Estimating the Impact of Necrotizing Soft Tissue Infections in the United States: Incidence and Re-Admissions

Background: Necrotizing fasciitis is a potentially lethal soft tissue infection characterized by rampant necrosis and destruction of subcutaneous tissues. Current estimates of necrotizing soft tissue infections in the United States are 4.3 infections per 100,000 of the population. Although the incidence of necrotizing soft tissue infections has decreased in the last decade, the toxic and lethal nature of the disease process lends utmost importance to accurate diagnosis and immediate management. The purpose of this review article is to report three cases of necrotizing fasciitis and provide literature review in regards to hallmark characteristics, predisposing risk factors and treatment optimization.Case: The first case depicts a newly diagnosed 43-year-old male HIV patient with necrotizing fasciitis infection characterized by Klebsiella, Serratia and anaerobic bacteria cultures. The second case describes the course of a 71-year-old male diagnosed with necrotizing fasciitis in the setting of a complicated anal fistula characterized by B. fragilis, S. anginosus and Prevotella species. The third and final case describes the course of a 44-year-old female diagnosed with necrotizing fasciitis in the setting of Ludwig’s Angina characterized by Klebsiella and Dubliensis species. Treatment was initiated with extensive wound debridement, multiple washouts and broad antibiotic regimens in all three cases. Additional hyperbaric oxygen therapy was administered in the third case.Conclusions: These case reports illustrate the range of severity and settings in which necrotizing fasciitis can occur. Significant morbidity and mortality rates are associated with a delay in treatment initiation. Given this, it is of utmost importance to develop and maintain a high clinical acumen for necrotizing soft tissue infections.

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Decreasing Incidence of Skin and Soft-tissue Infections in 86 US Emergency Departments, 2009–2014

Clinical Infectious Diseases ◽

10.1093/cid/ciy509 ◽

2018 ◽

Vol 68 (3) ◽

pp. 453-459 ◽

Cited By ~ 12

Author(s):

Ethan Morgan ◽

Sam Hohmann ◽

Jessica P Ridgway ◽

Robert S Daum ◽

Michael Z David

Keyword(s):

United States ◽

Soft Tissue ◽

Hiv Infection ◽

Emergency Departments ◽

Medical Center ◽

Academic Medical Center ◽

Significant Risk ◽

Significant Risk Factor ◽

The United States ◽

Soft Tissue Infections

Abstract Background The incidence of skin and soft-tissue infections (SSTIs), for which human immunodeficiency virus (HIV) is a significant risk factor, in United States emergency departments (EDs) increased dramatically after 2000 with the emergence of community-associated methicillin-resistant Staphylococcus aureus. Few studies have examined SSTI incidence among HIV-infected and non–HIV-infected patients in the United States after 2010. Methods Data were obtained for patient encounters at all academic medical center EDs affiliated with the Vizient clinical data warehouse assigned an SSTI-associated code based on the International Classification of Diseases, Ninth Revision, between 1 January 2009 and 31 December 2014. The rate was calculated per 1000 ED encounters by year and stratified by SSTI, HIV infection, or both, and by age group, race, payer type, and region of care. Poisson regression was used to assess temporal change over the study period. Results In 2009–2014, a total of 47317 HIV-associated and 820440 SSTI-associated encounters were recorded among 25239781 ED patient encounters. The rate of SSTIs decreased by 8% among all patients and by 14.6%, among those with HIV infection. The SSTI incidence overall decreased from 32.0 to 29.7 per 1000 ED encounters between 2009 and 2014. HIV-infected patients had a significantly higher rate of SSTIs than HIV-uninfected patients (adjusted rate ratio, 1.91; 95% confidence interval, 1.84–1.99). Conclusions The decline in SSTI incidence in US EDs between 2009 and 2014 is a remarkable epidemiologic shift from the increase in SSTIs after 2000, and further research is necessary to assess reasons for this decrease.

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Risk Factors and Predictors of Mortality in Streptococcal Necrotizing Soft-tissue Infections: A Multicenter Prospective Study

Clinical Infectious Diseases ◽

10.1093/cid/ciaa027 ◽

2020 ◽

Cited By ~ 11

Author(s):

Trond Bruun ◽

Eivind Rath ◽

Martin Bruun Madsen ◽

Oddvar Oppegaard ◽

Michael Nekludov ◽

...

Keyword(s):

Risk Factors ◽

Septic Shock ◽

Soft Tissue ◽

Blunt Trauma ◽

Gene Profiling ◽

Soft Tissue Infections ◽

Lasso Regression ◽

Factors Associated ◽

Necrotizing Soft Tissue Infections ◽

The Impact

Abstract Background Necrotizing soft-tissue infections (NSTI) are life-threatening conditions often caused by β-hemolytic streptococci, group A Streptococcus (GAS) in particular. Optimal treatment is contentious. The INFECT cohort includes the largest set of prospectively enrolled streptococcal NSTI cases to date. Methods From the INFECT cohort of 409 adults admitted with NSTI to 5 clinical centers in Scandinavia, patients culture-positive for GAS or Streptococcus dysgalactiae (SD) were selected. Risk factors were identified by comparison with a cohort of nonnecrotizing streptococcal cellulitis. The impact of baseline factors and treatment on 90-day mortality was explored using Lasso regression. Whole-genome sequencing of bacterial isolates was used for emm typing and virulence gene profiling. Results The 126 GAS NSTI cases and 27 cases caused by SD constituted 31% and 7% of the whole NSTI cohort, respectively. When comparing to nonnecrotizing streptococcal cellulitis, streptococcal NSTI was associated to blunt trauma, absence of preexisting skin lesions, and a lower body mass index. Septic shock was significantly more frequent in GAS (65%) compared to SD (41%) and polymicrobial, nonstreptococcal NSTI (46%). Age, male sex, septic shock, and no administration of intravenous immunoglobulin (IVIG) were among factors associated with 90-day mortality. Predominant emm types were emm1, emm3, and emm28 in GAS and stG62647 in SD. Conclusions Streptococcal NSTI was associated with several risk factors, including blunt trauma. Septic shock was more frequent in NSTI caused by GAS than in cases due to SD. Factors associated with mortality in GAS NSTI included age, septic shock, and no administration of IVIG.

