Urgent Surgical Debridement Research Articles

ThP6.10 - Overview of Necrotising Soft Tissue Infections' Risks and Outcomes

Abstract Introduction Necrotising Soft Tissue Infections (NSTI) are severe life-threatening conditions, which are increasing in incidence. Associated with high mortality and morbidity, NSTI’s are a significant burden to health care services globally. Identifying themes, risk factors and underlying causation is therefore of interest. Methods A retrospective data cohort study examining clinical data for all histologically confirmed NSTI cases in a single centre between 2012 to 2022 was conducted. Results 73 confirmed NSTI cases were identified. Patient co-morbidities included the following:CasesDiabetic34Smoker16Post-op12IVDU8Trauma7Immunosuppressed6Bowel Perf5Cancer5 68 patients underwent urgent surgical debridement, with an average of 3.59 (Range 1-11) further surgical interventions required. Patients spent an average of 8.24 days (Range 1-42 days) in ICU, with a hospital stay of 44.02 days. (Range 7-180 days) 6(8%) patients died (5 within first week of presentation). Defunctioning stomas were performed in 24 patients during the admission and 32 patients underwent reconstructive surgery after recovery from the acute phase. An array of causative organisms were identified with no clear delineating trends.NumberAnaerobes36Streptococcus35Staphylococcus20E Coli + Coliforms20Enterococcus15 Conclusion NSTIs continue to increase in incidence and prevalence. The old surgical adage ‘You will see one NSTI in your lifetime is no longer true. Associated morbidity and mortality is significant and a focus on early recognition and prevention is vital. Further larger data sets are required to delineate clear trends and associated risk factors that can effect meaningful health care policy change.

The microbiological profile of necrotising fasciitis at a secondary level hospital in Gauteng.

Necrotising fasciitis (NF) is a fulminant soft tissue infection that requires timely diagnosis, urgent surgical debridement, and appropriate antimicrobial therapy. The choice of empiric antimicrobial therapy depends on the microorganisms cultured and the antimicrobial resistance profile of the institution. Necrotising fasciitis has not been studied in our setting. The aim of the study was to audit the microbiological profile of NF and antimicrobial susceptibility profile. This was a retrospective study in a secondary level hospital from the period of 2014-2020. The patients' demographic data, clinical features, location of infection, comorbidities, laboratory and microbiological profiles were analysed. There were 53 patients during 2014-2020 with median age of 45.5 (38.5-56.0) years. The majority of the patients were males (35 [66.04%]), had no comorbidities (25 [47.17%]), and the lower limb was the most common anatomic site (17 [32.08%]). Type II (monomicrobial) NF was the predominant type (31 [58.49%]). Staphylococcus aureus was the most prevalent Gram-positive bacteria (18 [38%]) and Escherichia coli, the main species isolated in the Gram-negative bacteria (14 [36%]) with susceptibility to cloxacillin (94%) and amoxicillin and/or clavulanic acid (92%), respectively. Staphylococcus aureus and Escherichia coli were the most common bacteria with low rate of antimicrobial resistance. Amoxicillin and/or clavulanic acid and an adjunctive clindamycin are appropriate antimicrobial therapy for empiric treatment for NF in our setting. Amoxicillin and/or clavulanic acid and an adjunctive clindamycin can be used as an empiric treatment for NF.

Management of gunshot wounds near the elbow: experiences at a high-volume level I trauma center.

