Gas-Producing Infections in the Foot at a Large Academic Medical Center: A 10-Year Retrospective Review.

Gas-producing infections, such as clostridial and nonclostridial gas gangrene, crepitant cellulitis, and necrotizing fasciitis, are characterized in the literature by a variety of initial presentations, microbial burdens and surgical outcomes-ranging from debridement to amputation to death. The primary aim of this study was to identify the organisms cultured in gas-producing infections of the foot in patients that presented to a large academic medical center over a 10-year period. Our secondary aims were to report the prevalence of sepsis in this population upon presentation, and patient outcomes upon discharge. After a retrospective chart review of 207,534 procedures, 70 surgical cases met inclusion criteria. The most common organisms that grew in operating room cultures were Staphylococcus aureus, Group B Beta Streptococcus, and Enterococcus species. Just over half of the population presented with sepsis. After an average of 2 or more operations, 64% of patients underwent amputation. One death occurred. Gas-producing infections, or "gas gangrene," are primarily polymicrobial infections, rarely due to Clostridium perfringens, that warrant surgical exploration for optimal outcomes.

Analyzing Outcomes Among Older Adults With Necrotizing Soft-Tissue Infections in the United States.

BACKGROUND: Necrotizing soft-tissue infections (NSTIs) encompass a group of severe, life-threatening diseases with high morbidity and mortality. Evidence suggests advanced age is associated with worse outcomes. To date, no large data sets exist describing outcomes in older individuals, and risk factor identification is lacking. METHODS: Retrospective data were obtained from the 2015 Medicare 100% sample. Included in the analysis were those aged ≥65 y with a primary diagnosis of an NSTI (gas gangrene, necrotizing fasciitis, cutaneous gangrene, or Fournier's gangrene). Risk factors for in-hospital mortality and discharge disposition were examined. Continuous variables were assessed using central tendency, t-tests, and Wilcoxon rank-sum tests. Categorical variables were assessed using the chi-squared and Fisher's exact tests. Statistical significance was defined as P < 0.05. RESULTS: 1427 patient records were reviewed. 59% of patients were male, and the overall mean age was 75.4±8.6 y. 1385 (97.0%) patients required emergency surgery for their NSTI diagnosis. The overall mortality was 5.3%. Several underlying comorbidities were associated with higher rates of mortality including cancer (OR: 3.50, P = 0.0009), liver disease (OR: 2.97, P = 0.03), and kidney disease (OR: 2.15, P = 0.01). While associated with high in-hospital mortality, these diagnoses were not associated with a difference in the rate of discharge to home compared with skilled nursing or rehab. Overall, patients discharged to skilled nursing facilities or rehab had higher rates of underlying comorbidities than patients who were discharged home (3 or more comorbid illness 84.3% versus 68.6%, P < 0.0001); however, no individual comorbid illness was associated with discharge location. CONCLUSIONS: In our Medicare data set, we identified several medical comorbidities that are associated with increased rates of in-hospital mortality. Patients with underlying cancers had the highest odds of increased mortality. The effect on outcomes of the potentially immunosuppressive cancer treatments in these patients is unknown. These data suggest that patients with underlying illnesses, especially cancer, kidney disease, or liver disease have higher mortalities and are more likely to be discharged to skilled nursing facilities or rehab. It is unclear why these illnesses were associated with these worse outcomes while others including diabetes and heart disease were not. These data suggest that these particular comorbid illnesses may have special prognostic implications, although further analysis is necessary to identify the causative factors.

Gas gangrene, diabetes and amputations of upper extremities.

PURPOSES: The aim of the current study was to evaluate epidemiological data on amputations of upper extremities. METHODS: The main causes of upper extremity amputations performed in the period from January 1998 to January 2008 in Hospital de Base, São José do Rio Preto were retrospectively evaluated in a descriptive and quantitative cross-sectional study. Data, including the age of the patient, gender and the reason for surgery, were obtained from hospital records identified by the international classification of diseases (ICD) code for amputation. RESULTS: A total of 2919 amputations were performed in the period of this study with only 23 involving the upper extremities; thus 22 patients were included in this study as one was submitted to amputation of both arms. Fifteen patients (65.21%) were male with ages that ranged between 18 and 84 years old (mean = 41.6 years old). Seven patients (34.79%) were women with ages from 24 to 87 years old (mean = 58.8 years old). The causes for amputation were: accidents (14), gas gangrene (4), malignant neoplasms (3), arterial thrombosis (1) and unidentified cause (1). CONCLUSION: Gas gangrene of the upper extremities is associated to diabetes mellitus which highlights the severity of the disease.

