of rare pathogens was achieved. The wound was ultimately treated with wound vac therapy, followed by primary delayed closure of the upper extremity and skin grafting of the forearm. We present a case of NSTI secondary to Streptococcus constellatus, Actinomyces odontolyticus, and Gemella morbillorum in an intravenous (IV) drug user, successfully treated with early surgical intervention.
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Affiliation(s)
| | | | | | - Ronald Simon
- Surgery, Maimonides Medical Center, Brooklyn, USA
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Rathore A, Reich DA, Qadir N, Harrison C. A Case Report of Culture-Negative Necrotizing Fasciitis With Low Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) Score: A Diagnostic Dilemma. Cureus 2023; 15:e37268. [PMID: 37162772 PMCID: PMC10164443 DOI: 10.7759/cureus.37268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 04/07/2023] [Indexed: 05/11/2023] Open
Abstract
The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score is a diagnostic tool used to help clinicians identify necrotizing fasciitis (NF) in its early stages. This tool uses six laboratory values including the patient's white blood cell count, C-reactive protein level, serum sodium level, creatinine level, and hemoglobin level to help with risk stratification. Each of these laboratory values is assigned a point value and the total score is used to determine the likelihood that a patient has NF, with a score of 6 or higher considered to be strongly indicative. The LRINEC score has gained popularity in recent years, having been included in guidelines and society recommendations for the management of NF. However, some studies have challenged the validity of the LRINEC score. Prompt and accurate diagnosis of NF is imperative given the associated mortality rate, which can be as high as 30%-40%, especially if the diagnosis is delayed. We present a case of a patient with a delayed diagnosis of NF that was initially missed in the early stages in the setting of a low LRINEC, however, growing clinical suspicion eventually led to an accurate diagnosis and management.
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Affiliation(s)
- Azeem Rathore
- Internal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Daniel A Reich
- Medicine, University of Florida College of Medicine, Gainesville, USA
| | - Nadim Qadir
- Internal Medicine, Edward Via College of Osteopathic Medicine, Auburn, USA
| | - Charles Harrison
- Internal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
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Huang C, Zhong Y, Yue C, He B, Li Y, Li J. The effect of hyperbaric oxygen therapy on the clinical outcomes of necrotizing soft tissue infections: a systematic review and meta-analysis. World J Emerg Surg 2023; 18:23. [PMID: 36966323 PMCID: PMC10040118 DOI: 10.1186/s13017-023-00490-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 03/15/2023] [Indexed: 03/27/2023] Open
Abstract
BACKGROUND To determine the efficacy of hyperbaric oxygen therapy (HBO) in the treatment of necrotizing soft tissue infections (NSTI), we conducted a meta-analysis of the available evidence. METHODS Data sources were PubMed, Embase, Web of Science, Cochrane Library, and reference lists. The study included observational trials that compared HBO with non-HBO, or standard care. The primary outcome was the mortality rate. Secondary outcomes were the number of debridement, amputation rate and complication rate. Relative risks or standardized mean differences with 95% confidence intervals were calculated for dichotomous and continuous outcomes, respectively. RESULTS A total of retrospective cohort and case-control studies were included, including 49,152 patients, 1448 who received HBO and 47,704 in control. The mortality rate in the HBO group was significantly lower than that in the non-HBO group [RR = 0.522, 95% CI (0.403, 0.677), p < 0.05]. However, the number of debridements performed in the HBO group was higher than in the non-HBO group [SMD = 0.611, 95% CI (0.012, 1.211), p < 0.05]. There was no significant difference in amputation rates between the two groups [RR = 0.836, 95% CI (0.619, 1.129), p > 0.05]. In terms of complications, the incidence of MODS was lower in the HBO group than in the non-HBO group [RR = 0.205, 95% CI (0.164, 0.256), p < 0.05]. There was no significant difference in the incidence of other complications, such as sepsis, shock, myocardial infarction, pulmonary embolism, and pneumonia, between the two groups (p > 0.05). CONCLUSION The current evidence suggests that the use of HBO in the treatment of NSTI can significantly reduce the mortality rates and the incidence rates of complications. However, due to the retrospective nature of the studies, the evidence is weak, and further research is needed to establish its efficacy. It is also important to note that HBO is not available in all hospitals, and its use should be carefully considered based on the patient's individual circumstances. Additionally, it is still worthwhile to stress the significance of promptly evaluating surgical risks to prevent missing the optimal treatment time.
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Affiliation(s)
- Chengzi Huang
- Department of Anorectum, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yilian Zhong
- Department of Anorectum, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Chaochi Yue
- Department of Anorectum, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Bin He
- Department of Anorectum, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yaling Li
- Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, Luzhou, China.
| | - Jun Li
- Department of Anorectum, The Affiliated Hospital of Southwest Medical University, Luzhou, China.
