Diagnosis Of Necrotizing Soft Tissue Infections Research Articles

Interventions for necrotizing soft tissue infections in adults

Interventions for necrotizing soft tissue infections in adults

The roles of early surgery and comorbid conditions on outcomes of severe necrotizing soft-tissue infections.

Severe necrotizing soft-tissue infections (NSTIs) require immediate early surgical treatment to avoid adverse outcomes. This study aims to determine the impact of early surgery and comorbid conditions on the outcomes of NSTIs. A retrospective cohort study was performed on all subjects presenting with NSTI at an academic medical center between 2005 and 2016. Patients were identified based on ICD codes. Those under the age of 18 or with intraoperative findings not consistent with NSTI diagnosis were excluded. There were 115 patients with a confirmed diagnosis of NSTI with a mean age of 55 ± 18 years; 41% were females and 55% were diabetics. Thirty percent of patients underwent early surgery (< 6h). There were no significant differences between groups in baseline characteristics. The late group (≥ 6h) had prolonged hospital stay (38 vs. 23 days, p < 0.008) in comparison to the early group (< 6h). With every 1h delay in time to surgery, there is a 0.268day increase in length of stay, adjusted for these other variables: alcohol abuse, number of debridements, peripheral vascular disease, previous infection and clinical necrosis. Mortality was 16.5%. Multivariable analysis revealed that alcohol abuse, peripheral vascular disease, diabetes, obesity, hypothyroidism, and presence of COPD were associated with an increase in mortality. Early surgical intervention in patients with severe necrotizing soft-tissue infections reduces length of hospital stay. Presence of comorbid conditions such as alcohol abuse, peripheral vascular disease, diabetes, obesity and hypothyroidism were associated with increased mortality.

Necrotizing Soft Tissue Infections at a Tertiary Referral Hospital in Rwanda: Epidemiology and Risk Factors for Mortality.

Necrotizing soft tissue infections (NSTI) are emergency surgical conditions with severe physiologic and metabolic derangement. These infections are associated with increased rates of mortality and morbidity worldwide, particularly in developing countries if not diagnosed and treated early. This prospective, observational cohort study includes all patients aged 12 and above who presented at Department of Surgery, University Teaching Hospital of Kigali from April 2016 to January 2017 with NSTI. We describe epidemiology, operative management, and outcomes of care. We determined risk factors for mortality using multivariate logistic regression. We identified 175 patients with confirmed diagnosis of NSTI. The majority of patients (53%) were male, and the mean age was 44years. The median duration of symptoms was 8days [interquartile range (IQR) 5-14]. The median length of hospital stay was 23days (IQR 8-41). The overall mortality was 26%. Multivariate regression analysis revealed four independent predictors of mortality: presence of shock at admission [odds ratio (OR) 14.15, 95% confidence interval (CI) 0.96-208.01, p=0.050], renal failure (OR 8.92, 95% CI 1.55-51.29, p=0.014), infection located on the trunk (OR 5.60, 95% CI 0.99-31.62, p=0.050), and presence of skin gangrene (OR 4.04, 95% CI 1.18-13.76, p=0.026). In Rwanda, NSTI mortality is high and associated with advanced disease. It is imperative that efforts are focused on early consultation, diagnosis, and surgical management to prevent adverse outcomes.

Epidemiology and Outcomes of Hospitalized Children With Necrotizing Soft-Tissue Infections.