Gunshot-related fractures near the elbow are challenging, and available data to guide the practitioner are lacking. This report analyzes injury patterns and treatment strategies in a case series from a high-volume urban trauma center. All periarticular gunshot fractures near the elbow treated at a level 1 trauma center from 2014 to 2018 were retrospectively reviewed. Fracture location, patient demographics, concomitant injuries, treatment modalities, and complications were analyzed. Twenty-four patients were identified. All patients received prophylactic antibiotics upon admission and underwent urgent surgical debridement. Open reduction and internal fixation (ORIF) was performed with initial debridement in 22 of 24 patients. Seven patients sustained distal humerus fractures, 10 patients sustained isolated proximal ulna or proximal radius fractures, and seven had combined fracture patterns. Eleven patients presented with nerve palsy, and two had transected nerves. Two patients had vascular injury requiring repair. One patient required a temporary elbow-spanning external fixator and underwent staged debridement followed by ORIF. One patient with a grade IIIC fracture developed a deep infection that precluded ORIF. One patient required revision ORIF due to fracture displacement. This investigation reports on management of ballistic fractures near the elbow at a busy urban level I trauma center. Our management centered on rapid debridement, early definitive fixation, and intravenous antibiotic administration. We report on associated neurovascular injury, bone loss, and other challenges in this patient population. Level of evidence: IV.

Invasive fungal rhinosinusitis, clinical manifestations, and prognostic values: as case series audit

BackgroundInvasive fungal rhinosinusitis (IFRS) is a rare disorder with a high mortality rate. In this study, we reported four rare cases, two of them being the first reports in the literature, in addition, we reviewed retrospectively and discussed the effects of causative fungi, comorbid disorders, and intracranial involvement on mortality rate in 20 IFRS patients treated in the otolaryngology clinic between May 2019 and May 2021.ResultsThere were 10 (50%) males and 10 females with a median age of 51 years. Seven patients had rhinomaxillary, 11 had rhino-orbito-cerebral IFRS, and two had atypical presentations that could not be classified. The most frequent comorbid condition was diabetes mellitus (DM), and the most frequent causative fungi were Mucormycetes. There was no difference between DM and other comorbidity groups for orbital involvement (p = 0.37), intracranial involvement (p = 0.17), hard palate involvement (p = 1), cranial nerve palsies (p = 0.17), causative fungi (p = 0.14), or mortality (p = 0.35). Mucormycetes and other fungi were similar for orbital involvement (p = 0.34), intracranial involvement (p = 0.16), hard palate involvement (p = 0.64), and mortality rate (p=0.35); however, cranial nerve palsies were significantly more frequent in Mucormycetes group (p = 0.04).ConclusionsUrgent diagnosis and multidisciplinary treatment are mandatory in IFRS. Due to its high mortality rate, IFRS should always be kept in mind in cases with atypical presentation, particularly if the patient is in the risk group. The current gold standard in IFRS management is urgent wide surgical debridement and concomitant administration of antifungals.

Preoperative computed tomography in Fournier's gangrene does not delay time to surgery.

Fournier's gangrene (FG), a rapidly progressive necrotizing soft tissue infection of the external genitalia and perineum, necessitates urgent surgical debridement. The time to surgery effect of preoperative computed tomography (CT) in managing this condition is yet to be fully explored. The purpose of this study was to assess whether obtaining a preoperative CT in patients with FG impacts the time to surgical intervention. This was a single-center retrospective study of patients who underwent CT prior to surgical debridement of FG during a 9-year period vs patients who did not undergo CT. In 76 patients (male = 39, mean age = 51.8), 38 patients with FG received a preoperative CT, and 38 patients with FG did not receive CT prior to surgical debridement. Time to operating room and outcome metrics were compared between CT and non-CT groups. The time from hospital presentation to surgical intervention was not significantly different between patients who underwent CT and those who did not (6.65 ± 3.71 vs 5.73 ± 4.33 h, p = 0.37). There were also no significant differences in cost ($130,000 ± $102,000 vs $142,000 ± $152,000, p = 0.37), mortality (8 vs 7, p = 1), duration of hospital stay (15.5 ± 15 vs 15.7 ± 11.6 days, p = 0.95), average intensive care unit stay (5.82 ± 5.38 days vs 6.97 ± 8.58 days, p = 0.48), and APACHE score (12 ± 4.65 vs 13.9 ± 5.6, p =0.12). Obtaining a preoperative CT did not delay surgical intervention in patients with FG.

Post-COVID-19 mucormycosis: A prospective, observational study in patients undergoing surgical treatment.

