Case Of Necrotizing Soft Tissue Infection Research Articles

Impact of the COVID-19 Pandemic on Group A Streptococcal Necrotizing Soft Tissue Infections: A Retrospective Cohort Study.

Necrotizing soft tissue infections (NSTIs) are often caused by group A Streptococcus (GAS). As the number of invasive GAS infections decreased during the coronavirus disease 2019 (COVID-19) pandemic restrictions, this study aimed to compare the occurrence of GAS-NSTIs before, during, and after the COVID-19 pandemic restrictions. This retrospective cohort study included adult patients with NSTIs admitted to the intensive care unit (ICU) of the University Hospital Zurich, Switzerland, from July 2008 to December 2023. NSTI cases were categorized as pre-, during, and postrestrictions. The primary outcome was the proportion of GAS in NSTI, and the exploratory secondary outcome was in-hospital death. A data analysis was conducted using Firth logistic regression adjusted for age, sex, diabetes, and initially affected body region. Overall, 74 NSTI cases were identified, with 49 occurring before, 8 during, and 17 after the pandemic restrictions. GAS was isolated in 27 (36%) cases, with 17 (35%) pre- and 10 (59%) postrestrictions, but none during the restrictions. NSTIs caused by other bacteria persisted during the restrictions. The odds of GAS were significantly lower during the restrictions (adjusted odds ratio, 0.02; 95% CI, 0.001-0.81) compared with after, while no significant differences were found between the pre- and postrestriction periods. The significant decrease of GAS-NSTIs during the COVID-19 pandemic restrictions suggests that isolation measures may have prevented the transmission of GAS, resulting in a decline of GAS-NSTIs while NSTIs caused by bacteria transmitted by alternative routes persisted.

Real-time identification of life-threatening necrotizing soft-tissue infections using indocyanine green fluorescence imaging.

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. 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. 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. 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 (). 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 (). Real-time, accurate discrimination of NSTIs compared with non-necrotizing infections may be possible with perfusion-based ICG fluorescence imaging.

A case report of necrotizing soft tissue infection of the chest wall: Effective management with serial debridement.

IntroductionNecrotizing soft tissue infection (NSTI) of the chest wall is a rare, rapidly spreading, highly lethal surgical disease. Radical debridement interferes with the important anatomical function of the chest wall. We report a case of chest wall NSTI that was successfully managed with early diagnosis and serial debridement.Presentation of caseA 43-year-old, previously healthy woman presented with severe malaise and worsening right axillary pain. She was severely lethargic and had a painful, large, pale lesion with surrounding erythema of the right chest and trunk. Computed tomography revealed NSTI, with diffuse soft tissue inflammation extending from the axilla to the lower abdomen. There was no obvious entry portal. Prompt surgical drainage was established. Group A streptococcus infection was diagnosed. During her 3-month postoperative course, she underwent four more surgeries, including two debridements. This treatment proved successful and avoided the need for complicated muscle flap reconstruction. She was discharged on postoperative day 109.DiscussionGroup A streptococcus can cause NSTI even in immunocompetent patients without an entry portal. Radical debridement is recommended for infection control. Preserving anatomical chest wall function, however, is also important. Serial debridement with close follow-up solved the problem in this patient.ConclusionsSerial debridement with close follow-up enabled to avoid large tissue deficits and complicated reconstruction in the case of NSTI of the chest wall.

Necrotizing soft tissue infection at an uncommon site following tooth extraction

Necrotizing soft tissue infection (NSTI) is a disease characterized by rapidly progressive necrosis involving skin, subcutaneous tissue, fascia or muscle. It is commonly seen in extremities, perineum and lower abdomen. It is extremely uncommon for necrotizing fasciitis to occur along the chest wall, with only a few such cases being reported. We report one such rare case of NSTI in a 75 year old male who underwent left molar tooth extraction developed Ludwig’s angina which progressed to present as a painful swelling over the left side of the neck and chest with a necrotic patch of skin over manubrium sternum managed successfully.