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Yusuf Aliyu A, Adeleke OA. Nanofibrous Scaffolds for Diabetic Wound Healing. Pharmaceutics 2023; 15:pharmaceutics15030986. [PMID: 36986847 PMCID: PMC10051742 DOI: 10.3390/pharmaceutics15030986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 03/10/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
Chronic wounds are one of the secondary health complications that develop in individuals who have poorly managed diabetes mellitus. This is often associated with delays in the wound healing process, resulting from long-term uncontrolled blood glucose levels. As such, an appropriate therapeutic approach would be maintaining blood glucose concentration within normal ranges, but this can be quite challenging to achieve. Consequently, diabetic ulcers usually require special medical care to prevent complications such as sepsis, amputation, and deformities, which often develop in these patients. Although several conventional wound dressings, such as hydrogels, gauze, films, and foams, are employed in the treatment of such chronic wounds, nanofibrous scaffolds have gained the attention of researchers because of their flexibility, ability to load a variety of bioactive compounds as single entities or combinations, and large surface area to volume ratio, which provides a biomimetic environment for cell proliferation relative to conventional dressings. Here, we present the current trends on the versatility of nanofibrous scaffolds as novel platforms for the incorporation of bioactive agents suitable for the enhancement of diabetic wound healing.
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Affiliation(s)
- Anna Yusuf Aliyu
- College of Pharmacy, Faculty of Health, Dalhousie University, Halifax, NS B3H 4R2, Canada
| | - Oluwatoyin A Adeleke
- College of Pharmacy, Faculty of Health, Dalhousie University, Halifax, NS B3H 4R2, Canada
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30
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Hua J, Friedlander P. Cervical Necrotizing Fasciitis, Diagnosis and Treatment of a Rare Life-Threatening Infection. EAR, NOSE & THROAT JOURNAL 2023; 102:NP109-NP113. [PMID: 33570428 DOI: 10.1177/0145561321991341] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
IMPORTANCE Necrotizing fasciitis is a relatively uncommon and potentially life-threatening soft tissue infection, with morbidity and mortality approaching 25% to 35%, even with optimal treatment. The challenge of diagnosis for necrotizing soft tissue infections (NSTIs) is their rarity, with the incidence of approximately 1000 cases annually in the United States. Given the rapid progression of disease and its similar presentation to more benign processes, early and definitive diagnosis is imperative. FINDINGS Signs and symptoms of NSTIs in the early stages are virtually indistinguishable from those seen with abscesses and cellulitis, making definitive diagnosis difficult. The clinical presentation will depend on the pathogen and its virulence factors which ultimately determine the area and depth of invasion into tissue. There are multiple laboratory value scoring systems that have been developed to support the diagnosis of an NSTI. The scoring system with the highest positive (92%) and negative (96%) predictive value is the laboratory risk indicator for necrotizing fasciitis (LRINEC). The score is determined by 6 serologic markers: C-reactive protein (CRP), total white blood cell (WBC) count, hemoglobin, sodium, creatinine, and glucose. A score ≥ 6 is a relatively specific indicator of necrotizing fasciitis (specificity 83.8%), but a score <6 is not sensitive (59.2%) enough to rule out necrotizing fasciitis. In terms of imaging, computed tomography (CT) imaging, while more sensitive (80%) than plain radiography in detecting abnormalities, is just as nonspecific. Computed tomography imaging of NSTIs demonstrates fascial thickening (with potential fat stranding), edema, subcutaneous gas, and abscess formation. Magnetic resonance imaging (MRI) has demonstrated sensitivity of 100% and specificity of 86%, though MRI may not show early cases of fascial involvement of necrotizing fasciitis. CONCLUSIONS AND RELEVANCE Necrotizing soft tissue infections are rapidly progressive and potentially fatal infections that require a high index of clinical suspicion to promptly diagnose and aggressive surgical debridement of affected tissue in order to ensure optimal outcomes.Prompt surgical and infectious disease consultation is necessary for the treatment and management of these patients. While imaging is useful for further characterization, it should not delay surgical consultation. Necrotizing soft tissue infection remains a clinical diagnosis, although plain radiography, CT imaging, and ultrasound can provide useful clues. In general, the management of these patients should include rapid diagnosis, using a combination of clinical suspicion, laboratory data (LRINEC score), and imaging (MRI being the recommended imaging modality), prompt infectious disease and surgical consultation, surgical debridement, and delayed reconstruction. Laboratory findings that can more strongly suggest a diagnosis of NSTI include elevated CRP, elevated WBC, low hemoglobin, decreased sodium, and increased creatinine. Imaging findings include fascial thickening (with potential fat stranding), edema, subcutaneous gas, and abscess formation. Broad-spectrum antibiotics should be started in all cases of suspected NSTI. Surgical debridement, however, remains the lynchpin for treatment of cervical necrotizing fasciitis.