Post the second wave of COVID-19 in India, our institute became a dedicated center for managing COVID-19-associated mucormycosis (CAM), but there was a paucity of data regarding perioperative considerations in these patients. The objectives of present study was to describe the preoperative clinical profile, the perioperative complications and outcome of CAM patients undergoing urgent surgical debridement. This prospective observational study was conducted on CAM patients presenting for surgical debridement from July to September 2021. During preoperative visits, evaluation of extent of disease, any side effects of ongoing medical management and post-COVID-19 systemic sequalae were done. The details of anaesthetic management of these patients including airway management, intraoperative haemodynamic complications and need for perioperative blood transfusion were noted. One hundred twenty patients underwent surgical debridement; functional endoscopic sinus surgery (FESS) was carried out in 63% of patients, FESS with orbital exenteration in 17.5%, and maxillectomy in 12.5%. Diabetes mellitus was found in 70.8% and post-COVID new onset hyperglycemia in 29.1% of patients. Moderate-to-severe decline in post-COVID functional status (PCFS) scale was observed in 73.2% of patients, but with optimization, only 5.8% required ICU management. The concern during airway management was primarily difficulty in mask ventilation (17.5%). Intraoperatively, hemodynamic adverse events responded to conventional treatment for hypotension, judicious use of fluids and blood transfusion. Perioperatively, 10.8% of patients required blood transfusion and 4.2% of patients did not survive. Non-surviving patients were older, with a more aggressive involvement of CAM, and had comorbidities and a greater decline in functional capacity. A majority of patients reported a moderate-to-severe decline in PCFS that required a preoperative multisystem optimization and a tailored anesthetic approach for a successful perioperative outcome.

Predicting necrotising soft tissue infections in people who inject drugs: poor performance of the Laboratory Risk Indicator for Necrotising Fasciitis score and development of a novel clinical predictive nomogram in a retrospective cohort with internal validation.

Necrotising soft tissue infections (NSTI) can threaten life and limb. Early identification and urgent surgical debridement are key for improved outcomes. NSTI can be insidious. Scoring systems, like the Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC), exist to aid diagnosis. People who inject drugs (PWID) are high risk for NSTI. This study aimed to assess the utility of the LRINEC in PWID with lower limb infections and develop a predictive nomogram. A retrospective database of all hospital admissions due to limb-related complications secondary to injecting drug use between December 2011 and December 2020 was compiled through discharge codes and a prospectively maintained Vascular Surgery database. All lower limb infections were extracted from this database, dichotomised by NSTI and non-NSTI with the LRINEC applied. Specialty management times were evaluated. Statistical analyses involved: chi-square; Analysis of "variance"; Kaplan-Meier, and receiver operating characteristic curves. Nomograms were developed to facilitate diagnosis and predict survival. There were 557 admissions for 378 patients, with 124 (22.3%; 111 patients) NSTI. Time from admission to: theatre and computed tomography imaging respectively varied significantly between specialties ( P =0.001). Surgical specialties were faster than medical ( P =0.001). Vascular surgery received the most admissions and had the quickest time to theatre. During follow-up there were 79 (20.9%) deaths: 27 (24.3%) NSTI and 52 (19.5%) non-NSTI. LRINEC ≥6 had a positive predictive value of 33.3% and sensitivity of 74% for NSTI. LRINEC <6 had a negative predictive value of 90.7% and specificity of 63.2% for non-NSTI. Area under the curve was 0.697 (95% CI: 0.615-0.778). Nomogram models found age, C-reactive protein, and non-linear albumin to be significant predictors of NSTI, with age, white cell count, sodium, creatinine, C-reactive protein, and albumin being significant in predicting survival on discharge. There was reduced performance of the LRINEC in this PWID cohort. Diagnosis may be enhanced through use of this predictive nomogram.

A contemporaneous narrative review of Fournier's gangrene.