Effects of seasonal changes in temperature and humidity on incidence of necrotizing soft tissue infections in Halifax, Canada, 2001-2015.

Objectives:To explore weather seasonal variation in Necrotizing soft tissue infections (NSTI) in Halifax, Nova Scotia, Canada could be attributed to changes in environmental factors of temperature and humidity specifically.Methods:A retrospective chart review of NSTIs between 2001 and 2015. Regional temperature and humidity data were obtained from the Environment Canada Agency, Halifax, Canada. Chi-square was used for categorical variables and continuous data was used for correlation analyses. Logistic regression was performed to analyze mortality.Results:Of 170 NSTI patients identified, more presented from March to July, especially when the temperature was >10ºC. Higher incidence per 100,000 persons correlated with increased monthly temperatures (p<0.01). Monthly NSTI incidence was inversely related to mean humidity (p=0.005). Causative organism was associated with mean weekly temperature (p<0.01) but not humidity (p=0.66). Low body mass index, higher American Society of Anesthesiologists class, long intensive care unit stay, and shorter overall hospital stay were associated with mortality. No correlation was identified between temperature and humidity and mortality.Conclusion:This study demonstrates a tendency toward more frequent cases of NSTI with warmer, but less humid weather, without effect on severity or mortality.

Mortality of necrotizing fasciitis: relative influence of individual and hospital-level factors, a nationwide multilevel study, France, 2007-12.

Necrotizing soft-tissue infections (NSTI) are rare, life-threatening conditions. To assess whether admitting hospital characteristics were associated with NSTI mortality. We studied the French nationwide hospital discharge database (retrospective national cohort). All patients admitted in the period 2007-12 with an International Classification of Diseases 10 code of necrotizing fasciitis were eligible. We extracted data on the patients (age, sex, intensive care unit admission, comorbidities) and hospitals (public vs. private proprietary; for public hospitals, teaching, yes/no; and number of NSTI admissions, ≥ 3 NSTI cases/year, yes/no). Multivariable analyses were performed to identify independent predictors of 28-day mortality and in-hospital mortality using mixed logistic regression and Cox proportional hazards models, respectively. We identified 1537 patients (915 males) with a median age of 60 years (interquartile range 48-75), admitted to 326 hospitals, public (82%) and admitting < 3 NSTI cases/year (93%). Overall, 364 patients died [23·7%; 95% confidence interval (CI) 21·6-25·9]. Patients treated in public teaching centres with ≥ 3 NSTI cases annually had lower 28-day mortality (adjusted odds ratio 0·68; 95% CI 0·46-0·99; P = 0·045) and in-hospital mortality rates than patients treated in local hospitals, even after adjusting for potentially relevant individual risk factors. No significant association was found between mortality and interhospital transfer. Our findings highlight an increased survival in teaching centres with high-volume NSTI procedures. If confirmed in other settings, these findings reinforce the importance of expertise in early diagnosis and management of this condition.

Necrotizing Soft Tissue Infections in Laparoscopic Colectomy: A Case Report

Background: Necrotizing soft tissue infections (NSTI (are a major surgical complication relating to skin wounds. Although laparoscopic surgeries often cause minimal wound infection, NSTI is still a potentially fatal surgical complication. This article is going to report a case of necrotizing soft tissue infection (NSTI) following laparoscopic total colectomy. Case Presentation: An otherwise healthy 65-year-old woman with early stage of colon adenocarcinoma underwent laparoscopic colectomy. A diagnosis of NSTI was made five days after primary operation. The culture grew Enterococcus Faecalis (sensitive to: ciprofloxacin, ampicillin, vancomycin, Gentamycin and linezolid). The patient was treated with broad-spectrum antibiotics and surgical debridement. Conclusions: We report a case of NSTI with Enterococcus Faecalis following laparoscopic total colectomy. The isolated microorganism is not common in monobacterial NSTI. Administration of broad-spectrum antibiotics and surgical debridement help the patient to survive.