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Affiliation(s)
- Jack Hua
- Department of Radiology, Tulane University Medical School, New Orleans, LA, USA
| | - Paul Friedlander
- Department of Otolaryngology, Tulane University Medical School, New Orleans, LA, USA
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Verma S, Baveja P, Thakur N, Patnaik S, Tilak TVSVGK, Mutreja D. Young man with alleged snake bite and disseminated intravascular coagulation or a life-threatening but potentially curable malignancy: Clinicopathological correlation. THE NATIONAL MEDICAL JOURNAL OF INDIA 2023; 36:124-128. [PMID: 38692589 DOI: 10.25259/nmji_137_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Affiliation(s)
- Shipra Verma
- Department of Pathology, Armed Forces Medical College, Pune, Maharashtra, India
| | - Puneet Baveja
- Department of Pathology, Armed Forces Medical College, Pune, Maharashtra, India
| | - Nachiketa Thakur
- Department of Pathology, Armed Forces Medical College, Pune, Maharashtra, India
| | - Subhashish Patnaik
- Department of Anaethesiology, Armed Forces Medical College, Pune, Maharashtra, India
| | - T V S V G K Tilak
- Department of Medicine, Armed Forces Medical College, Pune, Maharashtra, India
| | - Deepti Mutreja
- Department of Pathology, Armed Forces Medical College, Pune, Maharashtra, India
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32
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SIRAGUSA L, SFORZA D, SENSI B, PATHIRANNEHALAGE DON C, DE LUCA L, CIANCIO MANUELLI M, TOMEI B, VATTERMOLI L, VILLA M, GRANDE M. Left thigh necrotizing fasciitis secondary to colocutaneous fistula in previously treated rectal cancer: case report of a single, late and fatal complication. Chirurgia (Bucur) 2023. [DOI: 10.23736/s0394-9508.22.05422-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
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Lee AH, Berlyand Y, Dutta S, Succi MD, Sonis JD, Yun BJ, Raja AS, Prabhakar A, Baugh JJ. CT utilization in evaluation of skin and soft tissue extremity infections in the ED: Retrospective cohort study. Am J Emerg Med 2023; 64:96-100. [PMID: 36502653 DOI: 10.1016/j.ajem.2022.11.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 11/22/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Skin and soft tissue infections (SSTI) are commonly diagnosed in the emergency department (ED). While most SSTI are diagnosed with patient history and physical exam alone, ED clinicians may order CT imaging when they suspect more serious or complicated infections. Patients who inject drugs are thought to be at higher risk for complications from SSTI and may undergo CT imaging more frequently. The objective of this study is to characterize CT utilization when evaluating for SSTI in ED patients particularly in patients with intravenous drug use (IVDU), the frequency of significant and actionable findings from CT imaging, and its impact on subsequent management and ED operations. METHODS We performed a retrospective analysis of encounters involving a diagnosis of SSTI in seven EDs across an integrated health system between October 2019 and October 2021. Descriptive statistics were used to assess overall trends, compare CT utilization frequencies, actionable imaging findings, and surgical intervention between patients who inject drugs and those who do not. Multivariable logistic regression was used to analyze patient factors associated with higher likelihood of CT imaging. RESULTS There were 4833 ED encounters with an ICD-10 diagnosis of SSTI during the study period, of which 6% involved a documented history of IVDU and 30% resulted in admission. 7% (315/4833) of patients received CT imaging, and 22% (70/315) of CTs demonstrated evidence of possible deep space or necrotizing infections. Patients with history of IVDU were more likely than patients without IVDU to receive a CT scan (18% vs 6%), have a CT scan with findings suspicious for deep-space or necrotizing infection (4% vs 1%), and undergo surgical drainage in the operating room within 48 h of arrival (5% vs 2%). Male sex, abnormal vital signs, and history of IVDU were each associated with higher likelihood of CT utilization. Encounters involving CT scans had longer median times to ED disposition than those without CT scans, regardless of whether these encounters resulted in admission (9.0 vs 5.5 h), ED observation (5.5 vs 4.1 h), or discharge (6.8 vs 2.9 h). DISCUSSION ED clinicians ordered CT scans in 7% of encounters when evaluating for SSTI, most frequently in patients with abnormal vital signs or a history of IV drug use. Patients with a history of IVDU had higher rates of CT findings suspicious for deep space infections or necrotizing infections and higher rates of incision and drainage procedures in the OR. While CT scans significantly extended time spent in the ED for patients, this appeared justified by the high rate of actionable findings found on imaging, particularly for patients with a history of IVDU.