Health-Related Quality of Life Is Decreased After Necrotizing Soft-Tissue Infections.

BACKGROUND: A necrotizing soft-tissue infection (NSTI) is a rare but severe infection with a high mortality rate of 12%-20%. Diagnosing is challenging and often delayed. Treatment consists of surgical debridement of all necrotic tissue and administration of antibiotics. Despite adequate treatment, survivors are often left with extensive wounds, resulting in mutilating scars and functional deficits. Both the disease and the subsequent scars can negatively influence the health-related quality of life (HRQoL). The present study was performed to contribute to the knowledge about HRQoL in patients after NSTI. METHODS: We retrospectively identified patients treated for NSTI in a tertiary center in the Netherlands. Patient and treatment characteristics were collected and patients were asked to fill in a Short Form 36 questionnaire. RESULTS: Forty-six patients with a diagnosis of NSTI were identified. Twenty-eight (61%) were male and mean age was 57 y. Thirty-nine patients (80%) survived. Thirty-one (84%) of the survivors returned the questionnaire after a median follow-up of 4.1 y (interquartile range [IQR], 2.4-5.9 y). Statistically significantly decreased scores when compared to the Dutch reference values were observed for the Short Form 36 domains, physical functioning, role-physical functioning, general health, and the combined Physical Component Score. No differences were observed for the other five domains or for the Mental Component Score. CONCLUSIONS: This study confirms that NSTI negatively affects HRQoL as reported by the patient, especially on the physical domains. To learn more about HRQoL in patients after NSTI, studies in larger groups with a more disease-specific questionnaire should be performed. LEVEL OF EVIDENCE: Level 3, prognostic and epidemiological.

Gas gangrene as a surgical emergency - own experience.

In this paper the authors would like to present a correct procedure in both surgical and hyperbaric treatment of patients with gas gangrene admitted to a surgical department during ER. Gas gangrene is not very common these days, but when it comes to dealing with gangrenous infection in the emergency it is quite likely to make errors in both diagnostic and therapeutic manners. When there is a gas gangrene in a patient at the emergency time plays crucial role and the proper application of procedures is vital for the patient's survival. 10 cases made the study group here, all of them were patients diagnosed and treated surgically due to gas gangrene. As shown here, It is important to perform a revision of surgical wounds after few hours since primary surgery and to begin hyperbaric treatment as quickly as possible. The findings and suggestions included in this study are supported by own experience of The 2nd Department of General and Gastrointestinal Surgery of Medical University in Bialystok, Poland.

A Rare Case of Myonecrosis with Soft-Tissue Emphysema in a Diabetic Foot Caused by Streptococcus anginosus Isolated in Pure Culture: A Case Study.

Streptococcus anginosus (SAG) is a known human pathogen and member of the Streptococcus milleri group. SAG is a known bacterial cause of soft-tissue abscesses and bacteremia and is an increasingly prevalent pathogen in infections in patients with cystic fibrosis. We describe a rare case of SAG as an infectious agent in a case of nonclostridial myonecrosis with soft-tissue emphysema. This is the only case found in the literature of SAG cultured as a pure isolate in this type of infection and was associated with a prolonged course of treatment in an otherwise healthy patient.

[Vascularised Fibula and Tendon Transfer in the Comprehensive Treatment of Forearm Fracture with Gas Gangrene Complication]. / Vaskularizovaná fibula a slachový transfer v komplexnej liecbe otvorenej zlomeniny predlaktia komplikovanej plynnou snetou.

