Necrotising soft tissue infections. / Nekrotiserende bløtdelsinfeksjoner.

Necrotising soft tissue infections can affect the skin, subcutaneous tissue, superficial fascia, deep fascia and musculature. The infections are severe, they spread quickly and can result in extensive tissue loss. Although rare, morbidity and mortality rates are high. Early clinical identification is crucial for the outcome, and rapid infection control through surgery and targeted antibiotic treatment is needed to save lives. Few prospective clinical trials have been conducted for the treatment of this type of infection. Specific challenges include rapid identification of the condition and the uncertain efficacy of the various treatment options. In this clinical review article, we describe clinical characteristics, diagnostics and treatment.

A Comparative Observation on Wound Healing After Surgery for Necrotizing Fasciitis: Kangfuxin Liquid Gauze versus Vaseline Gauze.

Objective: To evaluate the effectiveness of Kangfuxin Liquid (a traditional Chinese medicine) gauze and Vaseline gauze in wound healing after necrotizing fasciitis surgery. Method: The study was conducted at The First Affiliated Hospital of Baotou Medical College between February 2020 and February 2022. A total of 54 patients diagnosed with necrotizing fasciitis were randomly assigned to the Vaseline gauze group as the control group, and the Kangfuxin Liquid gauze group as the experimental group. Various aspects of treatment efficacy, wound healing conditions, healing indicators, pain scores, inflammation markers, and adverse reactions were compared between the two groups. Results: The total effective rate in the experimental group (100.00%) was significantly higher than that in the control group (77.78%), with a statistically significant difference The experimental group showed lower scores for secretion, granulation tissue morphology, redness, and swelling compared to the control group, with statistical significance. Additionally, the experimental group exhibited faster slough separation, new epidermis formation, and overall wound healing compared to the control group, with statistical significance. Visual analog scale (VAS) scores on postoperative days 3, 7, 9, and 14 were significantly lower in the experimental group than in the control group. Before treatment, there was no statistically significant difference in the levels of interleukin-17 (IL-17), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α) between the two groups. However, after treatment, both groups exhibited a decrease in inflammatory markers, and the experimental group had significantly lower levels of IL-17, IL-6, and TNF-α compared to the control group). Furthermore, the incidence of adverse reactions in the experimental group (3.70%) was significantly lower than that in the control group (22.22%). Conclusion: The utilization of Kangfuxin Liquid gauze in wound healing after necrotizing fasciitis surgery effectively promotes wound healing, provides precise therapeutic effects, significantly reduces patient pain, improves inflammation, and exhibits minimal adverse reactions, thus demonstrating high safety. Therefore, the application of Kangfuxin Liquid gauze in this clinical context is highly recommended.

Serologic Evaluations in the Distinction Between Sinusitis-Related Orbital Cellulitis and Periorbital Necrotizing Fasciitis.

PURPOSE: While sinusitis-related orbital cellulitis (SROC) and periorbital necrotizing fasciitis (PNF) share similar clinical presentations, they are managed differently, making rapid recognition of the appropriate clinical entity critical to optimal outcomes. This study was performed to assess whether serologic testing might help clinicians to distinguish between SROC and PNF. METHODS: A retrospective review analysis was used to compare initial complete blood counts and comprehensive metabolic panels among adult patients with SROC and PNF. Statistical evaluations were used to determine the significance of differences between the groups. RESULTS: Thirteen patients with PNF and 14 patients with SROC were identified. The 2 groups were similar in age, gender, and likelihood of immunosuppression ( p > 0.05 for each metric). Mean leukocyte counts were 18.52 (standard deviation = 7.02) and 10.31 (standard deviation = 5.77) for PNF and SROC, respectively ( p = 0.0057). White blood cell levels were above normal limits for 12 patients with PNF (92.3%) and 7 patients with SROC (50%) ( p = 0.017). No other laboratory test was significantly different between the 2 groups. CONCLUSIONS: While the majority of serologic testing was quite similar in patients with either SROC or PNF, leukocyte levels may represent an important clue to distinguish between the two diseases. Clinical evaluation remains the gold standard to make the proper diagnosis, but markedly elevated white blood cell counts should prompt clinicians to at least consider a diagnosis of PNF.