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Affiliation(s)
- Andy H Lee
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA, USA; Harvard Medical School, 25 Shattuck St., Boston, MA, USA.
| | - Yosef Berlyand
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA, USA; Harvard Medical School, 25 Shattuck St., Boston, MA, USA
| | - Sayon Dutta
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA, USA; Harvard Medical School, 25 Shattuck St., Boston, MA, USA
| | - Marc D Succi
- Harvard Medical School, 25 Shattuck St., Boston, MA, USA; Department of Radiology, Massachusetts General Hospital, 55 Fruit St., Boston, MA, USA
| | - Jonathan D Sonis
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA, USA; Harvard Medical School, 25 Shattuck St., Boston, MA, USA
| | - Brian J Yun
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA, USA; Harvard Medical School, 25 Shattuck St., Boston, MA, USA; Department of Emergency Medicine, Boston Medical Center, 725 Albany Street, Boston, MA, USA
| | - Ali S Raja
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA, USA; Harvard Medical School, 25 Shattuck St., Boston, MA, USA; Department of Radiology, Brigham and Women's Hospital, 75 Francis St., Boston, MA, USA
| | - Anand Prabhakar
- Harvard Medical School, 25 Shattuck St., Boston, MA, USA; Department of Radiology, Massachusetts General Hospital, 55 Fruit St., Boston, MA, USA
| | - Joshua J Baugh
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA, USA; Harvard Medical School, 25 Shattuck St., Boston, MA, USA
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Muacevic A, Adler JR, Maloof J. An Unusual Case of Deep Vein Thrombosis and Concurrent Necrotizing Fasciitis Following a Fall. Cureus 2023; 15:e33934. [PMID: 36819317 PMCID: PMC9937681 DOI: 10.7759/cureus.33934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2023] [Indexed: 01/19/2023] Open
Abstract
A 74-year-old male patient presented to the emergency department following a fall with signs and symptoms consistent with right lower extremity (RLE) deep vein thrombosis (DVT) and non-specific skin changes. Further imaging confirmed the initial diagnosis of DVT, and the patient was appropriately treated. However, his condition continued to deteriorate with worsening overlying skin changes, which prompted a computed tomography (CT) scan of his right femur without intravenous (IV) contrast. This revealed fluid tracking along the lateral compartment muscles, which raised suspicion of an abscess. Suspicion for necrotizing fasciitis (NF) was raised with a subsequent CT of the right femur with IV contrast that demonstrated a considerable increase in rim-enhancing fluid collections intramuscularly and extending into both the anterior and posterior compartments, likely correlating with increasing intermuscular abscesses. On imaging, no subcutaneous emphysema or gas accumulation was found, which is a common finding in NF. However, necrotic-appearing muscle was found on surgical debridement and wound cultures confirmed the diagnosis of methicillin-resistant Staphylococcus aureus (MRSA) NF. The patient was then treated with appropriate IV antibiotics and was discharged to long-term inpatient wound care. Similar presentations of DVT and NF made a prompt diagnosis of NF difficult, and it highlights the need for further imaging to rule out NF when a patient has a confirmed diagnosis of DVT.
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35
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Salastekar N, Su A, Rowe JS, Somasundaram A, Wong PK, Hanna TN. Imaging of Soft Tissue Infections. Radiol Clin North Am 2023; 61:151-166. [DOI: 10.1016/j.rcl.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Abstract
Surgical emergencies are common in the critical care setting and require prompt diagnosis and management. Here, we discuss some of the surgical emergencies involving the gastrointestinal, hepatobiliary, and genitourinary sites. In addition, foreign body aspiration and necrotizing soft-tissue infections have been elaborated. Clinicians should be aware of the risk factors, keys examination findings, diagnostic modalities, and medical as well as surgical treatment options for these potentially fatal illnesses.