Vascularized bone grafting was for the first time described in the 1970s. It has become a crucial component in the reconstruction of long bone defects and non-unions in a poorly vascularised environment. Although the vascularized bone is well described for the lower extremity and mandibular reconstructions, it started to be used for the upper extremity bone defects only recently. This publication presents a case of a young man with an open fracture of both the forearm bones. The treatment of the injury has been complicated with anaerobic gas gangrene of the forearm. This resulted in a non-union, radius shortening and necrosis of both the thumb extensors and flexors muscles. Once the acute infection was managed, the patient received a two-step treatment provided jointly by orthopaedic and plastic surgeons at the University Hospital in Bratislava. At the first stage auto transplantation of the vascularized fibula into the defect of radius was performed, with radial artery and radial veins being the recipient vessels. One year later, a tendon transfer was made in order to reconstruct the extension and flexion of the thumb. Donor tendons were the following: extensor indicis proprius and flexor digitorum superficialis for ring finger. The result of the reconstruction is the full incorporation of the fibular transplant (6 months after the primary operation) and the excellent range of motion of the hand and wrist. Thanks to the tendon transfer the function of the thumb, including the opposition, was achieved two months after the secondary surgery. Key words: defect of radius, tendon transfer, anaerobic infection, gas necrosis, microsurgery.

Sliding free transverse rectus abdominis myocutaneous flap for closure of a massive abdominal wall defect: A case report.

Despite considerable advances in reconstructive surgery, massive abdominal wall defects continue to pose a significant surgical challenge. We report the case of a 72-year-old morbidly obese female patient with Clostridium septicum-related gas gangrene of the abdominal wall. After multidisciplinary treatment and multiple extensive debridements, a massive full-thickness defect (40 cm × 35 cm) of the right abdominal wall was present. The abdominal contents were covered with a resorbable mesh to prevent evisceration. Finally, the composite defect was successfully reconstructed through a contralateral extended free transverse rectus abdominis myocutaneus (TRAM) flap (50 cm × 38 cm). An arterio-venous loop to the superficial femoral vessels using the great saphenous vein was necessary to allow the flap to reach the defect. Postoperatively, a minor wound healing disorder of the flap was successfully treated with split skin grafting. Six month after surgery, the patient presented with a completely healed flap coverage area and a small abdominal hernia without the need of further surgical revision. This case illustrates the use of a sliding free TRAM flap for closure of a massive abdominal wall defect.

[Life-threatening intrauterine infection with Clostridium perfringens].

In this case report, a 40-year-old woman with a history of a uterine leiomyoma presented with abdominal pain and fever. Initially, her symptoms were associated with a bleeding from an ovarian cyst seen on a CT scan of the abdomen showing free intraperitoneal fluid surrounding the internal genitals. Meanwhile, her blood cultures came out positive for Clostridium perfringens, and her condition deteriorated despite intravenous antibiotics. A new CT scan revealed intrauterine gas development. A laparotomy was performed with removal of the internal genitals, and the patient improved on continuous antibiotics.

Effect of transfer status on outcomes for necrotizing soft tissue infections.

BACKGROUND: Whether patients with necrotizing soft tissue infections (NSTI) who presented to under-resourced hospitals are best served by immediate debridement or expedited transfer is unknown. We examined whether interhospital transfer status impacts outcomes of patients requiring emergency debridement for NSTI. METHODS AND MATERIALS: We conducted a retrospective review studying patients with an operative diagnosis of necrotizing fasciitis, Fournier's gangrene, or gas gangrene in the 2010-2015 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data Files. Multivariable regression analyses determined if transfer status independently predicted 30-d mortality, major morbidity, minor morbidity, and length of stay. RESULTS: Among 1801 patients, 1243 (69.0%) were in the non-transfer group and 558 (31.0%) were in the transfer group. The transfer group experienced higher rates of 30-d mortality (14.5% versus 13.0%) and major morbidity (64.5% versus 60.1%) than the non-transfer group, which were not significant after risk adjustment (adjusted odds ratio [95% confidence interval]: 0.87 [0.62-1.22] and 1.00 [0.79-1.27], respectively). The transferred group experienced a longer median length of postoperative hospitalization (14 d [interquartile range 8-24] versus 11 d [6-20]), which maintained statistical significance after adjustment for other factors (adjusted beta coefficient [95% confidence interval]: 1.92 [0.48-3.37]; P = 0.009). CONCLUSIONS: Our results suggest that interhospital transfer status is not an independent risk factor for mortality or morbidity after surgical management of NSTI. Although expedient debridement remains a basic tenet of NSTI management, our findings provide some reassurance that transfer before initial debridement will not significantly jeopardize patient outcomes should such transfer be deemed necessary.

