Necrotizing Soft Tissue Infections, the Challenge Remains.

Femke Nawijn,Luke P H Leenen,Andrew B Peitzman,Falco Hietbrink

doi:10.3389/fsurg.2021.721214

Abstract

Background: Necrotizing Soft Tissue Infections (NSTIs) are uncommon rapidly spreading infection of the soft tissues for which prompt surgical treatment is vital for survival. Currently, even with sufficient awareness and facilities available, ambiguous symptoms frequently result in treatment delay.Objectives: To illustrate the heterogeneity in presentation of NSTIs and the pitfalls entailing from this heterogeneity.Discussion: NSTI symptoms appear on a spectrum with on one side the typical critically ill patient with fast onset and progression of symptoms combined with severe systemic toxicity resulting in severe physical derangement and sepsis. In these cases, the suspicion of a NSTI rises quickly. On the other far side of the spectrum is the less evident type of presentation of the patient with gradual but slow progression of non-specific symptoms over the past couple of days without clear signs of sepsis initially. This side of the spectrum is under represented in current literature and some physicians involved in the care for NSTI patients are still unaware of this heterogeneity in presentation.Conclusion: The presentation of a critically ill patient with evident pain out of proportion, erythema, necrotic skin and bullae is the classical presentation of NSTIs. On the other hand, non-specific symptoms without systemic toxicity at presentation frequently result in a battery of diagnostics tests and imaging before the treatment strategy is determined. This may result in a delay in presentation, delay in diagnosis and delay in definitive treatment. This failure to perform an adequate exploration expeditiously can result in a preventable mortality.

Highlights

Necrotizing soft tissue infections (NSTIs) are an ancient challenge, considering that Hippocrates first described the infection in the 5th century BC
The typical critically ill patient with fast onset and progression of symptoms combined with severe systemic toxicity resulting in systemic inflammatory response syndrome (SIRS) and sepsis
The sepsis protocol is immediately initiated and the patient is rapidly transported to the operating room without additional testing or imaging at the emergency department, since delay to the first debridement increases the need for subsequent debridements, as well as increases the risk at mortality [9, 30, 40, 41]

Summary

Introduction

Necrotizing soft tissue infections (NSTIs) are an ancient challenge, considering that Hippocrates first described the infection in the 5th century BC. The disease Hippocrates described as “erysipelas all over the body” later became known by a broad range of names, such as “the flesh-eating infection,” necrotizing fasciitis, Fournier gangrene and severe necrotizing soft tissue disease (SNSTD) [2,3,4]. All of those terms for this uncommon, rapidly spreading, progressive and potentially lethal infection of the soft tissues are currently represented in the internationally. Even with sufficient awareness and facilities available, ambiguous symptoms frequently result in treatment delay

Objectives

Findings

Discussion

Conclusion