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Affiliation(s)
- Vikram Saini
- Division of Infectious Disease (Drs Saini and Bhanot), Division of Pulmonary and Critical Care Medicine (Drs Saini and Ashraf), Department of General Surgery (Dr Babowice), and Division of Trauma Surgery and Surgical Critical Care (Ms Hamilton and Dr Khan), Allegheny Health Network, Pittsburgh, Pennsylvania
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37
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Feng J, Hsu WC, Chang DH, Hsu CH. Ruptured liver abscess causing necrotizing soft-tissue infection of the abdominal wall mimicking a carbuncle: A case report. Asian J Surg 2022:S1015-9584(22)01712-2. [PMID: 36509596 DOI: 10.1016/j.asjsur.2022.11.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 11/30/2022] [Indexed: 12/13/2022] Open
Affiliation(s)
- Jie Feng
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wei-Chun Hsu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Dun-Hao Chang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Division of Plastic and Aesthetic Surgery, Department of Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan.
| | - Chih-Ho Hsu
- Division of General Surgery, Department of Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan.
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38
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ICU Management of Invasive β-Hemolytic Streptococcal Infections. Infect Dis Clin North Am 2022; 36:861-887. [DOI: 10.1016/j.idc.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Lai CK, Towe CW, Patel NJ, Brown LR, Claridge JA, Ho VP. Re-Admission in Patients with Necrotizing Soft Tissue Infections: Continuity of Care Matters. Surg Infect (Larchmt) 2022; 23:866-872. [PMID: 36394462 PMCID: PMC9784599 DOI: 10.1089/sur.2022.243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background: Necrotizing soft tissue infections (NSTIs) are rapidly progressive infections with high mortality and complication rates. The incidence of NSTIs has been increasing steadily whereas mortality has decreased; survivors have a high risk of re-hospitalization. We hypothesized that re-admission to the index hospital where the first admission occurred would be associated with better clinical outcomes compared with re-admission to a non-index hospital. Patients and Methods: We identified patients from the 2017 Nationwide Readmissions Database with an index admission for NSTIs and examined all-cause re-admissions within 90 days of discharge. We noted whether re-admission occurred at the index or a non-index hospital. Survey-weighted logistic regression identified factors associated with death at the first re-admission and re-admission to index hospital. We also compared patient outcomes between patients admitted to index versus non-index hospitals. Results: We identified 27,051 NSTI survivors, of whom 6,954 (25.7%) had an unplanned re-admission within 90 days. A large proportion of re-admission occurred at non-index hospitals (28.3%; n = 1,966). Factors associated with non-index re-admission included prolonged index length of stay, discharge to short-term hospital, and leaving against medical advice. Patients re-admitted to index hospitals had a lower mortality rate (4.7% vs. 6.7%; p = 0.003), lower admission costs (in $1000; 45 [23-88] vs. 50 [24-104]; p = 0.004) and higher discharge rate to home (55.7% vs. 48.6%; p < 0.001). Conclusions: More than one-quarter of re-admissions among NSTI survivors were to non-index hospitals. Continuity of care is important because re-admission to the index hospital was associated with better patient outcomes.
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Affiliation(s)
- Clara K.N. Lai
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Christopher W. Towe
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Nimitt J. Patel
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Laura R. Brown
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | | | - Vanessa P. Ho
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
- Department of Population and Quantitative Health Sciences, Case Western Reserve School of Medicine, Cleveland, Ohio, USA
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40
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Vinkel J, Rib L, Buil A, Hedetoft M, Hyldegaard O. Investigating the Effects of Hyperbaric Oxygen Treatment in Necrotizing Soft Tissue Infection With Transcriptomics and Machine Learning (the HBOmic Study): Protocol for a Prospective Cohort Study With Data Validation. JMIR Res Protoc 2022; 11:e39252. [PMID: 36427229 PMCID: PMC9736759 DOI: 10.2196/39252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 10/20/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Necrotizing soft tissue infections (NSTIs) are complex multifactorial diseases characterized by rapid bacterial proliferation and progressive tissue death. Treatment is multidisciplinary, including surgery, broad-spectrum antibiotics, and intensive care; adjunctive treatment with hyperbaric oxygen (HBO2) may also be applied. Recent advances in molecular technology and biological computation have given rise to new approaches to infectious diseases based on identifying target groups defined by activated pathophysiological mechanisms. OBJECTIVE We aim to capture NSTI disease signatures and mechanisms and responses to treatment in patients that receive the highest standard of care; therefore, we set out to investigate genome-wide transcriptional responses to HBO2 treatment during NSTI in the host and bacteria. METHODS The Effects of Hyperbaric Oxygen Treatment Studied with Omics (HBOmic) study is a prospective cohort study including 95 patients admitted for NSTI at the intensive care unit of Copenhagen University Hospital (Rigshospitalet), Denmark, between January 2013 and June 2017. All participants were treated according to a local protocol for management of NSTI, and biological samples were obtained and stored according to a standard operational procedure. In the proposed study, we will generate genome-wide expression profiles of whole-blood samples and samples of infected tissue taken before and after HBO2 treatment administered during the initial acute phase of infection, and we will analyze the profiles with unsupervised hierarchical clustering and machine learning. Differential gene expression will be compared in samples taken before and after HBO2 treatment (N=85), and integration of profiles from blood and tissue samples will be performed. Furthermore, findings will be compared to NSTI patients who did not receive HBO2 treatment (N=10). Transcriptomic data will be integrated with clinical data to investigate associations and predictors. RESULTS The first participant was enrolled on July 27, 2021, and data analysis is expected to begin during autumn 2022, with publication of results immediately thereafter. CONCLUSIONS The HBOmic study will provide new insights into personalized patient management in NSTIs. TRIAL REGISTRATION ClinicalTrials.gov NCT01790698; https://clinicaltrials.gov/ct2/show/NCT01790698. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/39252.