Presence of periaortic gas in Clostridium septicum-infected aortic aneurysm aids in early diagnosis: a case report and systematic review of the literature.

BACKGROUND: Clostridium septicum-infected aortic aneurysm is a fatal and rare disease. We present a fatal case of C. septicum-infected aortic aneurysm and a pertinent literature review with treatment suggestions for reducing mortality rates. CASE PRESENTATION: A 58-year-old Japanese man with an unremarkable medical history presented with a 3-day history of mild weakness in both legs, and experienced paraplegia and paresthesia a day before admission. Upon recognition of signs of an abdominal aortic aneurysm and paraplegia, we suspected an occluded Adamkiewicz artery and performed a contrast-enhanced computed tomography scan, which revealed an aortic aneurysm with periaortic gas extending from his chest to his abdomen and both kidneys. Antibiotics were initiated followed by emergency surgery for source control of the infection. However, owing to his poor condition and septic shock, aortic repair was not possible. We performed bilateral nephrectomy as a possible source control, after which we initiated mechanical ventilation, continuous hemodialysis, and hemoperfusion. A culture of the samples taken from the infected region and four consecutive blood cultures yielded C. septicum. His condition gradually improved postoperatively; however, on postoperative day 10, massive hemorrhage due to aortic rupture resulted in his death. CONCLUSIONS: In this patient, C. septicum was thought to have entered his blood through a gastrointestinal tumor, infected the aorta, and spread to his kidneys. However, we were uncertain whether there was an associated malignancy. A literature review of C. septicum-related aneurysms revealed the following: 6-month mortality, 79.5%; periaortic gas present in 92.6% of cases; no standard operative procedure and no guidelines for antimicrobial administration established; and C. septicum was associated with cancer in 82.5% of cases. Thus, we advocate for early diagnosis via the identification of periaortic gas, as an aortic aneurysm progresses rapidly. To reduce the risk of reinfection as well as infection of other sites, there is the need for concurrent surgical management of the aneurysm and any associated malignancy. We recommend debridement of the infectious focus and in situ vascular graft with omental coverage. Postoperatively, orally administered antibiotics must be continued indefinitely (chronic suppression therapy). We believe that these treatments will decrease mortality due to C. septicum-infected aortic aneurysms.

Procalcitonin as a Biomarker for Predicting Amputation Level in Lower Extremity Infections.

Inflammatory markers are essential tools in the decision-making process for lower extremity infections. When coupled with objective findings, clinicians can more accurately diagnose and treat these entities. Typically, markers such as the white blood cell count, erythrocyte sedimentation rate, and C-reactive protein are used to initially assess these patients or monitor the progression of medical or surgical therapy. Procalcitonin is a newer inflammatory marker that is specific for an infectious process. Originally, procalcitonin was used to monitor antibiotic therapy and sepsis for patients in the intensive care setting, but it has now been expanded to other facets of medicine. The utility of procalcitonin has been described for diagnosing infection or osteomyelitis in diabetic foot ulcers. However, limited research has compared inflammatory marker levels and the level of amputation. A retrospective inpatient medical record review was performed of 156 consecutive patient occurrences during 25 months in which surgical intervention was required for a lower extremity infection and an initial procalcitonin level had been obtained. This initial procalcitonin value was then compared with the level of amputation at the final surgical intervention. A highly statistically significant difference was found when comparing those who underwent a below-the-knee or above-the-knee amputation (median procalcitonin 1.72 ng/mL) and those who did not (median procalcitonin 0.105 ng/mL; p < .001). Therefore, patients with higher initial procalcitonin values were more likely to undergo below-the-knee or above-the-knee amputation or require aggressive surgical intervention. Thus, the procalcitonin level can provide valuable initial information to the clinician.