Fournier's gangrene is a necrotizing infection of the external genitalia, perineal or perianal regions and is mainly seen in males. Its main risk factors include diabetes, chronic alcoholism, HIV and other immune-compromised states. Fournier's gangrene has an aggressive course associated with a mortality rate of 20%-30%, making early diagnosis and management very important. The Fournier Gangrene Severity Index (FGSI) has been traditionally used to predict the severity and prognosis. More recently, simplified FGSI (sFGSI) has been proposed and is helpful. However, timely diagnosis, supportive medical management and complete surgical debridement are still the cornerstones of treatment. These must be complemented with early and timely re-look debridements and appropriate reconstruction to cover soft tissue defects. This literature review aims to look at recent relevant research regards risk factors and prognostic features of Fournier's gangrene. A search was conducted on Google Scholar and PubMed databases for all articles related to Fournier's Gangrene. These included clinical reviews, case reports, case series and retrospective studies. Reports or studies which were not published in English were not reviewed. Various reconstructive techniques to cover the defects have also been revisited. Broad-spectrum antibiotics and urgent surgical debridement are the core management principles of Fournier's gangrene. Repeat debridement after 24 h is also recommended. Adjunctive therapies such as hyperbaric oxygen and vacuum-assisted closure are supported in most aspects of recent literature. Expectedly, there is a lack of randomised controlled studies in such emergency surgical conditions, which limits the widespread use of newer therapies to patients unresponsive to conventional management. Fournier's gangrene is a urological emergency with a high mortality rate. The aggressive nature of the infection necessitates early recognition and immediate surgical intervention. Negative pressure dressing and occasional hyperbaric oxygen as adjuncts should be used more routinely, especially if there is a delayed response to conventional treatment or in severe infections.

Tropical Diabetic Hand Syndrome: A Case Report and Literature Review

Tropical diabetic hand syndrome (THDS) is an acute complication that mainly affects patients with diabetes living in the tropics. The cause is usually unknown, but it is often preceded by minor trauma to the hand. Other risk factors for TDHS are poor glycaemic control, poorly treated wounds, malnutrition, and diabetic neuropathy. Early signs include swelling and ulceration of the hand. It can rapidly progress to sepsis and may further worsen, leading to deformity, disability, and amputation. If not treated promptly, death may occur. Unlike diabetic foot ulcer, TDHS often goes unreported. Here is a case of a 39-year-old female and a known patient with diabetes who presented to the outpatient department with swelling and tenderness of the left hand, along with foul-smelling purulent discharge. It began after the patient peeled off a patch of scaly, thickened skin over the distal part of their middle finger. Investigations showed high blood sugar and slightly increased leukocyte count. The patient was started on antihyperglycaemic medications and intravenous antibiotics. Urgent surgical debridement was done, which led to amputation of the middle finger. Thereafter, the patient showed significant improvement and was discharged with follow-up instructions. This case report emphasises the importance of timely intervention in cases of tropical diabetic hand syndrome, and the need for adequate patient education on this issue.

Serratia marcescens Septic Arthritis and Osteomyelitis after COVID-19: A Case Report and Literature Review

Purpose: Septic arthritis and osteomyelitis due to Serratia marcescens are very rare, with only a few cases reported in the literature. This report presents a case of septic arthritis and osteomyelitis of the hip joint caused by Serratia marcescens after COVID-19. Methods: A case report of a patient who had septic arthritis of Serratia marcescens was reported. A review of literature of the bone and joint infection caused by Serratia marcescens was also done. Results: The patient was successfully treated with an open arthrotomy, debridement, and intravenous antibiotics. After 9 months, the patient showed good functional outcomes, with no signs of recurrent infection. Conclusions: Septic arthritis caused by Serratia marcescens is a rare condition. Early diagnosis and urgent surgical debridement are key factors for success.

