Necrotizing Fasciitis Research Articles

Impact of Early Surgical Intervention of Plastic Surgeons on the Prognosis of Necrotizing Soft Tissue Infection.

BackgroundNecrotizing soft tissue infection (NSTI) is a rare, severe bacterial infection that causes rapidly progressive soft tissue necrosis from the skin to the muscle. The gold standard for treating NSTI is a prompt diagnosis, early surgical debridement of necrotic tissue, and antimicrobial therapy. This study investigated the relationship between the involvement of plastic surgeons and the clinical course of NSTI cases treated at Yokosuka General Hospital Uwamachi.MethodologyThis study involved 28 patients with NSTI who were treated at Yokosuka General Hospital Uwamachi. Patient background, outcomes (mortality and amputation), and days to the first surgery were compared in the early and nonearly plastic surgery intervention groups. Moreover, the duration of treatment was also compared in surviving patients. Differences between the two groups were analyzed using Fisher’s direct probability test, Mann-Whitney U test was used for comparison of continuous variables between the two groups, and Spearman’s rank correlation analysis was used for the bivariate correlation coefficient. The significance level was set at <5%.ResultsThere were eight and 20 patients in the early and nonearly plastic surgery intervention groups (14 in later intervention and six in nonintervention), respectively. A difference in the median number of days to the first surgery between the early (zero days) and the nonearly (two days) intervention groups was significant (p = 0.002). In the survival groups, the median treatment duration in the early (n = 8) and nonearly (n = 13) intervention groups was 44 and 82 days, respectively, which was significantly shorter in the early intervention group (p = 0.003).ConclusionsThe number of days until the first surgery and the length of the treatment period were significantly shorter in the early plastic surgery intervention group than in the nonearly intervention group.

Necrotizing Fasciitis and Fatal Septic Shock Associated with Streptococcus constellatus

Abstract Introduction/Objective Streptococcus anginosus group consists of three species: S. anginosus, S. intermedius, and S. constellatus (SC), normal flora in the human oral cavity, gastrointestinal and urogenital tracts. What makes them unique is their ability to form abscesses. Methods/Case Report We report a case of a 43 year old morbidly obese bipolar male presenting with general malaise and diarrhea. He had a history of uncontrolled diabetes mellitus Type 2 and persistent right thigh wound. Admitting labs revealed diabetic ketoacidosis. Physical examination revealed a right medial thigh ulcer with necrotic scrotal skin, after which he underwent urgent surgical debridement. Wound culture grew SC. Debrided tissue measured 44 x 17 x 4 cm. Histology revealed abscesses next to zones of pale gray necrotic tissue having a granular appearance without associated neutrophils. Gram stain of these pale gray zones revealed sheets of Gram positive cocci, consistent with Stage III necrotizing fasciitis (NF), which has 47% mortality. He died shortly after surgery with death attributed to septic shock. Toxic shock syndrome is most often associated with Group A Streptococcus. However, other rare pathogenic streptococci, including SC, may be associated with a similar syndrome. Gram stain is essential in confirming NF, characterized by pale gray necrosis with a granular appearance. Results (if a Case Study enter NA) NA Conclusion Our case highlights the risk of fatal NF due to SC. Identification of SC in a deep wound warrants early surgical intervention for adequate source control and administration of appropriate antibiotic. Poor diabetic control and ulcerated chronic thigh wound predisposed our patient to fatal necrotizing fasciitis due to SC, confirmed by Gram stain.

Predictors of Mortality in Patients With Necrotizing Fasciitis: A Literature Review and Multivariate Analysis.

Necrotizing fasciitis (NF) is a life-threatening infectious disease that can result in significant morbidity and mortality. Previously identified factors have not been verified in a large population. The objective of this study is to further examine the relationship of patient factors in NF mortality. This study is a retrospective review on patients ≥18 years old diagnosed with NF at the provincial referral centres from 2004 to 2016. The following data were examined: demographics, comorbidities, laboratory values, length of stay, and inhospital mortality. Three hundred forty patients satisfied the inclusion criteria: 297 survived and were discharged, 43 died in hospital. In multivariate analysis, a prognostic model for NF mortality identified age >60 years, elevated creatinine, abnormal blood platelets, and group A β-hemolytic Streptococcus (GABS) infection. Multiple factors were associated with mortality in NF. The strongest univariate association with mortality was age >60 years. In addition, a history of hypertension and/or dyslipidemia, renal disease, and the presence of GABS contributed to a predictive model for inhospital NF mortality.