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Factors affecting the rise of treatment of resistant bacteria in skin and soft tissue infections in the United States: 1993–2012

Journal of Dermatological Treatment ◽

10.1080/09546634.2016.1257773 ◽

2016 ◽

Vol 28 (5) ◽

pp. 417-421 ◽

Cited By ~ 2

Author(s):

Margaret E. Wetzel ◽

Alan B. Fleischer

Keyword(s):

United States ◽

Soft Tissue ◽

The United States ◽

Resistant Bacteria ◽

Soft Tissue Infections ◽

Factors Affecting

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National Public Health Burden Estimates of Endocarditis and Skin and Soft-Tissue Infections Related to Injection Drug Use: A Review

The Journal of Infectious Diseases ◽

10.1093/infdis/jiaa149 ◽

2020 ◽

Vol 222 (Supplement_5) ◽

pp. S429-S436

Author(s):

Isaac See ◽

Runa H Gokhale ◽

Andrew Geller ◽

Maribeth Lovegrove ◽

Asher Schranz ◽

...

Keyword(s):

Public Health ◽

United States ◽

Soft Tissue ◽

Drug Use ◽

Injection Drug Use ◽

The United States ◽

Data Sources ◽

Soft Tissue Infections ◽

Public Health Burden ◽

Health Burden

Abstract Background Despite concerns about the burden of the bacterial and fungal infection syndromes related to injection drug use (IDU), robust estimates of the public health burden of these conditions are lacking. The current article reviews and compares data sources and national burden estimates for infective endocarditis (IE) and skin and soft-tissue infections related to IDU in the United States. Methods A literature review was conducted for estimates of skin and soft-tissue infection and endocarditis disease burden with related IDU or substance use disorder terms since 2011. A range of the burden is presented, based on different methods of obtaining national projections from available data sources or published data. Results Estimates using available data suggest the number of hospital admissions for IE related to IDU ranged from 2900 admissions in 2013 to more than 20 000 in 2017. The only source of data available to estimate the annual number of hospitalizations and emergency department visits for skin and soft-tissue infections related to IDU yielded a crude estimate of 98 000 such visits. Including people who are not hospitalized, a crude calculation suggests that 155 000–540 000 skin infections related to IDU occur annually. Discussion These estimates carry significant limitations. However, regardless of the source or method, the burden of disease appears substantial, with estimates of thousands of episodes of IE among persons with IDU and at least 100 000 persons who inject drugs (PWID) with skin and soft-tissue infections annually in the United States. Given the importance of these types of infections, more robust and reliable estimates are needed to better quantitate the occurrence and understand the impact of interventions.

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Decreasing Incidence of Skin and Soft Tissue Infections With a Seasonal Pattern at an Academic Medical Center, 2006–2014

Open Forum Infectious Diseases ◽

10.1093/ofid/ofw179 ◽

2016 ◽

Vol 3 (4) ◽

Cited By ~ 7

Author(s):

Ethan Morgan ◽

Robert S. Daum ◽

Michael Z. David

Keyword(s):

United States ◽

Soft Tissue ◽

Medical Center ◽

Seasonal Pattern ◽

Academic Medical Center ◽

Late Summer ◽

International Classification Of Diseases ◽

The United States ◽

Incidence Density ◽

Soft Tissue Infections

Abstract Background. The incidence of skin and soft tissue infections (SSTIs) in the United States increased sharply after 2000 with the emergence of USA300 methicillin-resistant Staphylococcus aureus. We examined trends in SSTI incidence in 2006–2014 at the University of Chicago Medicine (UCM). Methods. Data were obtained for patient encounters at UCM with an International Classification of Diseases, Ninth Revision-coded SSTI diagnosis between January 1, 2006 and March 31, 2014. Incidence density was calculated per 1000 encounters by quarter and year. Encounters were stratified by inpatient, outpatient clinic and emergency department (ED) encounters and by age group, gender, and race. Poisson regression was used to assess change over time. Results. In 2006–2014, data were collected for 38 201 SSTI-associated encounters among 31 869 subjects. Among all patients treated at UCM, there was a decrease of 1% per year in the incidence of SSTIs during 2006–2013, with an overall decrease of 16%. There was a significant decrease in SSTI-related encounters among inpatients (rate ratio [RR] = 0.97; 95% confidence interval [CI], .96–.98), ED patients (RR = 0.98; 95% CI, .97–.98), adults (RR = 0.98; 95% CI, .97–.98), children (RR = 0.96; 95% CI, .95–.97), and African Americans (RR = 0.99; 95% CI, .98–.99). There was an annual seasonal trend, with the peak incidence occurring during the late summer. Conclusions. The incidence of SSTIs at UCM decreased in children and adults with seasonal variation, peaking during the summer months. This suggests a reversal of the massive increase in SSTI incidence in the United States after 2000.

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