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.

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.

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.

[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.

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.

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.

Clostridium septicum gas gangrene in the orbit: a case report.

Our report presents a case of Clostridium septicum gas gangrene in an unusual, orbital localization. The predisposing factors are typical: colon tumour and lymphatic malignancy. Most probably bacteria from the intestinal flora entered the bloodstream through the compromised intestinal wall and settled in the orbit resulting in the development of an abscess containing gas. At the site of the gas gangrene, an indolent B cell lymphoma was present. After surgery and antibiotic treatment, the patient healed from the C. septicum infection; but subsequently died as a consequence of the tumour.

A rare diagnostic challenge in acute appendicitis: a case report.

Although rare, acute appendicitis presenting as a remote abscess with cellulitis in the gluteal region, retroperitoneal region, groin, or thigh does occur and may present a diagnostic challenge. We report a case of a 78-year-old woman presenting with an extensive gas-forming abscess in the right gluteal region secondary to perforated appendicitis without significant gastrointestinal symptoms. Computed tomography (CT) demonstrated a retroperitoneal abscess extending along the sacropelvic surface of the ilium to the subcutaneous tissue. Subsequently, laparotomy revealed retrocecal appendicitis perforated at the base of the cecum, and contained in the retroperitoneum without any signs of peritonitis. This case not only represents an unusual manifestation of acute appendicitis, but also alerts us to the importance of anatomical considerations when interpreting disease extent with imaging. In the differential diagnosis of gluteal or upper thigh abscesses, the rare possibility of perforated acute appendicitis should be considered.

Management of gas gangrene in Wenchuan earthquake victims.

Gas gangrene is an emergency condition, which usually develops after injuries or surgery. This study was designed to investigate clinical characteristics, appropriate therapy, and effective control of nosocomial cross-infection of gas gangrene in Wenchuan earthquake victims. Data on diagnosis, treatment, and prevention of confirmed, suspected, or highly suspected gas gangrene were collected. Sixty-seven (2.41%) cases of suspected gas gangrene were found, in which 32 cases were highly suspected of gas gangrene and 5 cases were confirmed by culture of Clostridium perfringens. Thereof, injury sites were mainly located on the limbs, and typical indications, including crepitation, severe localized pain, swelling, wound discoloration, dark red or black necrotic muscle, foul smell as well as different degrees of systemic toxic performance were common among them. After hospitalization, all patients were isolated and had surgery quickly to remove dead, damaged or infected tissue. The wounds were also exposed for drainage and washed or padded with 3% liquid hydrogen peroxide for disinfection before all diagnostic test results were available. Additionally, high doses of antibiotics (mainly penicillin) were given for the prevention of infection, and supportive therapy was applied for corresponding symptoms control. Among those cases, no fatality was reported. In summary, in post-disaster emergency relief, the diagnosis of gas gangrene should be primarily based on clinical manifestations; while patient isolation, wound debridement and disinfection, as well as antibiotics treatment, is the main measures for proper treatment and control of nosocomial infection for gas gangrene.

Rapidly developing gas gangrene due to a simple puncture wound.

Gas gangrene, an infection caused by Clostridium perfringens, is a potentially fatal and physically disabling disease due to its sometimes incredibly rapid progression. An adolescent boy was referred to our university hospital with a history of nail puncture in the hand that occurred a few hours previously. The physical examination revealed a swollen and tender arm with crepitations up to the shoulder. Gas was coming out from the puncture wound with digital pressure on the forearm. The plain radiograph of the arm was typical of gas gangrene with the presence of gas under the skin and between muscular fibrils.Having received 1 dose of meropenem, the boy had surgery, in which his entire upper extremity had to be disarticulated from the shoulder. The maintenance antimicrobial therapy with intravenously administered penicillin G and clindamycin was continued for a duration of 10 days, at the end of which, the patient was discharged.The rapidly progressive character and the dramatic ending of this case made us wonder whether antimicrobial prophylaxis would play any role in the preventive management of puncture wounds.

[Massive intravascular hemolysis secondary to sepsis due to Clostridium perfringens]. / Hemólisis masiva intravascular secundaria a sepsis por Clostridium perfringens.

Massive hemolysis secondary to sepsis caused by Clostridium perfringens is a rare entity but appears fairly often in the literature. In nearly all published reports, the clinical course is rapid and fatal. We describe the case of a 75-year-old woman with diabetes who was admitted with symptoms consistent with acute cholecystitis. Deteriorating hemodynamics and laboratory findings were consistent with intravascular hemolysis, coagulation disorder, and renal failure. Gram-positive bacilli of the Clostridium species were detected in blood along with worsening indicators of hemolysis. In spite of antibiotic and surgical treatment, hemodynamic support and infusion of blood products, the patient continued to decline and died in the postoperative recovery unit 14 hours after admission. Mortality ranges from 70% to 100% in sepsis due to Clostridium perfringens, and risk of death is greater if massive hemolysis is present, as in the case we report. Only a high degree of clinical suspicion leading to early diagnosis and treatment can improve the prognosis. This bacterium should therefore be considered whenever severe sepsis and hemolysis coincide.

[Microbiological diagnosis of gas gangrene caused by Clostridium septicum (a clinical case)].

Microscopy of gram-stained impression smears is used for the rapid diagnosis of microorganisms in the wound. The shin tissues of patient P. with suspected gas gangrene of lower extremity soft tissues were microscopically found to have gram-positive spore-forming bacteria that were morphologically similar to C. bifermentans that were identified as C. septicum on cultural diagnosis. The pathogenic C. septicum strain spores were likely to be formed in the macroorganism upon exposure of the pathogen to a patient's defense factors and to a package of therapeutic measures. Microbiological data should be used only in combination with clinical and instrumental findings and the results of other laboratory studies when the optimal technology is chosen to treat gas infection. By keeping in mind that there may be clostridial gangrene in the patients and the experience of clinicians and bacteriologists may be insufficient in diagnosing this pathology, it is necessary to strengthen the training of physicians in the diagnosis of this pathology.

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.

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.