A 30-Day-Old Infant with Necrotizing Fasciitis of the Perineal Region Involving the Scrotum Due to Methicillin-Resistant Staphylococcus aureus (MRSA) and Extended-Spectrum ß-Lactamase (ESBL)-Producing Klebsiella pneumoniae: A Case Report.

BACKGROUND Fournier's gangrene is an idiopathic form of necrotizing fasciitis involving the genital and perineal regions; it is associated with high complication and mortality rates. Rarely, perineal infection may be caused by hospital-acquired antimicrobial-resistant bacteria. This report is of a 30-day-old infant with methicillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum ß-lactamase (ESBL)-producing Klebsiella pneumoniae necrotizing fasciitis involving the perineal region. CASE REPORT A 30-day-old male infant presented to the Emergency Department with rapidly progressive white discoloration of scrotal skin since 3 days prior to admission, progressing from 2-3 white spots to covering two-thirds of the scrotal skin. Pain upon urination was noted, with normal appetite and bowel movements. He had a history of diaper rash 6 days earlier accompanied by fever, and the rash was treated with topical antifungal and corticosteroid ointment. He was born at term by caesarean delivery, with birth weight 2900 g. Laboratory examinations revealed leukocyte count 23 000/µL and CRP 26.8 mg/dL. Hemoglobin was 10.6 g/dL, serum sodium was 134 mEq/L, blood glucose was 80 mg/dL, serum urea was 15 mg/dl, and creatinine was 0.27 mg/dL. Chest and abdominal X-rays were normal. He received broad-spectrum antibiotics and underwent surgical debridement, and necrotic tissue was obtained for biopsy and culture. Histology examination showed non-specific granulation tissue consistent with Fournier gangrene. Soft- tissue culture isolated MRSA and ESBL-K. Antibiotics were changed according to the sensitivity report. Blood and urine cultures were negative. CONCLUSIONS Immediate surgery and antibiotics are essential in treating Fournier gangrene to avoid life-threatening complications. Initial symptoms are non-specific. Diagnosis remains primarily clinical, confirmed by intraoperative macroscopic findings.

Use of Clindamycin for Necrotizing Soft Tissue Infection Decreases Amputation Rate.

OBJECTIVE: To identify the impact of clindamycin use on mortality and amputation rates in patients with necrotizing fasciitis. DESIGN: Retrospective review. SETTING: Level 1 trauma center, single-center study. PATIENTS/PARTICIPANTS: All patients from 2008 to 2019 with a diagnosis of necrotizing fasciitis. One hundred ninety patients were included in statistical analysis. INTERVENTION: Use of clindamycin in the initial antibiotic regimen in the treatment of necrotizing soft tissue infection. MAIN OUTCOME MEASUREMENTS: Amputation and mortality rates. RESULTS: Patients who received clindamycin had 2.92 times reduced odds of having an amputation when compared with their counterparts, even when American Society of Anesthesiologist scores, comorbidities, smoking, drug use, alcohol consumption, race, ethnicity, sex, and age were controlled for and regardless of other antibiotics started (P = 0.015). There was no significant difference in mortality rate between those patients who did and did not receive clindamycin as part of their initial antibiotic regimen (8.3% vs. 11.6%, respectively; P = 0.453). CONCLUSION: The use of clindamycin in the initial antibiotic regimen for treatment of NSTI was shown to significantly decrease rates of amputation but not mortality. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Necrotizing Fasciitis In A Patient with Metastatic Clear Cell Ovarian Carcinoma Treated with Bevacizumab.