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Affiliation(s)
- Julie Vinkel
- Department of Anaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Leonor Rib
- Biotech Research and Innovation Centre, University of Copenhagen, Copenhagen, Denmark
| | - Alfonso Buil
- Institute for Biological Psychiatry, Center of Psychiatry Sankt Hans, Roskilde, Denmark
| | - Morten Hedetoft
- Department of Anaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Ole Hyldegaard
- Department of Anaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Cooley J, Obaidi N, Diaz V, Anselmo K, Eriksson E, Carlsson AH, Chan RK, Nuutila K. Delivery of topical gentamicin cream via platform wound device to reduce wound infection—A prospective, controlled, randomised, clinical study. Int Wound J 2022; 20:1426-1435. [PMID: 36307989 PMCID: PMC10088835 DOI: 10.1111/iwj.13998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/18/2022] [Accepted: 10/20/2022] [Indexed: 11/28/2022] Open
Abstract
The platform wound device (PWD) is a wound coverage system that is designed to decrease wound infection rates by allowing for direct delivery of topical antibiotics and antimicrobials while creating a sealed, protective barrier around the area of injury. This study evaluated the safety and efficacy of the PWD as a protective dressing and a delivery system for topical antibiotics compared to the current standard of care (SoC). This was a multi-center, prospective, randomised, controlled clinical trial. The wounds were treated with the PWD with gentamicin cream or SoC dressings. The wounds were evaluated before the start of treatment and after 48-96 hours via clinical assessment, photographs, and qualitative bacterial swabs for bacterial analysis. The delivery of gentamicin via the PWD was safe and did not cause any adverse effects. The treatment decreased both inflammation and bacterial growth during the study period. No significant differences in the SoC were observed. The PWD is a transparent and impermeable polyurethane chamber that encloses and protects the injured area. The delivery of topical gentamicin via the PWD was safe and effective. Clinical assessment for infection found the PWD to be non-inferior to the current SoC treatment options.
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Affiliation(s)
| | | | | | | | - Elof Eriksson
- Applied Tissue Technologies LLC Hingham Massachusetts USA
| | | | | | - Kristo Nuutila
- Applied Tissue Technologies LLC Hingham Massachusetts USA
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Loloi J, Gottlieb J, MacDonald SM, Aboumohamed A, Ricci JA, Laudano M, Watts K. Case - Testicular thigh pouches for severe Fournier's gangrene: A how-to guide. Can Urol Assoc J 2022; 16:374-376. [PMID: 35621290 PMCID: PMC9565065 DOI: 10.5489/cuaj.7901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2023]
Abstract
Fournier’s gangrene is a surgical emergency that requires prompt debridement of infected tissue. When the majority of scrotum has been resected, placing the testicles into thigh pouches can allow for improved wound granulation/contracture prior to definitive tissue reconstruction. We present a surgical guide on how to create testicular thigh pouches without the use of thigh counter-incisions, and its utility in delayed wound healing for large scrotal wounds. This technique may serve as a valuable adjunct in the urologist’s and plastic surgeon’s armamentarium to optimize testicular coverage and subsequent genital reconstruction.