97 A Case Report: Necrotising Leukocytoclastic Vasculitis (NLV) Of the Breast Mimicking Necrotising Fasciitis (NF)

Leukocytoclastic vasculitis (LV) is an inflammation of the small vessels in the dermis characterised by the deposition of immunocomplexes in the involved vessel walls. It commonly manifests as palpable purpura, limited to the skin and predominantly of the lower limb. We report a rare case of necrotising LV (NLV) affecting bilateral breast, manifesting clinical features of necrotising fasciitis (NF), and emphasizes the potential diagnostic challenges that markedly influence the treatment and survival of patients.A 48-year-old female presented with an acute onset left breast skin necrosis and discolouration that rapidly progressed to the contralateral breast with surrounding erythema and oedema of the chest wall yet spared the intermammary cleft. Some non-blanching purpuric rash were also noted on upper abdomen and left lower limb. COVID-19 test was negative. CT scan showed extensive bilateral breast fat stranding and oedema. Patient became clinically septic with a moderately raised CRP and mild acute kidney injury. Radical mastectomies and chest wall excision were performed with intra-operative findings of cloudy fluid and easily peeled away subcutaneous tissue from fascia. Urgent gram stain and culture showed no organisms. Tissue biopsies subsequently showed the diagnosis of NLV. Chest wall defect was then reconstructed with split skin grafts, NLV treated with corticosteroids and patient made an uneventful recovery.This case highlights the incidence of a rare and aggressive manifestation of NLV on the breast that mimics NF, emphasizing the clinical differentiation that may lead to catastrophic results and significant cosmetic defect, if a differential diagnosis cannot be determined at the time.

Impact of prior antibiotic therapy on severe necrotizing soft-tissue infections in ICU patients: results from a French retrospective and observational study

Necrotizing soft-tissue infection (NSTI) is a life-threatening pathology that often requires management in intensive care unit (ICU). Therapies consist of early diagnosis, adequate surgical source control, and antimicrobial therapy. Whereas guidelines underline the need for appropriate routine microbiological cultures before starting antimicrobial therapy in patients with suspected sepsis or septic shock, delaying adequate therapy also strongly increases mortality. The aim of the present study was to compare the characteristics and outcomes of patients hospitalized in ICU for NSTI according to their antimicrobial therapy exposure > 24 h before surgery (called the exposed group) or not (called the unexposed group) before surgical microbiological sampling. We retrospectively included 100 consecutive patients admitted for severe NSTI. The exposed group consisted of 23(23%) patients, while 77(77%) patients belonged to the unexposed group. The demographic and underlying disease conditions were similar between the two groups. Microbiological cultures of surgical samples were positive in 84 patients and negative in 16 patients, including 3/23 (13%) patients and 13/77 (17%) patients in the exposed and unexposed groups, respectively (p = 0.70). The distribution of microorganisms was comparable between the two groups. The main antimicrobial regimens for empiric therapy were also similar, and the proportions of adequacy were comparable (n = 60 (84.5%) in the unexposed group vs. n = 19 (86.4%) in the exposed group, p = 0.482). ICU and hospital lengths of stay and mortality rates were similar between the two groups. In conclusion, in a population of severe ICU NSTI patients, antibiotic exposure before sampling did not impact either culture sample positivity or microbiological findings.

Necrotizing Soft Tissue Infection in the Elderly: Effect of Pre-Operative Factors on Mortality and Discharge Disposition.

Background: Necrotizing soft tissue infections (NSTIs) are rapidly progressing, life-threatening diseases associated with substantial morbidity and mortality, especially in patients 65 years or older. We aimed to evaluate clinical factors associated with mortality and discharge disposition after NSTIs in elderly patients. Patients and Methods: Retrospective data were obtained from the 2007-2017 American College of Surgeons-National Surgical Quality (ACS-NSQIP) database. Patients aged 65 years or older with a post-operative diagnosis of an NSTI (defined as gas gangrene, necrotizing fasciitis, or Fournier gangrene) were included. Univariable and multivariable analyses were performed to identify independent clinical and demographic factors associated with mortality and with discharge disposition. Results: A total of 1,460 patients were included. Median age was 71 years, 43% were females. Overall, 30-day mortality was 18.5% and 30-day morbidity was 63.6%. The most important predictors of mortality included pre-operative septic shock (odds ratio [OR], 6.36; 95% confidence interval [CI], 3.61-11.18), pre-operative dialysis dependence (OR, 2.99; 95% CI, 1.77-5.05), coagulopathy (international normalized ratio [INR], >1.5, OR, 2.25; 95% CI, 1.51-3.37), hepatobiliary disease (bilirubin >1.0 mg/dL; OR, 2.05; 95% CI, 1.38-3.04) and aged 80 years or older (OR, 3.36; 95% CI, 2.08-5.44). Patients without any of these risk factors had a mortality of 7.3%. Predictors of discharge to inpatient rehabilitation or skilled care included age 80 years or older (OR, 2.49; 95% CI, 1.44-4.30), American Society of Anesthesiologists (ASA) ≥3 (OR, 2.05; 95% CI, 1.03-4.05)] and amputation as opposed to debridement (OR, 2.53; 95% CI,1.48-4.32). Conclusions: We identified several pre-operative clinical factors that were associated with increased post-operative mortality and discharge to post-acute care. The next steps should focus on determining if optimization of modifiable predictors would improve mortality.