Lethality of Necrotizing Soft Tissue Infections after Blunt Rectal Injury

Background: Unlike penetrating rectal injury, the management of blunt rectal injury remains controversial. These injuries, often seen in association with complex urogenital injuries, severe pelvic fractures, and perineal de-gloving injuries, require multi-specialty, multi-modality therapy for management. Despite aggressive management, necrotizing soft tissue infections (NSTI) of the pelvis and perineum occur. As a result of the rarity of these injuries, consensus regarding optimal management strategies does not exist. Case Report: We report three cases of NSTI after blunt rectal injury in association with complex pelvic fractures, resulting in a 67% mortality rate and substantial morbidity. Pre-disposing factors and potential management strategies to minimize morbidity and optimize survival are presented. Conclusions: Necrotizing soft tissue infections after blunt rectal injury in association with severe pelvic fractures are uncommon and have a high mortality rate. Early aggressive identification and multi-modal therapy including extensive pelvic and perineal drainage are required to improve outcomes.

Necrotizing Soft Tissue Infections: A Review.

Soft tissue infections are a common reason for general surgical consultation. Necrotizing soft tissue infections (NSTI) are a rapidly progressive form of this infection that account for significant morbidity and many deaths. Review of relevant English-language publications. There are approximately 500-1,500 cases of NSTI annually in the United States, although accurate estimates of their frequency are difficult to obtain. These infections may be polymicrobial or monomicrobial, and substantial regional heterogeneity exists regarding anatomic location and the involved organisms. Source control with early surgical debridement and targeted anti-microbial therapy are the mainstays of treatment. Necrotizing soft tissue infections remain a common indication for general surgical consultation. Early diagnosis and prompt surgical treatment are essential for effective control.

The Case Files

The Case Files

Klebsiella necrotizing soft tissue infections in liver transplant recipients: a case series

Necrotizing soft tissue infections (NSTI) are rare but carry high mortality rates. NSTI with Klebsiella species have been previously described as associated with Klebsiella liver abscesses and endophthalmitis. Here, we describe 6 cases of NSTI in liver transplant recipients associated with Klebsiella pneumoniae, 4 of which were K. pneumoniae carbapenemase (KPC)-producing K. pneumoniae (CRKP). Increased awareness of this emerging pathogen and its association with necrotizing skin and soft tissue infection is critical, as early recognition and debridement may improve survival. Antimicrobial treatment of CRKP infections remains an ongoing challenge and implementation of enhanced infection control measures is essential.

Development and Validation of a Necrotizing Soft-Tissue Infection Mortality Risk Calculator Using NSQIP

Necrotizing soft-tissue infections (NSTI) are a group of uncommon, rapidly progressive infections requiring prompt surgical debridement and systemic support. A previous attempt to define risk factors for mortality from NSTI had multiple limitations. The objective of this study was to develop and validate a 30-day postoperative mortality risk calculator for patients with NSTI using NSQIP. The NSQIP Participant Use Files (2005-2010) were used as the primary data source. Patients diagnosed with NSTI were identified by ICD-9 codes. Multiple logistic regression analysis identified key preoperative variables predicting mortality. Bootstrap analysis was used to validate the model. In 1,392 identified NSTI cases, demographics were as follows: 42% were female, median age was 55 years (interquartile range 46 to 63 years), and median body mass index was 32 kg/m(2) (interquartile range 26 to 40 kg/m(2)). Thirty-day mortality was 13%. Seven independent variables were identified that correlated with mortality: age older than 60 years (odds ratio [OR]= 2.5; 95% CI 1.7-3.6), functional status (partially dependent: OR= 1.6; 95% CI 1.0-2.7; totally dependent: OR= 2.3; 95% CI 1.4-3.8), requiring dialysis (OR= 1.9; 95% CI 1.2-3.1), American Society of Anesthesiologists class 4 or higher (OR= 3.6; 95% CI 2.3-5.6), emergent surgery (OR= 1.6; 95% CI 1.0-2.3), septic shock (OR= 2.4; 95% CI 1.6-3.6), and low platelet count (<50K/μL: OR= 3.5; 95% CI 1.6-7.4; <150K/μL but >50K/μL: OR= 1.9; 95% CI 1.2-2.9). The receiver operating characteristic area was 0.85 (95% CI 0.82-0.87), which indicated a strong predictive model. Using bootstrap validation, the optimism-corrected receiver operating characteristic area was 0.83 (95% CI 0.81-0.86), which represents the model performance in future patients. The model was used to develop an interactive risk calculator. This risk calculator has excellent predictive ability for mortality in patients with NSTI. This simple interactive tool can aid physicians and patients in the decision-making process.