The purpose of this study was to evaluate the epidemiology and outcome of hospitalized children with a diagnosis of necrotizing soft-tissue infections (NSTIs). Demographic and outcome data of children 1 month to 18 years of age with a diagnosis of NSTI (International Classification of Diseases, 9th revision diagnosis codes 728.86 and 729.4) were extracted from the Kids' Inpatient Database 2009 and 2012. Univariate and multivariate analyses were done to determine the factors affecting mortality. The sample data were weighted to get national estimates. A total of 446 children with NSTI (prevalence of 1.12/10,000 discharges) were included. Males comprised 54%. The median age was 10 (interquartile range 4-16) years. The mortality rate was 6%. In addition, 29.3% of children with NSTI were discharged to either skilled nursing facilities or to home health care compared with 4.5% of children without NSTI (odds ratio 8.9; 95% confidence interval 7.3-10.9; P < 0001). A bacterial infection was reported in 72.1% of children. An infection with Staphylococcus, Streptococcus, Gram-negative bacteria, anaerobic bacteria, methicillin-resistant Staphylococcus areus and polymicrobia was present in 34.5%, 21.8%, 8.6%, 3.9%, 18.7% and 13.6% of cases, respectively. A compartment syndrome, severe sepsis/septic shock and toxic shock were documented in 4.4%, 22.2% and 3.2% of the cases, respectively. Severe sepsis/septic shock, the need for mechanical ventilation and Hispanic race were associated with increased mortality, whereas skin/muscle surgery was associated with lower mortality. NSTI in children is associated with high morbidity. The mortality is higher with the presence of severe sepsis/septic shock and among Hispanics and lower with surgical intervention.

Infecciones necrosantes de partes blandas atendidas en un servicio de urgencias de tercer nivel: evolución y correlación con la escala laboratory risk indicator for necrotizing fasciitis (LRINEC)

AimTo describe mortality and complications of patients seen in the emergency room, diagnosed with necrotizing soft tissue infection (NSTI) and the correlation of such complications with the Laboratory Risk Indicator for Necrotizing fasciitis scale (LRINEC). MethodsRetrospective observational study including patients with a diagnosis of NSTI in the emergency room of a tertiary hospital over 7 years. The results are shown as median, interquartile range and absolute range for quantitative variables. In the case of qualitative variables, the results are shown as absolute and relative frequency. The comparison between the categories of the LRINEC scale was performed through a post-hoc comparison from a non-parametric ANOVA analysis. Comparisons between LRINEC groups in the qualitative variables were performed using Fisher's Exact test. Results24 patients with a mean age of 51.9 years were identified. The LRINEC scale was used on 21 patients: in 10, the value indicated low risk (<6), in 4 it indicated intermediate risk (6 or 7) and in 7 it indicated high risk (≥8). The amputation rate in patients with low, intermediate and high risk was 10%, 25% and 66% respectively with a mortality of 4.2%. There was an increase in hospital stay between the low and high level of the scale (p=0,007). ConclusionsIn general, a change in the prognosis between the medium and high levels of the LRINEC scale could not be recorded, but was recorded in hospital stay between the low and the high level, practically tripling the median of days of hospital stay.

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.

Outcomes in necrotizing soft tissue infections treated with therapeutic plasma exchange.

Treatment of necrotizing soft tissue infections (NSTIs) includes prompt surgical debridement and antibiotics, but despite standard care, the morbidity and mortality remain high. Since therapeutic plasma exchange (TPE) has been considered for treatment of severe sepsis, this study evaluates the efficacy of TPE for patients with NSTI. This is a retrospective study of patients with diagnosis of NSTI who received treatment with and without TPE over an 11-year period. The primary outcome was in-hospital mortality. Fifty-two patients with NSTI treated with TPE (TPE group) and 125 patients with NSTI not treated with TPE (non-TPE group) were assessed. Nineteen (36.5%) patients died in the TPE group, and 35 (28%) patients died in the non-TPE group. Within the TPE group, there was significant improvement in white blood cell (WBC) count and sodium levels 7 days after TPE treatment, but no improvement in creatinine. Inverse probability weighting based on propensity scores was used to compare survival in the TPE and non-TPE groups and demonstrated that TPE was associated with an increased odds of death (odds ratio,2.8). A second analysis matched for six variables yielded 31 pairs and demonstrated no significant difference in mortality or length of stay. This study describes the largest series of patients with NSTIs treated with TPE and showed no evidence of clinical benefit. Further carefully designed studies with meaningful clinical endpoints would prove useful in assessing reproducibility and determining if there is a role for TPE in other forms of severe sepsis.

