Short Courses of Antibiotics Are Safe in Necrotizing Soft Tissue Infections

Introduction Necrotizing soft tissue infections (NSTIs) carry high morbidity and mortality. While early aggressive surgical debridement is well-accepted treatment for NSTIs, the optimum duration of adjunct antibiotic therapy is unclear. An increasing focus on safety and evidence-based antimicrobial stewardship suggests a value in addressing this knowledge gap. Objective To determine whether shorter antibiotic courses have similar outcomes compared to longer courses in patients with NSTI following adequate source control. Population 142 consecutive patients with surgically managed NSTI were identified on retrospective chart review between December 2014 and December 2018 at two academic medical centers. Results Patients were predominately male (74%) with a median age of 52 and similar baseline characteristics. The median number of debridements to definitive source control was 2 (IQR 1-3) with the short course group undergoing a greater number of debridements control 2.57 ± 1.8 vs 1.9 ± 1.2, ( P = .01). Of 142 patients, 34.5% received a short course and the remaining 65.5% received a longer course of antibiotics. There was no significant difference in the incidence of bacteremia or wound culture positivity between groups. There was also no significant difference in in-hospital mortality, 8% vs 6, ( P = .74), incidence of C. difficile infection, median length of stay, or 30-day readmission. Conclusion Provided adequate surgical debridement, similar outcomes in morbidity and mortality suggest antibiotic courses of 7 days or less are equally safe compared to longer courses.

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Hyperbaric oxygen therapy as an adjuvant to source control in necrotizing soft tissue infections

Undersea and Hyperbaric Medicine ◽

10.22462/11.12.2017.4 ◽

2017 ◽

Vol 44 (6) ◽

pp. 535-542

Author(s):

António Pedro Pinto Ferreira ◽

◽

Sérgio Santos Vide ◽

Tiago David Fonseca Fernandes ◽

Pedro Miguel Barata de Silva Coelho ◽

...

Keyword(s):

Soft Tissue ◽

Hyperbaric Oxygen ◽

Hyperbaric Oxygen Therapy ◽

Oxygen Therapy ◽

Source Control ◽

Soft Tissue Infections ◽

Necrotizing Soft Tissue Infections

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Demographics, Microbiology and Outcome in Necrotizing Soft Tissue Infections

The Southwest Respiratory and Critical Care Chronicles ◽

10.12746/swrccc.v1i1.10 ◽

2013 ◽

Vol 1 (1) ◽

pp. 4

Author(s):

Chance Witt ◽

Sharmila Dissanaike

Keyword(s):

Soft Tissue ◽

Univariate Analysis ◽

Tertiary Care ◽

Binary Logistic Regression ◽

Binary Logistic Regression Analysis ◽

Comorbid Condition ◽

High Morbidity ◽

Care Hospital ◽

Soft Tissue Infections ◽

Necrotizing Soft Tissue Infections

Background: Necrotizing soft tissue infections (NSTI) are potentially severe infections that have a high morbidity and mortality even with modern medical care. This study examines factors associated with outcomes in patients with NSTI in an academic tertiary care hospital. Design: This is a retrospective cohort study of patients admitted with NSTI between 2003 and 2008. Baseline demographics and comorbid conditions, laboratory and clinical parameters, timing of surgery, and outcomes, including length of stay and mortality, were compared with univariate analysis; significant factors were then analyzed for their effects on mortality using binary logistic regression analysis. Results: Sixty-nine patients with NSTI were analyzed; 61% were men. Diabetes (39%) was the most common comorbid condition. Most infections (55%) were polymicrobial. The most common organism in monomicrobial infections was Staphylococcus aureus, and 50 % of these isolates were methicillin resistant. Nine patients (13%) required amputation. Mortality was 20%, and the most significant predictor of mortality was a higher respiratory rate on admission (p=0.02). Conclusion: Patients in this series frequently had diabetes, usually had polymicrobial infections, and had a 20% mortality rate.