Not just full of hot air: hyperbaric oxygen therapy increases survival in cases of necrotizing soft tissue infections.

The utility of hyperbaric oxygen therapy (HBOT) in the treatment of necrotizing soft tissue infections (NSTIs) has not been proved. Previous studies have been subject to substantial selection bias because HBOT is not available universally at all medical centers, and there is often considerable delay associated with its initiation. We examined the utility of HBOT for the treatment of NSTI in the modern era by isolating centers that have their own HBOT facilities. We queried all centers in the University Health Consortium (UHC) database from 2008 to 2010 that have their own HBOT facilities (n=14). Cases of NSTI were identified by International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes, which included Fournier gangrene (608.83), necrotizing fasciitis (728.86), and gas gangrene (040.0). Status of HBOT was identified by the presence (HBOT) or absence (control) of ICD-9 procedure code 93.95. Our cohort was risk-stratified and matched by UHC's validated severity of illness (SOI) score. Comparisons were then made using univariate tests of association and multivariable logistic regression. There were 1,583 NSTI cases at the 14 HBOT-capable centers. 117 (7%) cases were treated with HBOT. Univariate analysis showed that there was no difference between HBOT and control groups in hospital length of stay, direct cost, complications, and mortality across the three less severe SOI classes (minor, moderate, and major). However, for extreme SOI the HBOT group had fewer complications (45% vs. 66%; p<0.01) and fewer deaths (4% vs. 23%; p<0.01). Multivariable analysis showed that patients who did not receive HBOT were less likely to survive their index hospitalization (odds ratio, 10.6; 95% CI 5.2-25.1). At HBOT-capable centers, receiving HBOT was associated with a significant survival benefit. Use of HBOT in conjunction with current practices for the treatment of NSTI can be both a cost-effective and life-saving therapy, in particular for the sickest patients.

Outcomes from treatment of necrotizing soft-tissue infections: results from the National Surgical Quality Improvement Program database

Background Necrotizing soft-tissue infections (NSTIs) are a group of uncommon, rapidly progressive, potentially fatal disorders. The National Surgical Quality Improvement Program (NSQIP) Registry was used to determine current data on the incidence, treatment, and outcomes of NSTIs. Methods There were 688 NSTI cases identified for years 2005 to 2008. Ten control patients for each NSTI patient were also selected. Demographic, laboratory, and outcome data were collected to compare both groups. Results Evidence of systemic inflammatory response syndrome (SIRS), sepsis, or septic shock occurred in 83% of NSTI cases. Mortality was 12% for NSTI patients versus 2% for controls. Regression analysis showed that age, emergent surgery, transfer from an outside hospital, sepsis, and several comorbid diseases correlated with mortality but not sex or diabetes. Direct admission was associated with reduced mortality. Conclusions NSTIs are seen regularly in academic centers, and their incidence may be increasing. Despite a high incidence of comorbid conditions and frequent presentation with sepsis, mortality is lower than previously reported, reflecting ongoing progress in the treatment of these disorders at NSQIP hospitals.