Abstract
IntroductionA small percentage of patients with skin infections later develop necrotizing fasciitis (NF). Diagnostic testing is needed to identify patients with skin infections at low risk of NF who could be discharged from the emergency department (ED) after antibiotic initiation. Elevated lactate has been associated with NF; existing estimates of the frequency of NF are based on retrospective reviews, and cases often lack testing for lactate. We present the incidence of patients with skin infections who developed NF and their baseline lactates.MethodsIn four phase-3 trials, 2883 adults with complicated or acute bacterial skin and skin structure infections were randomized to dalbavancin or comparator, with early and late follow-up visits through Day 28. We prospectively collected baseline plasma lactates in one trial to assess an association with NF.ResultsNF was diagnosed in 3/2883 patients (0.1%); all three survived. In the study with prospectively collected baseline lactates (n = 622), 15/622 (2.4%) had a lactate ≥4 millimoles per liter (mmol/L), including 3/622 (0.5%) with a lactate ≥7 mmol/L. NF was not seen in patients with a lactate <4 mmol/L; NF was seen in 1/15 (6.7%) with a lactate ≥4 mmol/L, including 1/3 (33.3%) with lactate ≥7 mmol/L.ConclusionsNF incidence within 72 hours of antibiotic initiation in patients with complicated or acute bacterial skin and skin structure infections was extremely low (0.1%) and occurred in 6.7% with a lactate ≥4 mmol/L. Lactate <4 mmol/L can be used to identify patients at low risk of NF who could be safely discharged from the ED after antibiotic initiation.
Highlights
A small percentage of patients with skin infections later develop necrotizing fasciitis (NF)
Lactate
What was the major finding of the study? Lactate
Summary
A small percentage of patients with skin infections later develop necrotizing fasciitis (NF). A small percentage of patients with serious skin infections later develop life-threatening necrotizing fasciitis (NF). NF has an annual incidence ranging from 0.3-15.5 cases per 100,000 population.[1] It involves the epidermis, dermis, subcutaneous tissue, fascia, and muscle, and is a surgical diagnosis, characterized by friable superficial fascia and dishwater-gray exudate.[1] NF can occur after minor or major breaches in skin or mucosa and requires emergent and extensive surgical debridement.[1] It is defined as polymicrobial (type I) involving aerobic and anaerobic organisms with gas in the tissue in patients with underlying conditions such as diabetes, while monomicrobial NF (type II) most commonly involves Streptococcus pyogenes, followed by methicillin-resistant Staphylococcus aureus (MRSA), and can occur in persons without underlying conditions.[1] In invasive skin infections caused by S. pyogenes, the initial lesion may be mildly erythematous and swollen but progress to extensive inflammation over the 24
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