BACKGROUND Necrotizing fasciitis is a life-threatening infection of the deep soft tissues that leads to progressive destruction of the fascia and subcutaneous fat. It typically spreads along the muscle fascia planes because of the relatively poor blood supply. Muscle tissue is usually spared because of its better blood supply. The usual risk factors for necrotizing fasciitis include trauma, malnutrition, obesity, uncontrolled diabetes mellitus, alcoholism, cirrhosis, neutropenia, and recent surgery. CASE REPORT We present a case of a middle-aged female who presented with necrotizing fasciitis of the right gluteal region. Her medical history was significant for well-controlled diabetes mellitus (hemoglobin A1c: 6.6), and clear cell carcinoma of ovaries (stage IV). She was on active chemotherapy with bevacizumab, paclitaxel, and carboplatin. She underwent incision and debridement of right gluteal abscess with drainage of 200 ml of foul-smelling pus and was started on intravenous antibiotics. Her blood cultures were negative, but the cultures taken from the right gluteal abscess showed moderate growth of Escherichia coli. The antibiotics were de-escalated and the patient was discharged with outpatient follow-up. CONCLUSIONS Bevacizumab, a humanized monoclonal IgG antibody, is a novel treatment for metastatic ovarian cancer. It is associated with necrotizing fasciitis due to anti-angiogenic, pro-thrombotic, and poor wound healing properties. It should be stopped in the patients presenting with necrotizing fasciitis.

Murine Soft Tissue Infection Model to Study Group A Streptococcus (GAS) Pathogenesis in Necrotizing Fasciitis.

Group A streptococcus (GAS) necrotizing fasciitis (NF) causes high morbidity and mortality despite prompt intravenous administration of antibiotics, surgical soft-tissue debridement, and supportive treatment in the intensive care unit. Since there is no effective vaccine against GAS infections, a comprehensive understanding of NF pathogenesis is required to design more efficient treatments. To increase our understanding of NF pathogenesis, we need a reliable animal model that mirrors, at least in part, the infectious process in humans. This chapter describes a reliable murine model of human NF that mimics the histopathology observed in humans, namely the destruction of soft tissue, a paucity of infiltrating neutrophils, and the presence of many gram-positive cocci at the center of the infection.

Necrotizing fasciitis of the vulva due to carbapenem-resistant Enterobacteriaceae as a complication of acute myeloid leukemia treatment: a case report.

BACKGROUND: Carbapenem-resistant Enterobacteriaceae strains have been reported in healthcare facilities with a rising incidence and are a major concern owing to infections that are often severe and can be potentially fatal, with limited therapeutic options. Klebsiella pneumonia represents the most frequently isolated microorganism. CASE PRESENTATION: We report the case of a Caucasian 52-year old Caucasian woman with acute myeloid leukemia was admitted to the inpatient hematology unit at a university referral hospital in Portugal. This hospital has endemic colonization of Carbapenem-resistant Enterobacteriaceae and contention measures are being implemented to reduce spreading of these multidrug resistant bacteria. After receiving first line chemotherapy according to the intermediate-dose cytarabine regimen, in context of deep medullary aplasia, the patient developed a localized infection of the vulva, which progressed to a necrotizing fasciitis. This is a rare, life-threatening, and fulminant infection. Carbapenem-resistant Klebsiella was isolated in both vulvar exudate and blood cultures. The patient underwent multiple schemes of antimicrobials, but progressed with multiorgan compromise and was admitted to the intensive care unit for a short period for stabilization. Surgical debridement was performed twice with clinical improvement and, after 6 weeks, a skin graft was executed with good response. Reevaluation of the hematologic disease showed a complete response to first cycle of induction therapy. Despite success in resolving this complex infection, decisions regarding antibiotic treatment represented a tremendous challenge for the whole team. The importance of multidisciplinary collaboration was key for the patient's recovery and survival, and therefore, needs to be acknowledged. CONCLUSIONS: This clinical case raises awareness on a clinical entity that can be life threatening and, therefore, requires a high level of suspicion to assure an early integrated approach to avoid complications. Endemic spreading of carbapenem-resistant Enterobacteriaceae is becoming a reality, and health policies need to be urgently undertaken at the national level to decrease morbidity and mortality because of health facilities-related infections.