Late Presentation of Xeroderma Pigmentosa With Squamous Cell Carcinoma in Septic Shock: Report of a Rare Case

Xeroderma pigmentosum (XP) is a rare autosomal recessive pathology affecting nucleotide excision repair against ultraviolet radiation. This leads to an increased predisposition to developing ophthalmological, neurological, and cutaneous conditions with an increased cell turnover. This case reports a late presentation of XP presenting with metastatic squamous cell carcinoma (SCC) and septic shock in an eight-year-old Indian male. Emergency management with IV fluid boluses and broad-spectrum antibiotics showed no improvement in vitals. Urgent surgical debridement and tumor debulking failed to improve laboratory values. Postoperative leukocytosis with fever spikes warranted the need to transfer the patient to a super-specialty oncology unit. Such an adverse presentation is commonly seen in XP-related invasive squamous cell carcinoma. Preventive management requires early identification and a multidisciplinary approach involving dermatologists, ophthalmologists, and surgeons. Late presentations revolve around control of the disease process by sharp debridement and chemotherapy with regular surveillance as the lesions tend to reoccur even after excision and chemotherapy.

Necrotizing Fasciitis- A Lethal Soft Tissue Infection: Review Article

Background: Necrotizing Fasciitis is a rapidly progressive soft tissue infection that is almost fatal without prompt treatment. This review highlights about the basic approach to the diagnosis and treatment of NF. Description: Various nomenclatures have been used to describe necrotizing soft tissue infections. These infections are classified on the basis of the microbes involved, depth of invasion and anatomical sites involved. Diabetes is the most common risk factor for NF. The masquerading cutaneous manifestations make the diagnosis of NF a challenge. Laboratory parameters, imaging techniques and scoring systems have been designed to aid in early diagnosis. Conclusion: High index of clinical suspicion is needed to make prompt diagnosis of NF. Urgent aggressive surgical debridement with antimicrobial therapy limits the morbidity and mortality associated with NF.

Diagnosis and Treatment of Invasive Mold Diseases.

Although invasive fungal diseases are relatively less common than superficial diseases, there has been an overall increase in their incidence. Here, I review the epidemiology, diagnosis, and treatment of invasive mold diseases (IMDs) such as aspergillosis, mucormycosis, hyalohyphomycosis, and phaeohyphomycosis. Histopathologic demonstration of tissue invasion by hyphae or recovery of mold by the culture of a specimen obtained by a sterile procedure provides definitive evidence of IMD. If IMD cannot be confirmed through invasive procedures, IMD can be diagnosed through clinical criteria such as the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Instituteof Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) definitions. For initial primary therapy of invasive aspergillosis, voriconazole or isavuconazole is recommended and lipid formulations of amphotericin B are useful primary alternatives. Echinocandins are representative antifungal agents for salvage therapy. Treatment of invasive mucormycosis involves a combination of urgent surgical debridement of involved tissues and antifungal therapy. Lipid formulations of amphotericin B are the drug of choice for initial therapy. Isavuconazole or posaconazole can be used as salvage or step-down therapy. IMDs other than aspergillosis and mucormycosis include hyalohyphomycosis and phaeohyphomycosis, for which there is no standard therapy and the treatment depends on the clinical disease and status of the patient.

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.

Complications and Soft-Tissue Coverage After Complete Articular, Open Tibial Plafond Fractures.