Necrotizing soft tissue infection: principles of diagnosis and management

Necrotizing soft tissue infection (NSTI) is a rare and sometimes deadly infective condition affecting the subcutaneous tissue and fascia, with or without involvement of the muscle. This paper reviews the broader definition of necrotizing infections, including infective myositis. The symptoms, signs and laboratory-based diagnostic tools are discussed. Early diagnosis of NSTI is often a challenge due to inconsistent features of necrosis at presentation; however, features of necrosis can also develop within hours. Clear risk factors and patterns of bacteriology exist, some of which define prognosis. Modern concepts, including debridement zones and an operative strategy are discussed. Time to debridement significantly impacts mortality outcomes and is a key message of this article.

Necrotizing soft tissue infections: The role of the LRINEC score

Necrotizing fasciitis is a life-threatening soft tissue infection which requires prompt diagnosis and early debridement. This study was conducted to validate whether the LRINEC score can help in the management of Necrotizing Soft Tissue Infections (NSTI). This was a retrospective, observational study of patients admitted to our hospital with a diagnosis of NSTI. The LRINEC score was calculated for each case based on points assigned for each of the six laboratory variables at the time of patient presentation, including C-reactive protein, total white cell count, haemoglobin, serum sodium, serum creatinine and blood glucose. The study included 57 males and three females. Their ages ranged from 27-75 years, the mean age being 48.72 ± 10.16 years. The mean age among diabetic patients was slightly higher. In 37 patients, the condition was of unknown aetiology. Diabetes was the most common comorbid condition found in 19 (31.67%) patients. The wound culture was polymicrobial in all patients. Four patients died, giving a mortality of 6.67% in this study. The LRINEC score was calculated for each patient and according to the score, the patients were categorized into low-, intermediate- and high-risk groups. Notably, amputations were required only in the high-risk group. The four patients who died also belonged to the high-risk category. It was also noted in this study that patients with scrotal NSTI had a low LRINEC score compared to those with trunk and lower extremity NSTI. The LRINEC score is helpful in predicting the clinical course of NSTI and helps in taking necessary precautions to reduce the mortality of the disease.

Early surgical intervention and its impact on patients presenting with necrotizing soft tissue infections: A single academic center experience.

Objectives:Early diagnosis and emergent surgical debridement of necrotizing soft tissue infections (NSTIs) remains the cornerstone of care. We aimed to study the effect of early surgery on patients' outcomes and, in particular, on hospital length of stay (LOS) and Intensive Care Unit (ICU) LOS.Materials and Methods:Over a 6-year period (January 2003 through December 2008), we analyzed the records of patients with NSTIs. We divided patients into two groups based on the time of surgery (i.e., the interval from being diagnosed and surgical intervention): Early (<6 h) and late (≥6 h) intervention groups. For these two groups, we compared baseline demographic characteristics, symptoms, and outcomes. For our statistical analysis, we used the Student's t-test and Pearson Chi-square (χ2) test. To evaluate the clinical predictors of early diagnosis of NSTIs, we performed multivariate logistic regression analysis.Results:In the study population (n = 87; 62% males and 38% females), age, gender, wound locations, and comorbidities were comparable in the two groups. Except for higher proportion of crepitus, the clinical presentations showed no significant differences between the two groups. There were significantly shorter hospital LOS and ICU LOS in the early than late intervention group. The overall mortality rate in our study patients with NSTIs was 12.5%, but early intervention group had a mortality of 7.5%, but this did not reach statistical significance.Conclusions:Our findings show that early surgery, within the first 6 h after being diagnosed, improves in-hospital outcomes in patients with NSTIs.