Diagnostic Key Points and Surgical Management of Necrotizing Fasciitis: A Retrospective Study.

Necrotizing fasciitis (NF) is a fatal disease with a high mortality rate that can be easily misdiagnosed. The aim of this study was to improve the diagnostic rate of NF and overall survival. We conducted a single-center, retrospective, noncontrolled study involving 36 patients who were admitted to our department between December 2017 and October 2019, and summarized the diagnostic key points and timing of surgical treatment. All patients were diagnosed at our department and underwent multiple courses of treatment. The records included information regarding underlying diseases, bacterial culture results, laboratory risk indicator for necrotizing fasciitis (LRINEC) score, number of procedures, and type of antibiotics. All 36 cases of NF were cured and showed good patient condition on follow-up; the mean number of surgeries was three, and the mean duration of hospitalization was 37 days (range, 21-83 days). The LRINEC scores of 16 patients were ≥8 points. Seventeen patients with underlying diabetic disease had higher inflammatory index scores than those without diabetes. The LRINEC scores of patients with (n = 17) and without (n = 19) DM were 7.40 ± 2.99 and 3.80 ± 2.39, respectively (P < .01). Cases of NF that were treated with early incision and surgical abscess drainage required fewer surgeries and a shorter length of hospitalization. Thus, surgeons should be more aware of NF and aim to make an early and accurate diagnosis using various approaches. Complete surgical debridement plays an essential role in NF treatment, and diabetes mellitus is a significant adverse factor that exacerbates the severity of NF. Negative-pressure techniques are useful in cases involving nonanaerobic infections and cause minimal complications.

Short Courses of Antibiotics Are Safe in Necrotizing Soft Tissue Infections.

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. To determine whether shorter antibiotic courses have similar outcomes compared to longer courses in patients with NSTI following adequate source control. 142 consecutive patients with surgically managed NSTI were identified on retrospective chart review between December 2014 and December 2018 at two academic medical centers. 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. Provided adequate surgical debridement, similar outcomes in morbidity and mortality suggest antibiotic courses of 7days or less are equally safe compared to longer courses.

NECROTIZING SOFT TISSUE INFECTION BY SERRATIA MARCESCENS: AN EARLY DIAGNOSIS WITH THE UTILIZATION OF LABORATORY RISK INDICATOR FOR NECROTIZING FASCIITIS (LRINEC) SCORE