To evaluate the incidence of nonunion and wound complications after open, complete articular pilon fractures. Second, to study the effect that both timing of fixation and timing of flap coverage have on deep infection rates. Retrospective case series. Three Academic Level 1 Trauma Centers. One hundred sixty-one patients with open OTA/AO type 43C distal tibia fractures treated with open reduction internal fixation (ORIF) between 2002 and 2018. The mean (SD) age was 46 (14) years, 70% male, with median (interquartile range) follow-up of 2.1 (1.3-5.0) years (minimum 1 year). There were 133 (83%) type 3A and 28 (17%) type 3B open fractures. Fracture fixation: acute, primary (<24 hours) versus delayed, staged ORIF (>24 hours). Soft-tissue coverage: rotational or free flap. Primary outcomes included deep infection and nonunion. Secondary outcomes included rates of soft-tissue coverage and reoperation. Acute fixation (<24 hours) was performed in 36 (22%) patients; 125 (78%) underwent delayed, staged fixation. Deep infection occurred in 27% patients and was associated with men (33% vs. 16%, P = 0.029), smoking (38% vs. 23%, P = 0.047), and type 3B fractures (39% vs. 25%, P = 0.046). Acute fixation of type 3A fractures demonstrated a higher rate of infection (38% vs. 20% P = 0.036) than delayed, staged fixation. In type 3B fractures, early flap coverage (<1 week) demonstrated a lower rate of infection (18% vs. 53%, P = 0.066) and 20% (vs. 43%) with a single-staged "fix and flap" procedure (P = 0.408). Nonunion occurred in 36 (22%) and was associated with deep infection (43% vs. 15%, P < 0.001). Fifteen (42%) were septic nonunions. Twenty-nine of the 36 (81%) nonunions achieved radiographic union after median (interquartile range) 27 (20-41) weeks and median (range) 1 (1-3) revision ORIF procedures. There was no difference in the rate of secondary union between septic and aseptic nonunions (85% vs. 86%, P = 1.00). There was a high rate of secondary procedures (47%): revision ORIF (17%), irrigation and debridement (15%), and removal of implants (11%). Complete articular, open pilon fractures are associated with a high rate of complications after ORIF. Early fixation carries a high risk of deep infection; however, early flap coverage for 3B fractures seems to play a protective role. We advocate for aggressive management including urgent surgical debridement and very early soft-tissue cover combined with definitive fixation during single procedure if possible. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Treatment of HeartMate III-LVAD driveline infection by negative pressure wound therapy: Result of our case series.

Driveline infection is one of the most frequent complications following left ventricular assist device (LVAD) treatment and there is no consensus for its management. The standard approach to treat foreign-body infection is complete device ablation, which is not always feasible and therefore not an elected method for LVAD driveline infections. Here we share the results from a series of cases successfully treated for driveline infection by negative pressure wound therapy (NPWT) therapy. Between 2016 and 2020, five male patients were hospitalized in our unit with a driveline infection of HeartMate III-LVAD®. Ultrasonography and/or thoraco-abdominal CT confirmed the diagnosis, infection localization, and abscess formation. Following an antibiotic treatment, an urgent surgical abscess drainage and debridement of the infected tissues were performed. At the end of the procedure, NPWT was applied. NPWT re-dressing and debridement of wound was performed every 3–4 days. The wound was closed surgically after obtaining negative culture results and good healing. The patients were discharged in good condition, without signs of infection. Two patients underwent successful heart transplantation after 1 and 13 months. Other patients did not show any residual or recurrent infection during the follow-up within 25 months. Driveline infection following LVAD implantation is a significant complication and a challenging in terms of management for both; the surgical team and the patient. These results from our case series report a successful and less invasive approach by using NPWT for the treatment of LVAD driveline infections.

COVID-19-associated mucormycosis presenting to the Emergency Department-an observational study of 70 patients.

SummaryBackgroundMucormycosis (MM) is a deadly opportunistic fungal infection and a large surge in COVID-19-associated mucormycosis (CAM) is occurring in India.AimOur aim was to delineate the clinico-epidemiological profile and identify risk factors of CAM patients presenting to the Emergency Department (ED).DesignThis was a retrospective, single-centre, observational study.MethodsWe included patients who presented with clinical features or diagnosed MM and who were previously treated for COVID-19 in last 3 months of presentation (recent COVID-19) or currently being treated for COVID-19 (active COVID-19). Information regarding clinical features of CAM, possible risk factors, examination findings, diagnostic workup including imaging and treatment details were collected.ResultsSeventy CAM patients (median age: 44.5 years, 60% males) with active (75.7%) or recent COVID-19 (24.3%) who presented to the ED in between 6 May 2021 and 1 June 2021, were included. A median duration of 20 days (interquartile range: 13.5–25) was present between the onset of COVID-19 symptoms and the onset of CAM symptoms. Ninety-three percent patients had at least one risk factor. Most common risk factors were diabetes mellitus (70%) and steroid use for COVID-19 disease (70%). After clinical, microbiological and radiological workup, final diagnosis of rhino-orbital CAM was made in most patients (68.6%). Systemic antifungals were started in the ED and urgent surgical debridement was planned.ConclusionCOVID-19 infection along with its medical management have increased patient susceptibility to MM.