Prognostic factors in necrotizing soft-tissue infections (NSTI): A cohort study

Necrotizing soft-tissue infection (NSTI) is uncommon but life-threatening. A recent meta-analysis estimated the overall mortality at 23.5%. We sought to identify risk factors associated with mortality in a cohort of patients with NSTI in a tertiary care center. We identified 512 patients with NSTI between 1996 and 2012 in the national hospital database Program for Medicalization of Information Systems and examined risk factors of mortality with NSTI by univariate and multivariate analysis. We included 109 patients with a confirmed diagnosis of NSTI; 31 (28%) died at a median follow-up of 274 days (range 2-6135 days). On multivariate analysis, independent risk factors of mortality were age older than 75 years (hazard ratio [HR] 4.4, 95% confidence interval [CI] 1.8-10.3), multifocal NSTI (HR 5.9, 95% CI 1.9-18.5), severe peripheral vascular disease (HR 5.1, 95% CI 1.5-17.0), hospital-acquired infection (HR 3.9, 95% CI 1.4-10.7), severe sepsis (HR 7.4, 95% CI 1.7-33.1), and septic shock on hospital admission (HR 13.9, 95% CI 3.8-50.4). This was a retrospective cohort, which disallows a precise record of the delay between diagnosis and surgery. Our findings for this robust cohort of patients with a definite diagnosis of NSTI could help clinicians stratify NSTI severity at clinical course onset.

The care of necrotizing soft-tissue infections: patterns of definitive intervention at a large referral center.

The objective of this study was 1) to assess the methods employed in treating necrotizing soft-tissue infections (NSTIs) by an experienced referral center; 2) to characterize the patient population who is at risk for the development of NSTI and determine predictors of mortality within this population; and 3) to compare outcomes between those who are transferred to a burn center after diagnosis and those who present directly to such a center. A retrospective chart review was performed on 81 patients during a 6-year period who were admitted to our institution with a diagnosis of NSTI. Once admitted, variables associated with surgical and medical management were collected, and patient outcomes were recorded. All variables were analyzed for their prognostic value. Multiple comorbidities were common, with obesity being the most common preexisting condition. Acute kidney injury and multiple organ failure on admission were found to be predictive for increased mortality (P < .01). Patients who presented directly to our institution were quicker to grafting (P = .04) and underwent fewer total operations (P = .05) than transferred patients. Overall mortality was 20% and was comparable across direct admits vs transfers, and over time. NSTI remains a significant source of morbidity and mortality, especially in obese patients and those with significant comorbidities. Treatment at a burn center may reduce morbidity; however, associated mortality remains constant. Similarly, while hospital course and morbidity at our institution may be improved from years past, mortality has remained consistent over time.

Contemporary trends in necrotizing soft-tissue infections in the United States

Necrotizing soft-tissue infections (NSTI) are rare, potentially fatal, operative emergencies. We studied a national cohort of patients to determine recent trends in incidence, treatment, and outcomes for NSTI. We queried the Nationwide Inpatient Sample (1998-2010) for patients with a primary diagnosis of NSTI. Temporal trends in patient characteristics, treatment (debridement, amputation, hyperbaric oxygen therapy [HBOT]), and outcomes were determined with Cochran-Armitage trend tests and linear regression. To account for trends in case mix (age, sex, race, insurance, Elixhauser index) or receipt of HBOT on outcomes, multivariable analyses were conducted to determine the independent effect of year of treatment on mortality, any major complication, and hospital length of stay (LOS) for NSTI. We identified 56,527 weighted NSTI admissions, with an incidence ranging from approximately 3,800-5,800 cases annually. The number of cases peaked in 2004 and then decreased between 1998 and 2010 (P < .0001). The percentage of female patients decreased slightly over time (38.6-34.1%, P < .0001). Patients were increasingly in the 18- to 34-year-old (8.8-14.6%, P < .0001) and 50- to 64-year-old age groups (33.2-43.5, P < .0001), Hispanic (6.8-10.5%, P < .0001), obese (8.9-24.6%, P < .0001), and admitted with >3 comorbidities (14.5-39.7%, P < .0001). The percentage of patients requiring only one operative debridement increased somewhat (43.2-46.2%, P < .0001), whereas the use of HBOT was rare and decreasing (1.6-0.8%, P < .0001). The percentage of patients requiring operative wound closure decreased somewhat (23.5-20.8%, P < .0001). Although major complication rates increased (30.9-48.2%, P < .0001), hospital LOS remained stable (18-19 days) and mortality decreased (9.0-4.9%, P < .0001) on univariate analyses. On multivariable analyses each 1-year incremental increase in year was associated with a 5% increased odds of complication (odds ratio 1.05), 0.4 times decrease in hospital LOS (coefficient -0.41), and 11% decreased odds of mortality (odds ratio 0.89). There were potentially important national trends in patient characteristics and treatment patterns for NSTI between 1998 and 2010. Importantly, though patient acuity worsened and complication rates increased, but LOS remained relatively stable and mortality decreased. Improvements in early diagnosis, wound care, and critical care delivery may be the cause.