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Necrotizing soft tissue infections (NSTIs) include a vast array of necrotizing forms that affect the deeper layers of tissues including fasciitis and myositis. Though rare, with approximately 500 to 1500 estimated cases per year, many providers find the diagnosis difficult due to unaffected appearance of overlying tissue on initial presentation. This case showcases complexities of a Type II-Monomicrobial NSTI-Serratia Marcescens, and the benefit of utilizing the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, for early identification of NSTIs. CASE PRESENTATION: A 66-year-old-male with history of DM with complaint of left lower extremity edema. He reported an insidious onset of swelling that started five days prior to arrival with no precipitating or consequential factors. He was hemodynamically stable with 3+ pitting edema extending beyond the left thigh, erythema below the left knee with blisters on the medial aspects of the left leg. Serum studies showed a D-Dimer 12.6, CRP 1.9, and ESR 29. Venous doppler was consistent with extensive left deep vein thrombosis with CT imaging negative for abscess or subcutaneous air. He was treated with IV Clindamycin and therapeutic anticoagulation. Days later, the cellulitis had progressed nearly three times the original size with a worsening leukocytosis, ESR 111, and CRP 17.5. A surgical debridement showed multiple cavitary abscesses. Pathology showed necrotizing soft tissue infection with Serratia M. He was started on a prolonged course of IV Pip-Tazo and Vancomycin, with eventual preservation of extremity function. DISCUSSION: NSTI has a rapid clinical course and is associated with a high mortality, ranging 14-39%. Early signs of NSTI are dubious and mimic simple soft tissue infections which evolve in a course of days. Serratia M., is extremely rare and atypical with only 17 reported cases. It is an opturnitistic infection affecting the immunocompromised, it thrives in higher concentrations activating cascades of hyperreactive cellular responses. Inflammatory mediators upregulate factors VII and VIIa and reduce anti-coagulation proteins precipitating a pro-thrombotic event. Initially, it was unclear if the patient had NSTI with a LRINEC score of 2/12. The second encounter, his score was 7/12, suggestive of NSTI. The final LRINEC score indicated a positive predictive value of 92%. A study by Wong et. al. performed a prospective study utilizing the LRINEC score resulting with positive predictive value of 92% and negative predictive value 96% suggesting to be a beneficial tool. CONCLUSIONS: The LRINEC score is beneficial in identifying NSTI early. Early diagnosis is crucial, it is estimated that between 85-100% of NSTI are initially missed and often confused for myositis, DVT, cellulitis, or deep tissue abscess. A high index of suspicion is imperative in lieu of absent cutaneous findings early in the course of the disease process. REFERENCE #1: Goldstein, Ellie J. C., et al. "Necrotizing Soft-Tissue Infection: Diagnosis and Management." OUP Academic, Oxford University Press, 1 Mar. 2007, academic.oup.com/cid/article/44/5/705/348724. REFERENCE #2: www.samsonconsulting.co.uk. Misdiagnosing Necrotising Fasciitis, www.glynns.co.uk/necrotising-fasciitis/misdiagnosing-necrotising-fasciitis.php. REFERENCE #3: Guberman, Ronald. "Case Study: Treating Necrotizing Fasciitis Caused By Serratia Marcescens." Podiatry Today, 24 Aug. 2011, www.podiatrytoday.com/treating-necrotizing-fasciitis-caused-iserratia-marcescensi. DISCLOSURES: No relevant relationships by Swetha Paduri, source=Web Response No relevant relationships by Nehal Patel, source=Web Response No relevant relationships by Charmi Patel, source=Web Response No relevant relationships by Paul Roach, source=Web Response

CATASTROPHIC COMPLICATIONS OF CHEMOTHERAPY EXTRAVASATION

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Chemotherapy is the mainstay of cancer treatment. Hematological side effects are well described; however, not many dermatological complications have been reported. We present a case of fatal necrotizing fasciitis (NF) secondary to chemotherapy extravasation. CASE PRESENTATION: 55-year-old African American man with anaplastic ALK-negative large T cell lymphoma presented with fatigue, fevers, and palpitations for several weeks. Physical examination was remarkable for tachycardia and tachypnea; he required 4 liters of supplemental oxygen to saturate >90%. Laboratory workup was remarkable for WBC 18.200 m/mm3 and ESR 67 mm/h. CT scan revealed significant mediastinal lymphadenopathy. The symptoms were attributed to the malignancy and CHOP chemotherapy was started. Shortly thereafter, a painful blister at the infusion site was noted. It was deemed to be a local cutaneous vesicant effect from doxorubicin; chemotherapy was stopped and topical dimethyl sulfoxide (DMSO) was applied. No infectious process was identified but the patient continued to be febrile and tachycardic. He developed hypotension hence broad-spectrum antibiotics were started. His respiratory status deteriorated and he was intubated. A new subcutaneous tissue induration near the blister rose concern for necrotizing fasciitis (NF) and he was emergently taken to the OR. The fascia was compromised and the biceps muscle was found to be necrotic. He underwent multiple surgical debridements; however, he developed septic shock and died. DISCUSSION: Necrotizing soft tissue infections are a rare but potentially fatal complication of chemotherapy. As vesicants, doxorubicin, and vincristine extravasation is known to result in tissue necrosis. Doxorubicin, an anthracycline, is associated with the highest risk for cutaneous damage. Other risk factors are immunosuppression, obesity, and previous frequent blood draws. DMSO helps with the reabsorption of chemotherapeutics. NF is characterized by rapid fascial destruction with relative skin-sparing; accompanied by pain and systemic toxicity. Prompt identification is of paramount importance; however, the diagnosis is challenging as early symptoms tend to be vague. Early surgical debridement and fasciotomy improve survival; broad-spectrum antibiotic coverage and hyperbaric oxygen therapy should be started rapidly as well. Overwhelming sepsis leads to death in more than 70% of the cases. CONCLUSIONS: Chemotherapy extravasation can cause severe skin lesions and death. Initial symptoms may be mild, however, a high degree of suspicion is needed as delays in treatment are associated with poor outcomes. REFERENCE #1: Kreidieh FY, Moukadem HA, El Saghir NS. Overview, prevention and management of chemotherapy extravasation. World J Clin Oncol. 2016;7(1):87-97. doi:10.5306/wjco.v7.i1.87 DISCLOSURES: No relevant relationships by Daniel Bustamante-Soliz, source=Web Response No relevant relationships by Dennis Kumi, source=Web Response No relevant relationships by Valeria Trelles Garcia, source=Web Response No relevant relationships by Catherine Weir, source=Web Response