[Skin and soft tissue infection caused by Streptococcus pneumoniae: report of 15 cases]. / Infección de piel y partes blandas por Streptococcus pneumoniae: presentación de 15 casos.

OBJECTIVE: Streptococcus pneumoniae is a very rare cause of skin and soft tissue infections (SSTI). The aim of this study was to determine the clinical and microbiological characteristics of these infections. METHODS: The medical records of patients with SSTIs due to S. pneumoniae diagnosed at the University Hospital of Guadalajara between January 2012 and December 2020 were retrospectively reviewed. Microbiological identification was performed using conventional procedures. Antimicrobial sensitivity was performed using the MicroScan WalkAway-96 plus automatic system and E-test strips following the recommendations of the European Committee on Antimicrobial Susceptibility Testing (EUCAST). RESULTS: Fifteen cases of SSTIs were diagnosed. 73,3% of the cases presented underlying diseases, neoplasias being the most frequent. 60% of the cases presented predisposing factors, immunosuppression being the most common. The clinical presentations were: abscesses in different locations, ulcers, surgical wounds, lactational mastitis and necrotizing fasciitis. Polymicrobial infections were detected in 73.3% and the etiology was nosocomial in 6.6%. The clinical course was favorable in 90.9% of the cases. The antibiotics with the highest percentages of sensitivity against S. pneumoniae were cefotaxime, levofloxacin, vancomycin, linezolid and rifampicin. CONCLUSIONS: S. pneumoniae should be kept in mind as a possible causative agent of SSTIs, especially in patients with neoplasias and immunosuppression. Its involvement in infections such as lactational mastitis and necrotizing fasciitis should be highlighted. The clinical evolution is favorable in most patients, but it is important to pay special attention to cases of necrotizing fasciitis due to the severity of these infections.

Combined Timed Surgery and Conservative Management of Primary Necrotizing Fasciitis of the Breast: A Case Report.

BACKGROUND Necrotizing fasciitis is a life-threatening infection that involves the deep fascia and the surrounding tissue, but rarely involves the female breast. The most common treatment for necrotizing fasciitis of the breast is total mastectomy. However, the use of negative pressure wound therapy (NPWT), after surgical debridement, is reported to promote the more rapid development of granulation tissue, before reconstructive surgery. This report presents the case of a 53-year-old woman with necrotizing fasciitis of the breast who underwent combined timed surgery and conservative management. CASE REPORT A 53-year-old woman presented with necrotizing fasciitis of the right breast, involving the right lateral chest wall and flank. She was referred to the Intensive Care Unit (ICU) of the hospital with septic shock. After hemodynamic stabilization was achieved, she underwent surgical debridement. Excised breast tissues were sent for histology, and intraoperative swabs were collected and sent for microbiological examination. Intravenous antibiotic therapy and hyperbaric oxygen therapy commenced. The patient was managed with NPWT dressings, followed by reconstructive breast surgery. The right chest and flank completely healed. CONCLUSIONS This case has shown that early diagnosis and management of necrotizing fasciitis of the breast can be life-saving and may allow for breast conservation. Early aggressive debridement combined with NPWT dressings and reconstructive breast surgery resulted in successful wound healing and preservation of the breast with a satisfactory cosmetic outcome.

Cervical Necrotizing Fasciitis After Surgery of a Mandibular Fracture.

INTRODUCTION: Cervical necrotizing fasciitis (CNF) is a rapid progressing and potentially fatal infection of connective tissues that spreads along the fascial planes. It commonly develops from odontogenic sources. In this article, the authors present a case of CNF which was developed after open reduction and internal fixation (ORIF) of a mandibular fracture. CLINICAL CASE: A 19-year-old male patient with no past medical history was admitted due to a mandibular fracture. Following ORIF surgery, on third post-operative day, Physical examination revealed extensive cervical swelling extending from submandibular to suprasternal area, with tender and erythematous skin. Soon after confirmation of CNF diagnosis, surgical debridement and wide spectrum antibiotic therapy was performed. The residual soft tissue defect was reconstructed following infection subsidence. CONCLUSION: Our study aims to highlight the risk of CNF development during postoperative period of a simple mandibular fracture ORIF surgery which is considered a routine maxillofacial procedure. Early detection and adequate emergency treatment including immediate surgical intervention are critical in the management of these patients.