Hyperbaric oxygen therapy in necrotizing soft tissue infections

BackgroundSurgical debridement and antibiotics are the mainstays of therapy for patients with necrotizing soft tissue infections (NSTIs), but hyperbaric oxygen therapy (HBO) is often used as an adjunctive measure. Despite this, the efficacy of HBO remains unclear. We hypothesized that HBO would have no effect on mortality or amputation rates. MethodsWe performed a retrospective analysis of our institutional experience from 2005 to 2009. Inclusion criteria were age > 18 y and discharge diagnosis of NSTI. We abstracted baseline demographics, physiology, laboratory values, and operative course from the medical record. The primary endpoint was in-hospital mortality; the secondary endpoint was extremity amputation rate. We compared baseline variables using Mann-Whitney, chi-square, and Fisher's exact test, as appropriate. Significance was set at P < 0.05. ResultsWe identified 80 cases over the study period. The cohort was 54% male (n = 43) and 53% white (n = 43), and had a mean age of 55 ± 16 y. There were no significant differences in demographics, physiology, or comorbidities between groups. In-hospital mortality was not different between groups (16% in the HBO group versus 19% in the non-HBO group; P = 0.77). In patients with extremity NSTI, the amputation rate did not differ significantly between patients who did not receive HBO and those who did (17% versus 25%; P = 0.46). ConclusionsHyperbaric oxygen therapy does not appear to decrease in-hospital mortality or amputation rate after in patients with NSTI. There may be a role for HBO in treatment of NSTI; nevertheless, consideration of HBO should never delay operative therapy. Further evidence of efficacy is necessary before HBO can be considered the standard of care in NSTI.

Using Clinical Pathways to Aid in the Diagnosis of Necrotizing Soft Tissue Infections Synthesis of Evidence

Necrotizing soft tissue infections (NSTIs) are rare, rapidly spreading infections that occur in the soft tissue compartments. The mortality rate is high and has been found to decrease if patients are treated early and aggressively with surgical debridement and broad-spectrum antibiotics. Unfortunately these infections present similarly to other types of skin and soft tissue infections (SSTIs) making diagnosis difficult. This paper reviews the evidence surrounding the early diagnosis of NSTIs. This was used to develop a clinical practice guideline (CPG) for implementation in the emergency department (ED) setting to assist the provider in distinguishing NSTIs from SSTIs to potentially decrease the time from presentation to diagnosis. A review of the literature was performed. Studies were identified and critiqued by two reviewers independently for clinical relevance, study design, and statistical analysis. Signs and symptoms, or "hard signs," associated with NSTIs include: pain out of proportion to the exam, rapidly spreading infection, presence of bullae, skin ecchymosis or sloughing, gas in the tissues, skin anesthesia, edema extending beyond the erythema, and symptoms of sepsis. Unfortunately only 43% of the patients with an NSTI will present with these signs. Studies have found an association between laboratory values and NSTIs with the most commonly associated findings being leukocytosis, azotemia, and hyponatremia. Using these complimentary clinical and laboratory values, the Laboratory Risk Indicator for NECrotizing fasciitis (LRINEC) score is an emerging tool that providers can use to determine the risk of an NSTI. A clinical pathway was developed and implemented in the ED for all patients presenting with an SSTI to assist providers in confirming or negating the presence of an NSTI. Educating ED providers about the signs, symptoms, and laboratory findings associated with NSTIs will lead to earlier diagnosis and treatment and decreased morbidity and mortality.