Hyperbaric Oxygen as Adjunctive Therapeutic in Management of Craniocervical Necrotizing Fasciitis: Case Series and Treatment Protocol

BackgroundOdontogenic infections are commonly encountered in OMS practices. Rarely, odontogenic infections can progress into craniocervical necrotizing fasciitis (CCNF). CCNF of the head and neck is a rare, potentially lethal disease process involving infection and subsequent destruction of fascial planes. Mortality ranges from 33% to 50% if the mediastinum is involved.1,2 CCNF diagnosis is based on clinical suspicion. Typical findings include dishwater-like purulence and easy spread of fascial planes using fingers.3 Treatment for CCNF usually consists of aggressive surgical debridement, source control, and intravenous antibiotics. Patients often experience prolonged hospital stays, around 24-33 days1,2 and require 2-5 debridements.1 Hyperbaric oxygen (HBO) has shown promising results as an adjunctive therapy in management. The authors' study reviewed their institution's protocols for CCNF of odontogenic origin and use of HBO in their treatment. MethodsPatients with deep neck fascial space infections of odontogenic origin at Hennepin County Medical Center (HCMC) were included. Inclusion criteria were odontogenic infections involving fascial spaces with a high degree of concern for CCNF based on clinical and radiographic presentation at the time of treatment and/or confirmed CCNF. Exclusion criteria were patients with deep fascial space infections of non-odontogenic source and those who did not receive HBO. Five patients were identified. Data, such as age, gender, length of hospital stay (LOS), intervention by outside providers, hierarchical condition category (HCC), and bacteria species, were recorded for each patient. Descriptive statistics were used to summarize quantitative variables. ResultsFrom 2016 to 2020, 5 patients were identified who had odontogenic infections, with high concern for necrotizing fasciitis based on clinical presentation for CCNF. There were 3 females and 2 males, with an average age of 44.6+/-8.65 years. The mean number of washouts/debridement procedures was 4.4+/-1.25. Patients required on average 3.4+/-0.87 HBO dives. The mean LOS was 18.8+/-6.37 days. Three patients underwent care by an outside provider prior to admission to the hospital, while 2 sought care at an urgent care or emergency department. The HCC for these patients ranged from 0 to 3. All patients grew milleri group streptococcus; 3 patients grew Candida species. No mortalities were recorded. DiscussionThis protocol involved initiating HBO dives within 24 hours of suspected or confirmed CCNF, followed by subsequent daily surgical debridements and HBO sessions. The HBO dives were at 2.8 ATA for 45 minutes followed by staged decompression for a total of 90 minutes. This protocol resulted in shorter LOS. In 1994, a comparative study with a comparable population was completed at this institution, in which HBO was not used for suspected CCNF. This study showed 2.8 average surgical debridements and LOS of 34 days, compared to 18.8+/-6.37 days in the authors' study.4 The increased number of surgical debridements in the authors' series theoretically decreased the bacterial burden, compared to the previous series. HBO theoretically reduced the bacterial burden, improved immune response, and spurred healing. HBO may reduce LOS for CCNF patients and should be considered as adjunctive therapy.

A Case of Perianal Necrotizing Fasciitis from Perianal Abscess with Integrated Chinese and Western Medicine Treatment

This article discusses a case of perianal necrotizing fasciitis from perianal abscess with integrated Chinese and western medicine treatment. It has been concluded that the treatment of perianal necrotizing fasciitis from perianal abscess should focus on dispelling evil, tonifying deficiency, or attack and supplement at the same time in order to achieve the purpose of dispelling evil without harming the right while supporting the right without leaving evil.