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Necrotizing Soft-Tissue Infection: Laboratory Risk Indicator for Necrotizing Soft Tissue Infections Score

Journal of Laboratory Physicians ◽

10.4103/0974-2727.129092 ◽

2014 ◽

Vol 6 (01) ◽

pp. 046-049 ◽

Cited By ~ 7

Author(s):

Madhuri Kulkarni ◽

Vijay Kumar GS ◽

Sowmya GS ◽

Madhu CP ◽

Ramya SR

Keyword(s):

Soft Tissue ◽

Immunocompromised Host ◽

High Morbidity ◽

Risk Indicator ◽

Soft Tissue Infections ◽

Acinetobacter Species ◽

Mortality And Morbidity ◽

Necrotizing Soft Tissue Infections ◽

Lrinec Score ◽

Immunocompromised Hosts

ABSTRACTNecrotizing soft tissue infections (NSTI) can be rapidly progressive and polymicrobial in etiology. Establishing the element of necrotizing infection poses a clinical challenge. A 64-year-old diabetic patient presented to our hospital with a gangrenous patch on anterior abdominal wall, which progressed to an extensive necrotizing lesion within 1 week. Successive laboratory risk indicator for necrotizing softtissue infections (LRINEC) scores confirmed the necrotizing element. Cultures yielded Enterococci, Acinetobacter species and Apophysomyces elegans and the latter being considered as an emerging agent of Zygomycosis in immunocompromised hosts. Patient was managed with antibiotics, antifungal treatment and surgical debridement despite which he succumbed to the infection. NSTI’s require an early and aggressive management and LRINEC score can be applied to establish the element of necrotizing pathology. Isolation of multiple organisms becomes confusing to establish the etiological role. Apophysomyces elegans, which was isolated in our patient is being increasingly reported in cases of necrotizing infections and may be responsible for high morbidity and mortality. This scoring has been proposed as an adjunct tool to Microbiological diagnosis when NSTI’s need to be diagnosed early and managed promptly to decrease mortality and morbidity, which however may not come in handy in an immunocompromised host with polymicrobial aggressive infection.

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Mandatory Operative Re-Exploration after Initial Debridement of Necrotizing Soft Tissue Infections: Is it Mandatory?

The American Surgeon ◽

10.1177/000313481708301021 ◽

2017 ◽

Vol 83 (10) ◽

pp. 1117-1121

Author(s):

Lara H. Spence ◽

Huan Yan ◽

Ashkan Moazzez ◽

Alexander Schwed ◽

Jessica Keeley ◽

...

Keyword(s):

Septic Shock ◽

Soft Tissue ◽

Clinical Examination ◽

Source Control ◽

Soft Tissue Infections ◽

Duration Of Symptoms ◽

Safe Strategy ◽

Necrotizing Soft Tissue Infections ◽

Operative Debridement ◽

Prompt Diagnosis

Necrotizing soft tissue infections (NSTIs) are aggressive infections requiring prompt diagnosis and extensive surgical debridement. Traditionally, patients undergo mandatory re-exploration to ensure adequacy of source control. The purpose of this study is to determine if re-exploration in the operating room is mandatory for all patients with NSTIs. An eight-year retrospective analysis of adult patients with NSTIs was performed comparing two groups: mandatory operative re-exploration versus operative re-exploration based on clinical examination findings. Outcomes measured included mortality, number of debridements, and length of stay (LOS). Twenty-two per cent of patients underwent a mandatory re-exploration. These patients were older, had a higher incidence of diabetes, and a longer duration of symptoms. There were no significant differences between groups with regard to the physical examination, severity of sepsis, time to repeat debridements, or in-hospital mortality, whereas LOS and the total number of debridements were increased in mandatory re-exploration. Bacteremia and septic shock were predictive of the need for further debridement in patients in the operative re-exploration based on clinical examination findings group. Mandatory re-exploration after initial debridement may not be necessary in all patients with NSTIs. Instead, bedside wound checks may be a safe strategy to determine the need for further operative debridement.

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Necrotizing Soft Tissue Infections: Surgeon’s Prospective

International Journal of Inflammation ◽

10.1155/2013/609628 ◽

2013 ◽

Vol 2013 ◽

pp. 1-7 ◽

Cited By ~ 11

Author(s):

Shashi Prakash Mishra ◽

Shivanshu Singh ◽

Sanjeev Kumar Gupta

Keyword(s):

Soft Tissue ◽

Clinical Features ◽

Current Paper ◽

Surgical Debridement ◽

Diagnostic Workup ◽

Soft Tissue Infections ◽

Clostridial Myonecrosis ◽

Risk Of Mortality ◽

Necrotizing Soft Tissue Infections ◽

Principles Of Treatment

Necrotizing soft tissue infections (NSTIs) are fulminant infections of any layer of the soft tissue compartment associated with widespread necrosis and systemic toxicity. Delay in diagnosing and treating these infections increases the risk of mortality. Early and aggressive surgical debridement with support for the failing organs significantly improves the survival. Although there are different forms of NSTIs like Fournier’s gangrene or clostridial myonecrosis, the most important fact is that they share common pathophysiology and principles of treatment. The current paper summarizes the pathophysiology, clinical features, the diagnostic workup required and the treatment principles to manage these cases.