Necrotizing Soft Tissue Infections: Delayed Surgical Treatment Is Associated With Increased Number of Surgical Debridements and Morbidity

Early surgical treatment is crucial in the management of necrotizing soft tissue infections (NSTI), a severe, potentially life threatening, rapidly progressive infection. The purpose of this study was to determine the influence of surgical procedure timing on the number of surgical debridements required. A retrospective study including 47 patients with the diagnosis of NSTI admitted to a large academic hospital from December 2004 to December 2010 was conducted. Demographics, basic laboratories on admission, medical comorbidities, site of infection, and intraoperative culture results were compared between patients with early (≤12 hour) and late (>12 hour) surgical treatment. The x-y plot for the study population and linear regression analyses were used to define the time cut point. Outcomes included the total number of debridements, mortality, hospital length of stay, and complications. Adjustment for confounding factors was done with binary regression logistic model for categorical outcomes and analysis of covariants for continuous outcomes. Overall mortality was 17.0%. The average number of surgical debridements in patients with delay surgical treatment >12 hours from the time of emergency department admission was significantly higher than those who had an operation within 12 hours after admission (7.4 ± 2.5 vs. 2.3 ± 1.2; p < 0.001). Delayed surgical debridement was associated with significantly higher mortality, higher incidence of septic shock and renal failure, and more surgical debridements than patients with early surgical debridements. After adjusting for possible confounding factors, the average number of surgical debridements and the presence of septic shock and acute renal failure were still significantly higher in patients in whom surgery was delayed >12 hours. In patients with NSTI, a delay of surgical treatment of >12 hours is associated with an increased number of surgical debridements and higher incidence of septic shock and acute renal failure.

Development of a Computed Tomography-Based Scoring System for Necrotizing Soft-Tissue Infections

Necrotizing soft-tissue infections (NSTIs) are associated with significant morbidity and mortality, but a definitive nonsurgical diagnostic test remains elusive. Despite the widespread use of computed tomography (CT) as a diagnostic adjunct, there is little data that definitively correlate CT findings with the presence of NSTI. Our goal was the development of a CT-based scoring system to discriminate non-NSTI from NSTI. Patients older than 17 years undergoing CT for evaluation of soft-tissue infection at a tertiary care medical center over a 10-year period (2000-2009) were included. Abstracted data included comorbidities and social history, physical examination, laboratory findings, and operative and pathologic findings. NSTI was defined as soft-tissue necrosis in the dictated operative note or the accompanying pathology report. CT scans were reviewed by a radiologist blinded to clinical and laboratory data. A scoring system was developed and the area under the receiver operating characteristic curve was calculated. During the study period, 305 patients underwent CT scanning (57% men; mean age, 47.4 years). Forty-four patients (14.4%) evaluated had an NSTI. A scoring system was retrospectively developed (table). A score >6 points was 86.3% sensitive and 91.5% specific for the diagnosis of NSTI (positive predictive value, 63.3%; negative predictive value, 85.5%). The area under the receiver operating characteristic curve was 0.928 (95% confidence interval, 0.893-0.964). The mean score of the non-NSTI group was 2.74. We have developed a CT scoring system that is both sensitive and specific for the diagnosis of NSTIs. This system may allow clinicians to more accurately diagnose NSTIs. Prospective validation of this scoring system is planned.