Local Trends of Antibiotic Prescriptions for Necrotizing Fasciitis Patients in Two Tertiary Care Hospitals in Central Malaysia.

Background: Necrotizing fasciitis (NF) is a rapidly progressive inflammatory infection of the soft tissue (also known as the fascia) with a secondary necrosis of the subcutaneous tissues, leading to a systemic inflammatory response syndrome (SIRS), shock and eventually death despite the availability of current medical interventions. The clinical management of this condition is associated with a significant amount of morbidity with a high rate of mortality. The prognosis of the disease is affected by multiple factors, which include the virulence of the causative pathogen, local host immunity, local wound factors and empirical antibiotics used. The local trends in the prescription of empirical antibiotics are often based on clinical practice guidelines (CPG), the distribution of the causative microorganism and the cost-effectiveness of the drug. However, there appears to be a paucity of literature on the empirical antibiotic of choice when dealing with necrotizing fasciitis in the clinical setting. This paper will outline common causative microorganisms and current trends of prescription in two tertiary centres in Central Malaysia. Methods: This was a cross-sectional study using retrospective data of patients treated for NF collected from two tertiary care hospitals (Hospital Seremban and Hospital Ampang) in Central Malaysia. A total of 420 NF patients were identified from the five years of retrospective data obtained from the two hospitals. Results: The top three empirical antibiotics prescribed are ampicillin + sulbactam (n = 258; 61.4%), clindamycin (n = 55; 13.1%) and ceftazidime (n = 41; 9.8%). The selection of the antibiotic significantly impacts the outcome of NF. The top three causative pathogens for NF are Streptococcus spp. (n = 79; 18.8%), Pseudomonas aeruginosa (n = 61; 14.5%) and Staphylococcus spp. (n = 49; 11.7%). The patients who received antibiotics had 0.779 times lower chances of being amputated. Patients with a lower laboratory risk indicator for necrotizing fasciitis (LRINEC) score had 0.934 times lower chances of being amputated. Conclusions: In this study, the most common empirical antibiotic prescribed was ampicillin + sulbactam followed by clindamycin and ceftazidime. The antibiotics prescribed lower the risk of having an amputation and, hence, a better prognosis of the disease. Broad-spectrum empirical antibiotics following surgical debridement reduce the mortality rate of NF.

Antibiotics in Necrotizing Soft Tissue Infections.

Necrotizing soft tissue infections (NSTIs) are rare life-threatening bacterial infections characterized by an extensive necrosis of skin and subcutaneous tissues. Initial urgent management of NSTIs relies on broad-spectrum antibiotic therapy, rapid surgical debridement of all infected tissues and, when present, treatment of associated organ failures in the intensive care unit. Antibiotic therapy for NSTI patients faces several challenges and should (1) carry broad-spectrum activity against gram-positive and gram-negative pathogens because of frequent polymicrobial infections, considering extended coverage for multidrug resistance in selected cases. In practice, a broad-spectrum beta-lactam antibiotic (e.g., piperacillin-tazobactam) is the mainstay of empirical therapy; (2) decrease toxin production, typically using a clindamycin combination, mainly in proven or suspected group A streptococcus infections; and (3) achieve the best possible tissue diffusion with regards to impaired regional perfusion, tissue necrosis, and pharmacokinetic and pharmacodynamic alterations. The best duration of antibiotic treatment has not been well established and is generally comprised between 7 and 15 days. This article reviews the currently available knowledge regarding antibiotic use in NSTIs.

Necrotizing Soft Tissue Infections, the Challenge Remains.

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.

Differentiating Upper Extremity Necrotizing Soft Tissue Infection From Serious Cellulitis and Abscess.