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Affiliation(s)
- Justin Loloi
- Department of Urology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Josh Gottlieb
- Department of Urology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Susan M. MacDonald
- Department of Urology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, United States
| | - Ahmed Aboumohamed
- Department of Urology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Joseph A. Ricci
- Department of Plastic and Reconstructive Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Melissa Laudano
- Department of Urology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Kara Watts
- Department of Urology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
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Gibson D, Chow O, Seth I, Siu AHY, Kwei J. Compartment syndrome as a novel complication of extended spectrum beta lactamase Escherichia coli necrotising soft tissue infection – A case report. Int J Surg Case Rep 2022; 99:107574. [PMID: 36096081 PMCID: PMC9568700 DOI: 10.1016/j.ijscr.2022.107574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 08/27/2022] [Accepted: 08/27/2022] [Indexed: 01/22/2023] Open
Abstract
Introduction and importance Necrotising soft tissue infections (NSTI) encompass a group of destructive soft tissue disease processes which can involve skin, subcutaneous tissue, fascia and or muscle, associated with rapid spread along tissue planes and mortality. Clinical presentations include progressive pain, suppuration/necrosis and systemic toxicity with haemodynamic instability. While diagnosis is based on clinical findings it can be augmented with imaging. Treatment is typically in the form of resuscitation, immediate administration of broad spectrum intravenous antibiotics and urgent source control through radical surgical debridement. Case presentation An 82-year-old man presented with left forearm/hand pain and fevers in the context of immunocompromise. Examination found tense swelling of the left volar and dorsal forearm and hand, absent distal pulses with pain and paraesthesia over both surfaces. He underwent surgical debridement with fasciotomy and remained in intensive care with blood cultures revealing ESBL E. coli. Clinical discussion Compartment syndrome is a rare complication of NSTI and its clinical presentation can obscure early diagnosis. ESBL E. coli is an uncommon pathogen to cause monomicrobial infection and must be accounted for when considering broad spectrum empirical antibiotic cover. Conclusion Review of this case and the literature show a rare presentation of NSTI and highlights the importance of early diagnosis based on even a small index of suspicion. It also shows the key significance rationalisation of antibiotics as soon as practicable, given that even broad spectrum empirical cover can be inappropriate in the context of novel microorganisms, particularly in high risk patients. First recorded case of monomicrobial ESBL E. coli compartment syndrome ESBL E. coli NSTI is rare and not covered by many empirical antimicrobial guidelines. Compartment syndrome secondary to NSTI is uncommon and associated with streptococci. Early recognition and prompt management are essential to prognosis.
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Ali AA, Bilgrami Z. A woman with flank pain and swelling. J Am Coll Emerg Physicians Open 2022; 3:e12809. [PMID: 36187508 PMCID: PMC9494201 DOI: 10.1002/emp2.12809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 08/01/2022] [Indexed: 11/10/2022] Open
Affiliation(s)
- Afrah A. Ali
- Department of Emergency Medicine University of Maryland School of Medicine Baltimore Maryland USA
| | - Zaid Bilgrami
- Department of Internal Medicine University of Maryland Medical Center–Midtown Campus Baltimore Maryland USA
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Saleem HA, Al-Natour O, Mahfouz IA, Assamen MA, Al-Natour S. Necrotizing fasciitis following episiotomy in a woman with Hailey-Hailey disease: A case report. Case Rep Womens Health 2022; 36:e00461. [DOI: 10.1016/j.crwh.2022.e00461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 11/08/2022] Open
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Utility of Diagnostic Imaging in the Early Detection and Management of the Fournier Gangrene. Diagnostics (Basel) 2022; 12:diagnostics12102320. [PMID: 36292011 PMCID: PMC9600881 DOI: 10.3390/diagnostics12102320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/03/2022] [Accepted: 09/19/2022] [Indexed: 12/02/2022] Open
Abstract
Fournier gangrene represents a urologic emergency. It is a rapidly progressing necrotizing fasciitis that comprises the perineal, perianal, and genital regions and has a high mortality rate. Diagnosis is usually made clinically, but radiological diagnostics, such as ultrasound (US), computed tomography (CT), or magnetic resonance imaging (MRI), can determine the extent of the disease in relation to pelvic structures. Early and accurate diagnosis precipitates the initiation of the effective treatment and, thus, affects the outcome of the therapy. The article reports an illustrative case study of a patient with Fournier gangrene, secondary to a perianal fistula and perianal abscess with a massive accumulation of fluid around the anus and testicles, requiring unilateral orchidectomy. Rapid radiological diagnosis via MRI enabled precise assessment of the degree of the disease, early surgical intervention, and a successful outcome.