Gangrena gaseosa / Gangrène gazeuse / Gas gangrene

Se presenta un paciente masculino de 29 años, mestizo, recluso, quien 7 días antes de haber sido remitido al servicio de urgencias del Hospital Universitario Amalia Simoni se había inoculado, en autoagresión, heces fecales en la pierna y el muslo derechos. Refirió dolor y presentaba gran toma del estado general. A la exploración física se constató aumento de volumen generalizado del miembro inferior derecho, con zonas de eritema marcado que alternaban con áreas de necrosis que incluso afectaban el abdomen bajo, aumento de la temperatura local; a la palpación, dolor intenso con amplia zona de crepitación subcutánea, además de bulas de contenido serohemático, pútrido, de olor fétido. La radiografía reveló aumento marcado de la opacidad de las partes blandas, bandas de gas a nivel del tejido celular subcutáneo y presencia de numerosas bulas sin toma ósea. Se decidió tratamiento quirúrgico multidisciplinario que incluyó la desarticulación en guillotina del miembro inferior derecho a nivel de la cadera y toilette amplia, medidas de soporte vital, y la combinación de clindamicina, vancomicina y meronem. La gangrena gaseosa es una infección fulminante de los tejidos blandos con una mortalidad elevada; la sospecha diagnóstica y el entendimiento de la fisiopatología mejoran el pronóstico. El soporte vital, el equilibrio del medio interno, el uso de antimicrobianos de amplio espectro y un tratamiento quirúrgico agresivo, disminuyen la mortalidad(AU)

A case of a 29-year convict mestizo male patient is presented here. This patient is referred to the emergency department of Traumatology at Amalia Simoni University Hospital, seven days after having self-inoculated with stool in his right leg and thigh as self-harm. The patient complained of pain and his general was very poor. Physical examination revealed generalized increase in volume of the right lower limb, with marked erythema areas alternating with areas of necrosis that were even affecting the lower abdomen; increased local temperature, tenderness, pain with subcutaneous crepitus in wide area were found, as well as bulls serohematic bulls, putrid, foul-smelling. Radiography reveals marked increase in opacity of the soft tissues, bands of gas at the level of subcutaneous tissue and the presence of numerous bulls without bone involvement. Multidisciplinary surgical treatment was decided including the guillotine disarticulation of the right leg to hip level and wide toilette, life support, and the combination of clindamycin, vancomycin, and meronem. Gas gangrene is a fulminant soft tissue infection with high mortality; the suspected diagnosis and understanding of the pathophysiology improve prognosis. Life support, balance the internal environment, the use of broad-spectrum antimicrobials and aggressive surgical treatment, reduce mortality(AU)

Un patient âgé de 29 ans, métis, reclus, référé au service d'urgences à l'hôpital universitaire "Amalia Simoni" dû à une automutilation (inoculation de selle dans la jambe et la cuisse droites), est présenté. Il a exprimé une douleur et une sensation de mal-être. Dans l'examen physique, on a pu constater une inflammation du membre inférieur droit; des zones érythémateuses très marquées alternant avec des zones nécrosées, même arrivant à l'abdomen bas; une augmentation de la température locale; une douleur violente avec une zone de crépitements à la palpation, et des bulles à contenu séro-hématique, putréfié et fétide. La radiographie a révélé une augmentation significative de l'opacité des parties molles, des bandes gazeuses au niveau du tissu cellulaire sous-cutané, et une présence de nombreuses bulles sans prise osseuse. On a décidé un traitement chirurgical pluridisciplinaire consistant à une désarticulation en guillotine du membre inférieur droit au niveau de la hanche et un curettage profond; des soins intensifs, et une combinaison de clindamycine, vancomycine et méropénème. La gangrène gazeuse est une infection fulminante des tissus mous avec un taux de mortalité très haut. Le diagnostic suspecté et la compréhension de la physiopathologie améliorent le pronostic. Les soins intensifs, l'équilibre du milieu intérieur, l'emploi d'antimicrobiens à large spectre et un traitement chirurgical agressif font réduire le taux de mortalité(AU)

Clostridium septicum aortitis and colon carcinoma.

BACKGROUND: Clostridium septicum (C. septicum) aortitis is a rare but highly fatal infection that has a strong association with occult malignancy. Aneurysmal transformation of C. septicum aortitis is common and has been reported to occur in as little as 1 to 3 weeks. We report a case of C. septicum Aortitis with concomitant adenocarcinoma of the ascending colon detected via CT scan. Imaging findings of colonic malignancy with aortitis are highly suggestive of infection with C. septicum. Given the high associated mortality and rapid progression, early recognition on imaging could have life saving implications. Additionally, imaging findings of aortitis in conjunction with C. septicum bacteremia should prompt the careful evaluation for malignancy, most notably colonic or hematologic.