[Rubor, calor, dolor, tumor†: skin and soft tissue infections]. / Rubor, calor, dolor, tumor†: infections de la peau et des tissus mous.

Skin infections are a frequent cause of consultation, yet the diagnosis can be challenging for physicians. Microbiological documentation is rare, and empiric antibiotic regimens should cover the most commonly identified bacteria, i.e. streptococci Staphylococcus aureus. Other pathogens should be considered in case of immunosuppression or certain exposures. Necrotizing fasciitis (NF) is a severe but rare infection. Early surgical management in parallel with antibiotics is the cornerstone of treatment. Despite the high incidence of these infections, little progress has been made in their management and some areas of uncertainty exist, especially regarding the optimal duration of treatment, the prevention of recurrences and the use of polyclonal immunoglobulins for NF. This article reviews the main aspects of diagnosis and treatment of these infections.

Les infections de la peau sont fréquentes mais leur diagnostic peut représenter un défi pour le clinicien. La documentation de l'étiologie microbiologique est rare et le traitement empirique doit couvrir les germes fréquents, notamment Streptococcus spp. et Staphylococcus aureus. Des bactéries inhabituelles peuvent être retrouvées lors d'immunosuppression ou exposition spéciale. La fasciite nécrosante (FN) est une infection sévère mais rare, dont le traitement repose sur la chirurgie rapide et l'antibiothérapie. Malgré leur fréquence, peu de progrès ont été réalisés dans la prise en charge de ces infections et des incertitudes persistent par rapport à la durée optimale de traitement, la prophylaxie pour les récurrences ou l'utilité des immunoglobulines polyclonales intraveineuses pour la FN. Cet article aborde les aspects diagnostiques et thérapeutiques de ces infections.

Gemella morbillorum as a source bacteria for necrotising fasciitis of the torso.

A 66-year-old man presented with upper back cellulitis and imaging findings consistent with a necrotising soft tissue infection. He was started on broad-spectrum intravenous antibiotics and was taken to the operating room for immediate surgical debridement. On postoperative day 5, the culture was noted to be growing Gemella morbillorum, an exceedingly rare cause of necrotising soft tissue infections in immunocompetent hosts. His condition improved, and he was transitioned to oral antibiotics and discharged home.

Necrotizing skin and soft-tissue infections in the intensive care unit.

BACKGROUND: Necrotizing skin and soft-tissue infections (NSTI) are rare but potentially life-threatening and disabling infections that often require intensive care unit admission. OBJECTIVES: To review all aspects of care for a critically ill individual with NSTI. SOURCES: Literature search using Medline and Cochrane library, multidisciplinary panel of experts. CONTENT: The initial presentation of a patient with NSTI can be misleading, as features of severe systemic toxicity can obscure sometimes less impressive skin findings. The infection can spread rapidly, and delayed surgery worsens prognosis, hence there is a limited role for additional imaging in the critically ill patient. Also, the utility of clinical scores is contested. Prompt surgery with aggressive debridement of necrotic tissue is required for source control and allows for microbiological sampling. Also, prompt administration of broad-spectrum antimicrobial therapy is warranted, with the addition of clindamycin for its effect on toxin production, both in empirical therapy, and in targeted therapy for monomicrobial group A streptococcal and clostridial NSTI. The role of immunoglobulins and hyperbaric oxygen therapy remains controversial. IMPLICATIONS: Close collaboration between intensive care, surgery, microbiology and infectious diseases, and centralization of care is fundamental in the approach to the severely ill patient with NSTI. As many aspects of management of these rare infections are supported by low-quality data only, multicentre trials are urgently needed.