Diagnosis of Necrotizing Soft Tissue Infections by Computed Tomography

In contrast to previous beliefs, we hypothesize that computed tomography (CT) scanning is sensitive and specific for the diagnosis of necrotizing soft tissue infections (NSTIs). Retrospective and prospective case series. Academic medical center. Patients who were clinically suspected of having NSTIs from January 1, 2003, through April 30, 2009, and who underwent imaging with a 16- or 64-section helical CT scanner were studied. The CT result was considered positive if inflamed and necrotic tissue with or without gas or fluid collections across tissue planes was found. The disease (NSTI) was considered present if surgical exploration revealed elements of infection and necrosis of the soft tissues and pathological analysis confirmed the findings. The disease was considered absent if surgical exploration and pathological analysis failed to identify any of these findings or the patient was successfully treated without surgical exploration. Sensitivity and specificity of CT for diagnosing NSTI. Of 67 patients with study inclusion criteria, 58 underwent surgical exploration, and NSTI was confirmed in 25 (43%). The remaining 42 patients had either nonnecrotizing infections during surgical exploration (n = 33) or were treated nonoperatively with successful resolution of the symptoms (n = 9). The sensitivity of CT to identify NSTI was 100%, specificity was 81%, positive predictive value was 76%, and negative predictive value was 100%. No differences were found in demographics, white blood cell count on admission, symptoms, or site of infection between those with a false- or true-positive CT result. A negative CT result reliably excludes the diagnosis of NSTI. A positive CT result correctly identifies the disease with a high likelihood.

Low sensitivity of physical examination findings in necrotizing soft tissue infection is improved with laboratory values: a prospective study

Background When clinical “hard signs” of necrotizing soft tissue infection (NSTI) are present, establishing the diagnosis of NSTI is not difficult. However, hard signs of NSTIs are often absent on presentation, thus potentially delaying diagnosis and surgical intervention. A prior retrospective study performed at our institution demonstrated that admission white blood cell (WBC) count >15,400/μL × 10 9/L and/or serum sodium (Na) <135 mEq/L could help differentiate NSTI from non-NSTI. The purpose of this study was to prospectively determine how often “hard signs” of NSTI are present and to evaluate how knowledge of laboratory parameters influence our surgeons' abilities to diagnose and manage NSTI. Methods Prospective observational data collection to determine the sensitivity of NSTI “hard signs” and administration of a questionnaire in which the surgeon was asked whether he believed the patient had an NSTI based on physical examination (PE) alone, and then after being informed of the Na level and WBC count. Results Twenty-one patients with a mean age of 41 years had NSTI. Mean admission WBC count and Na level were 31,500/μL and 127 mEq/L, respectively. Only 9 (43%) had hard signs of NSTI. Suspicion for NSTI increased from 9 to 18 (86%) after evaluating laboratory criteria ( P = .008). Conclusions Fewer than half of the patients presented with hard clinical signs of NSTI. Admission WBC count >15,400/μL or serum Na <135 mEq/L significantly increased suspicion for NSTI and aided early diagnosis.

Necrotizing Soft-Tissue Infection: Diagnosis and Management

Necrotizing soft-tissue infections (NSTIs) are highly lethal. They are frequent enough that general and specialty physicians will likely have to be involved with the management of at least 1 patient with NSTI during their practice, but they are infrequent enough that familiarity with the disease will seldom be achieved. Establishing the diagnosis of NSTI can be the main challenge in treating patients with NSTI, and knowledge of all available tools is key for early and accurate diagnosis. The laboratory risk indicator for necrotizing fasciitis score can be helpful for distinguishing between cases of cellulitis, which should respond to medical management alone, and NSTI, which requires operative debridement in addition to antimicrobial therapy. Imaging studies are less helpful. The mainstay of treatment is early and complete surgical debridement, combined with antimicrobial therapy, close monitoring, and physiologic support. Novel therapeutic strategies, including hyperbaric oxygen and intravenous immunoglobulin, have been described, but their effect is controversial. Identification of patients at high risk of mortality is essential for selection of patients that may benefit from future novel treatments and for development and comparison of future trials.