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47
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Rose B, Powell TG, Jones M, Chillag SA, Kemper S. Case Reports of Heroin Injection Site Necrosis: A Novel Antecedent of Nicolau Syndrome. Cureus 2022; 14:e29235. [PMID: 36258944 PMCID: PMC9573776 DOI: 10.7759/cureus.29235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2022] [Indexed: 11/05/2022] Open
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Nawijn F, Kerckhoffs MC, van Heijl M, Keizer J, van Koperen PJ, Hietbrink F. Impact of Comorbidities on the Cause of Death by Necrotizing Soft Tissue Infections. Surg Infect (Larchmt) 2022; 23:729-739. [PMID: 36067160 DOI: 10.1089/sur.2022.135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background: The aim of this study was to identify the cause of death in patients with necrotizing soft tissue infections (NSTIs) stratified by patient's pre-existing comorbidities (American Society of Anesthesiologists [ASA] classification 3/4 vs. ASA 1/2). Differences in clinical presentation, mortality rate, and factors associated with mortality between those two comorbidity groups were investigated. Patients and Methods: A retrospective multicenter study of patients with NSTIs between 2010 and 2020 was conducted. The primary outcome was the cause of death within the first 30 days. Furthermore, factors associated with mortality were identified. All analysis were stratified by severity of comorbidities (ASA 1/2 or ASA 3/4). Results: Of the 187 patients, 39 patients (21%) died within 30 days. American Society of Anesthesiologists 1/2 patients (overall mortality rate, 11%) died more often as direct result of the infection compared with ASA 3/4 patients (overall mortality rate, 33%) (ASA 1/2 group: 92% vs. ASA 3/4 group: 48%; p = 0.013). American Society of Anesthesiologists 3/4 patients died more often due to withdrawal of life-sustaining therapies based on assumed poor outcome after severe critical illness (ASA 1/2 group: 52% vs. ASA 3/4 group: 8%; p = 0.013). Conclusions: Mortality rates of patients with NSTIs varied from 11% in previously healthy patients to 33% in patients with multiple or severe comorbidities. The predominant cause of mortality was overwhelming infection and associated sepsis in healthy patients whereas in patients with multiple or severe pre-existing medical disease, death most often occurred after treatment limitations based on patient's wishes and prognosis.
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Affiliation(s)
- Femke Nawijn
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Monika C Kerckhoffs
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mark van Heijl
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Surgery, Diakonessenhuis, Utrecht, The Netherlands
| | - Jort Keizer
- Department of Surgery, St. Antonius Hospital, Utrecht, The Netherlands
| | - Paul J van Koperen
- Department of Surgery, Meander Medical Center, Amersfoort, The Netherlands
| | - Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Barker T, Wagstaff M, Ricketts S, Bruscino-Raiola F. Use of a bilayer biodegradable synthetic dermal matrix for the management of defects arising from necrotising fasciitis. J Wound Care 2022; 31:724-732. [PMID: 36113547 DOI: 10.12968/jowc.2022.31.9.724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The aim of this article is to provide a brief overview of necrotising fasciitis, including causative factors, incidence, diagnosis and clinical outcomes. Various surgical treatment options are outlined, including methods of soft tissue reconstruction after wide excision of infected and necrotic tissues. The role of dermal matrices, including a synthetic biodegradable temporising matrix made of polyurethane, are described in terms of wound bed preparation, surgical application and clinical outcomes.
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Affiliation(s)
- Timothy Barker
- PolyNovo Biomaterials Pty Ltd, 2/320 Lorimer Street, Port Melbourne, VIC 3207, Australia
| | - Marcus Wagstaff
- Adult Burns Service, Royal Adelaide Hospital, Port Road, Adelaide, SA 5000, Australia.,Department of Plastic and Reconstructive Surgery, Royal Adelaide Hospital, Port Road, Adelaide, SA 5000, Australia
| | - Sophie Ricketts
- Plastic, Hand and Faciomaxillary Surgery, The Alfred, Commercial Road, Melbourne, VIC 3004 Australia
| | - Frank Bruscino-Raiola
- Plastic, Hand and Faciomaxillary Surgery, The Alfred, Commercial Road, Melbourne, VIC 3004 Australia
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50
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Kejela S, Bekele S. Retroperitoneal necrotizing soft tissue infections: A case report and literature review. Clin Case Rep 2022; 10:e6368. [PMID: 36188031 PMCID: PMC9487450 DOI: 10.1002/ccr3.6368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 09/08/2022] [Indexed: 11/12/2022] Open
Abstract
Necrotizing soft tissue infections of the retroperitoneal is a rare disease identity. Here we present a 50‐year‐old male patient who underwent surgical exploration for retroperitoneal necrotizing soft tissue infection. Postoperatively, he was put on broad‐spectrum antibiotics. He passed on after the first exploration and debridement. Retroperitoneal necrotizing soft tissue infections are rare but deadly entities. Maintain a high index of suspicion in patients with a typical peritoneal signs is mandatory for early detection.
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Affiliation(s)
- Segni Kejela
- Department of Surgery, College of Health Sciences Addis Ababa University Addis Ababa Ethiopia
| | - Solomon Bekele
- Department of Surgery, College of Health Sciences Addis Ababa University Addis Ababa Ethiopia
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