IntroductionNecrotizing soft tissue infection (NSTI) of the upper extremity (UE) is a rapidly progressing infection that requires early diagnosis and emergent treatment to decrease risks of loss of limb or life. Clinical presentation, particularly of early NSTI, can appear similar to serious cellulitis or abscess. The purpose of this study was to identify factors that are associated with NSTI rather than serious cellulitis and abscess to differentiate patients with similar clinical presentations.MethodsThis study uses a retrospective cohort design that compares patients ultimately diagnosed with UE NSTI versus those diagnosed with UE serious cellulitis or abscess. Cohorts were matched using the Laboratory Risk Indicators for Necrotizing Fasciitis (LRINEC) score in the setting of UE soft tissue infection. Laboratory values, vital signs, subjective symptoms, and social factors including substance abuse and domiciled status were recorded. Continuous variables were compared using the Mann-Whitney U test, whereas categorical variables were compared using the chi-squared test or the Fisher exact test (for expected values less than 5). A binary logistic regression for continuous and categorical variables was also performed. Significance was set at p<0.05. Univariate and multivariate analyses were performed.ResultsMultivariate statistical analysis and clinical interpretation of data identified four factors more associated with a diagnosis of NSTI than serious cellulitis or abscess: elevated lactate on hospital presentation, a patient-reported history of fever, male gender, and homelessness. ConclusionsIn patients with upper extremity infections, the clinical presentation of NSTI and serious cellulitis or abscess may appear similar. In this retrospective cohort of patients matched with LRINEC scores, elevated lactate, subjective fever, male gender, and homelessness were significantly associated with NSTI rather than serious cellulitis or abscess.

Necrotizing Fasciitis and Diabetic Foot: Results of a Prompt Identification, Surgery and Antibiotic Therapy (P.I.S.A.) Protocol

Necrotizing fasciitis (NF) is a rapidly progressive, life-threatening infection, involving the skin, soft tissue and fascia. We evaluated outcomes of its surgical management in diabetic foot (DF) patients in a tertiary referral centre. We retrospectively searched for NF in the database of our DF Section from 2016 to 2018. All cases were treated according to a multiprofessional integrated protocol, with Prompt Identification, Surgical debridement and systemic Antibiotic therapy (P.I.S.A. Protocol). We analysed short-term evolution (surgical procedures and major amputations), and long-term outcomes (survival and healing rates). Sixty-eight patients were referred to our DF clinic for suspicion of NF. The diagnosis was confirmed in 54 (79.4%; male/female 40/14; type 1/2 diabetes 6/48; age 62.8 ± 8.1 years; duration of diabetes 13.6 ± 10.1 years). According to the microbiological results, cases were classified as Type 1 (33-61.2%), 2 (7-12.9%) and 3 (14-25.9%). No significant differences were observed. All patients underwent a decompressive fasciotomy. Six patients (11.1%) required also a forefoot amputation and 12 (22.2%) a toe or ray amputation. No major amputation was performed in the short-term period. During the follow-up (26 ± 12 months) 46 patients (85%) healed in 94 ± 11 days. Of the remaining 8: 5 (9.2%) died for other reasons before healing, 2 (3.7%) recurred and one (1.9%) required a major amputation. Our experience reveals a relatively high prevalence of NF in DF; despite this, we observed how, when promptly and aggressively treated, NF has a good prognosis and it is not associated with an excess of limb loss and deaths.

Differentiating Lower Extremity Necrotizing Soft Tissue Infection from Severe Cellulitis by Laboratory Parameters and Relevant History Points

BackgroundNecrotizing soft tissue infection (NSTI) of the lower extremity (LE) is a rapidly progressing infection that requires early diagnosis and prompt treatment to decrease risks of loss of limb or life. Clinical presentation, particularly of early NSTI, can appear similar to severe cellulitis. The purpose of this study is to identify factors that are associated with NSTI rather than severe cellulitis to differentiate patients with similar clinical presentation.MethodsThis retrospective cohort design study compares patients finally diagnosed with LE NSTI versus those diagnosed with severe cellulitis. Cohorts were matched using the modified Laboratory Risk Indicator for Necrotizing Fasciitis (m-LRINEC) score in the setting of LE soft tissue infection. Laboratory values, vital signs, subjective symptoms, and social factors including substance abuse were recorded. Univariate and multivariate analyses were performed.ResultsMultivariate statistical analysis and clinical interpretation of data identified four factors more associated with a diagnosis of NSTI than severe cellulitis: elevated lactate, a patient-reported history of fever, male gender, and intravenous substance user.ConclusionIn patients with lower extremity infections, the clinical presentation of NSTI and severe cellulitis may appear similar. In this retrospective cohort of patients matched with m-LRINEC scores, elevated lactate, subjective fever, male gender, and intravenous substance abuser were significantly associated with NSTI rather than severe cellulitis. Further studies of these factors in the clinical setting can help tailor the differential diagnosis in the care of patients with severe lower extremity infections. Matched with m-LRINEC scores, elevated lactate, subjective fever, male gender, and intravenous substance abuser were significantly associated with NSTI rather than severe cellulitis. Further studies of these factors in the clinical setting can help tailor the differential diagnosis in the care of patients with severe lower extremity infections.