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Clinicopathological profile and management outcome of skin and soft tissue infections at tertiary care centre of sub Himalayan region

International Surgery Journal ◽

10.18203/2349-2902.isj20180809 ◽

2018 ◽

Vol 5 (3) ◽

pp. 946

Author(s):

Hemant K. Nautiyal ◽

Ayush Agarwal ◽

Gurvansh Singh Sachdev ◽

P. K. Sachan

Keyword(s):

Soft Tissue ◽

Early Diagnosis ◽

Tertiary Care ◽

Clinical Signs ◽

High Morbidity ◽

Soft Tissue Infections ◽

Tertiary Care Centre ◽

Systemic Involvement ◽

Significant Difference ◽

Chi Square Analysis

Background: Many times, it is difficult to differentiate between Necrotizing soft tissue infections (NSTI) and Non NSTI based on symptoms, signs and investigations. Only early diagnosis and debridement can prevent high morbidity associated with it.Methods: This prospective observational, study was conducted in the department of General Surgery, over a period of 1 year on consecutive 100 admitted patients. Clinical signs, symptoms and vital parameters of NSTI group and Non NSTI group were compared. Biochemical investigations, systemic involvement and treatment received was also evaluated. Chi-square analysis was performed to compare categorical variables.Results: A 77.8% of the NSTI and 54.7% of the Non NSTI infections occurred in males. Significant difference was found in mean age in patients with NSTI (50.9±13.1) and Non NSTI (41.1±15). Type II DM (38.9%) and hypertension (8.3%) were more commonly associated with NSTI patients. Mean pulse rate, respiratory rate and body temperature were significantly more in NSTI group. Patients with NSTI had significantly less hemoglobin and increased creatinine as compared to Non NSTI group. In NSTI group, 83% of patients had necrotizing fasciitis along with myonecrosis followed by Fournier’s gangrene (13.8%). Among Non NSTI group perianal abscess and subcutaneous abscess constituted 45.31% of patients. Methicillin sensitive staphylococcus aureus was found in 43.8% and 38.9% of Non NSTI and NSTI groups respectively.Conclusions: Classical symptoms and signs of NSTI are not reliable and often investigations also fail to differentiate between NSTI and Non NSTI. Type 2 diabetes mellitus patients are more prone to it. High level of clinical suspicion is required for early diagnosis. Timely and adequate debridement of NSTI is necessary to decrease morbidity and mortality.

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Associations of Plasma Nitrite, L-Arginine and Asymmetric Dimethylarginine With Morbidity and Mortality in Patients With Necrotizing Soft Tissue Infections

Shock ◽

10.1097/shk.0000000000000975 ◽

2018 ◽

Vol 49 (6) ◽

pp. 667-674 ◽

Cited By ~ 4

Author(s):

Marco B. Hansen ◽

Lars S. Rasmussen ◽

Peter Garred ◽

Katrine Pilely ◽

Anna M. Wahl ◽

...

Keyword(s):

Soft Tissue ◽

Asymmetric Dimethylarginine ◽

Morbidity And Mortality ◽

Soft Tissue Infections ◽

Necrotizing Soft Tissue Infections ◽

Plasma Nitrite

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Cervical Necrotizing Fasciitis, Diagnosis and Treatment of a Rare Life-Threatening Infection

Ear Nose & Throat Journal ◽

10.1177/0145561321991341 ◽

2021 ◽

pp. 014556132199134

Author(s):

Jack Hua ◽

Paul Friedlander

Keyword(s):

Soft Tissue ◽

Necrotizing Fasciitis ◽

Definitive Diagnosis ◽

Clinical Suspicion ◽

Plain Radiography ◽

Surgical Debridement ◽

Soft Tissue Infections ◽

Necrotizing Soft Tissue Infections ◽

Life Threatening ◽

Fat Stranding

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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