Magnitude and outcomes of complex perineal injury - A retrospective analysis of five years' data from a Level 1 trauma centre.

Complex perineal injuries pose a major diagnostic and therapeutic challenge to trauma surgeons. A retrospective review of the hospital records of 29 patients with complex perineal injury following blunt trauma was done. Demographic profile, management and outcomes were collected. Quality of life analysis was conducted for patients with complex perineal injuries who were discharged. The most predominant mode of injury was a road crash: being a pedestrian run over by a heavy motor vehicle. Pelvic fracture was seen in 20, anorectal involvement in 22 and urogenital injuries in 14. Urgent surgical debridement was done in all patients, faecal diversion in 27 and urinary diversion in 14. There were nine deaths, three from haemorrhage, and the remainder from sepsis and multi-organ dysfunction. Complex perineal injury remains a major cause of morbidity and mortality in trauma patients. There is a need to ensure adequate rehabilitation services for such patients.

Diagnosis and Treatment of Severe Fournier's Gangrene: Introduction of a Surgical Approach, Evaluation of Risk Factors, Microbiological Characteristics and Review of the Literature

Fournier's gangrene is a necrotising fasciitis type I occurring in the perineal and genital region. The disease expands progressively and still has poor outcome, especially in critical ill patients. This study's focus was placed on the evaluation of risk factors and comorbidities, on the bacteriological spectrum, laboratory analyses, mortality and the course according to the algorithmic approach. The medical records were reviewed of 10 patients with severe Fournier's gangrene from 2010 to 2019 who underwent intensive care therapy for at least 48 hours. Ten patients with Fournier's gangrene and sepsis and intensive therapy lasting at least 48 hours were recorded and analysed descriptively. The patient cohort consisted of six men and four women with a median age of 62 years (range 42 - 78 years). The median time between the onset of symptoms and hospitalisation was four days (range 3 - 5 days). The commonest aetiological event was a minor trauma. Predisposing factors included diabetes mellitus (30%) and overweight (80% BMI > 25). 90% of patients exhibited polymicrobial infection. All patients had systemic sepsis with SOFA-Score between 3 and 17 points. The mortality rate was 40%. Significant differences between surviving and deceased patients were shown by PCT, INR and aPTT (p < 0.05). Severe Fournier's gangrene continues to be a major challenge with a high mortality rate. Only rapid diagnosis, urgent extensive surgical debridement and intensive care therapy can lead to a favourable outcome in these critically ill patients. Vacuum-assisted closure can be successfully used in the management of soft-tissue defects.

Recurrent Necrotizing Fasciitis: A Case Report of Fulminant and Sub-Acute Necrotizing Fasciitis in a Diabetic Patient

Necrotizing fasciitis is an uncommon and deadly disease entity characterized by rapidly progressing skin and soft tissue destruction. It presents on a spectrum from an initially indolent appearing sub-acute form to a hyperacute fulminant course. It may often be misdiagnosed due to the paucity of signs early in the disease course and as it can initially mimic other less serious soft tissue infections. Necrotizing soft tissue infections have both high morbidity and mortality.We present a case of a 72-year-old male patient with two anatomically and temporally separate necrotizing infections. The first necrotizing infection was diagnosed after an extended time, due to the subacute disease course in the setting of an abdominal wall infection. The second presentation was a hyperacute fulminant course in the setting of a necrotizing infection of the scrotum. In both instances, once identified, appropriate management was followed: resuscitation, broad-spectrum antibiotics, and most importantly radical surgical debridement. Extensive multidisciplinary inpatient and outpatient input was required to aid the patient’s recovery.The presented case demonstrates the necrotizing soft tissue infection’s spectrum of disease and the diagnostic dilemma it presents to family physicians and emergency departments alike. The only definitive management step is immediate and radical resection of the affected tissue. Extensive debridement and the resultant tissue defect require comprehensive multidisciplinary care during the extended rehabilitation and wound care treatment plan. Rapid recognition, urgent surgical debridement, and specialist care are required to reduce the mortality and morbidity associated with necrotizing soft tissue infections.