Laboratory risk indicator for necrotising fasciitis [LRINEC] score as a tool for differentiating necrotising fasciitis from other soft tissue infections

Necrotizing fasciitis (NF) is often fatal, characterized by extensive necrosis of the subcutaneous tissues and fascia. The present study was aimed to validate the Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score as a tool to predict/diagnose NF and to differentiate it from other soft tissue infections depending on the score. A Prospective Observational study was conducted in ESICMC PGI MSR, Medical College Hospital, Rajajinagar, Bengaluru, from Jan 2019 to June 2020. Patients ≥18 years of age with severe soft tissue infections were included in the study. Based on the LRINEC score, the patients were categorised as low (≤5), moderate (6-7) and high risk (≥8) for the prediction of onset or diagnosis of NF. Data analysis was performed using SPSS version 21.0. A total of 55 patients were included in the study. A significant 3 association was observed Dweitpharatgmee(npt=o0f.0X4X2)X, ,LURnINivEerCsitsycorfeX(pX=X0,.0X0X01X),TCraRineiancgtiavnedPRroetseianrc(hCRHPo;spi=ta0l.,0C00it1y),,Choauenmtroyglobin (p=0.008), serum 4 sodium levels (p=0.004), serum creatinine (0.D00e1p)a,ratmndenatmopfuXtaXtiXon, F(pac=u0l.t0y0o4f).XAXmXp,uCtaityio,nCwouanstdryone in 5 cases. Only 1 mortality was observed in LRINEC high risk group with NSSTI. To conclude, LRINEC scoring system showed a better positive predictive value in identifying the onset of NF and risk strategizing of the patients with severe soft tissue infections.

Are neutrophil count and neutrophil/lymphocyte ratio useful as markers of polycystic ovary syndrome in early reproductive age?

Necrotizing fasciitis (NF) is often fatal, characterized by extensive necrosis of the subcutaneous tissues and fascia. The present study was aimed to validate the Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score as a tool to predict/diagnose NF and to differentiate it from other soft tissue infections depending on the score. A Prospective Observational study was conducted in ESICMC PGI MSR, Medical College Hospital, Rajajinagar, Bengaluru, from Jan 2019 to June 2020. Patients ≥18 years of age with severe soft tissue infections were included in the study. Based on the LRINEC score, the patients were categorised as low (≤5), moderate (6-7) and high risk (≥8) for the prediction of onset or diagnosis of NF. Data analysis was performed using SPSS version 21.0. A total of 55 patients were included in the study. A significant 3 association was observed with age (p=0.042), LRINEC score (p=0.0001), C Reactive Protein (CRP; p=0.0001), haemoglobin (p=0.008), serum Department of XXX, University of XXX, XXX Training and Research Hospital, City, Country sodium levels (p=0.004), serum creatinine (0.001), and amputation (p=0.004). Amputation was done in 5 cases. Only 1 mortality was observed 4Department of XXX, Faculty of XXX, City, Country in LRINEC high risk group with NSSTI. To conclude, LRINEC scoring system showed a better positive predictive value in identifying the onset of NF and risk strategizing of the patients with severe soft tissue infections. This study has aimed to contribute to the literature by investigating the value of inflammatory biomarkers of polycystic ovary syndrome (PCOS) that can be tested via a complete blood count. This retrospectively designed case-control study included 197 women in early reproductive age; who were in the age range of 18-24 years and who were admitted to the gynecology outpatient clinic. A total of 111 PCOS patients; in whom the diagnosis of PCOS was made based on Rotterdam criteria, were included in the study. A control group was formed by including 86 healthy women. All measurements of inflammatory biomarkers were obtained from the complete blood count test results. Of the inflammatory markers; the neutrophil count and the neutrophil/lymphocyte ratio were statistically significantly higher in the PCOS group compared to the control group (p=0.016 and p=0.002, respectively); however, the measured values of other parameters were similar between two groups. To evaluate whether or not the neutrophil count and neutrophil/lymphocyte ratio could be used as a screening tool to exclude PCOS, we constructed a receiver-operating characteristic curve (ROC). The ROC curve for the neutrophil count was 0.60 (p=0.016) and NLR was 0.627 (p=0.002). The neutrophil count and NLR were higher in the PCOS cases compared to the age-matched individuals in the control group. This finding confirms the presence of inflammation in PCOS cases of early reproductive age. However, it has been demonstrated that the diagnostic values of these markers are not strong in distinguishing PCOS patients from healthy individuals.