[Necrotising soft-tissue infections: diagnostics and treatment]. / Necrotiserende wekedeleninfecties: diagnostiek en behandeling.

Necrotising soft-tissue infections occur in the soft tissue compartment consisting of the dermis, subcutaneous tissue, superficial fascia (fascia of Scarpa), deep fascia and muscle. Although this severe and acutely life-threatening infection has a low incidence, both GPs and specialists will see a necrotizing soft-tissue infection more than once during their career. The mortality related to necrotising soft-tissue infections has been halved during the past 15 years from nearly 40 to 20% due to adequate treatment. Laboratory examination and X-ray findings could be of added value, but the gold standard remains biopsy of the fascia and Gram staining. Treatment consists of prompt volume resuscitation in case of sepsis, administration of broad spectrum antibiotics and surgical debridement; this debridement should be as skin-sparing as possible. The use of hyperbaric oxygen therapy has remained a controversial issue, unless a patient has gas gangrene, caused by Clostridium species. A multidisciplinary treatment and admission to a tertiary intensive care unit are indispensable for the treatment of a septic patient with necrotizing soft-tissue infection.

Malignancy, mortality, and medicosurgical management of Clostridium septicum infection.

BACKGROUND: Necrotizing Clostridium septicum infections (CSI) have a strong association with malignancy or immunosuppression. To clarify this relationship and determine how it impacted mortality, the experience with CSI at a single institution was reviewed. METHODS: Records of all patients admitted to our hospital with culture proven clostridial infection from 1966 through 1993 were reviewed. RESULTS: Among patients presenting with clinical gas gangrene, 281 had culture proven clostridial infection and 32 (11.4%) had CSI. The mortality among CSI patients was 56%, whereas 26% of all patients with clostridial infections died (p = 0.001). An associated malignancy was found in 50% of patients with CSI, whereas this was seen in only 11% of patients with other clostridial infections (p = 0.0001 for CSI versus clostridial infection overall). The remaining patients with spontaneous CSI all had evidence of immunosuppression. CONCLUSIONS: The high mortality and likelihood of associated malignancy or hematologic disease underscore the importance of a high index of suspicion and the need to search for and treat associated conditions in all patients with CSI.

A five year review of anaerobic, necrotizing soft tissue infections: a nursing perspective.

Anaerobic necrotizing soft tissue infections are known for their devastating effects of tissue destruction and death. These infections may occur as a result of trauma, surgical intervention or occur spontaneously in predisposed individuals. They are caused by a wide range of anaerobic organisms and may be categorised according to the tissue involvement as Necrotizing Fasciitis and Myonecrosis. A five year review of patients admitted for hyperbaric oxygen (HBO) therapy and requiring intensive care revealed a patient group numbering 25, roughly equally divided between the two classifications of tissue involvement. Trauma was an aetiological factor in 5 of these cases. Cancer and diabetes mellitus were also prominent aetiological factors. Treatment consisted of the triad of early selective/aggressive surgery, high dose antibiotic therapy and HBO therapy. The mortality of the group was 25%. Delay in treatment was associated with increased mortality. Nursing care, for this particular patient group is demanding, requiring particular attention to wound care, analgesia, transport, psychosocial care of patient with mutilating wounds, nutrition and temperature homeostasis. It is a cause for concern that two cases occurred after elective orthopaedic procedures requiring the application of plaster of paris (POP) cast over a leg.

Gas gangrene.

Gas gangrene is not a disease of the past. Despite improved awareness, earlier care of trauma victims, new antibiotics, and advanced monitoring techniques, histotoxic clostridia continue to cause loss of life and limb. A 20-year literature review on gas gangrene (Part I) indicates that a combined therapy approach with early recognition, surgical intervention, appropriate antibiotics, and hyperbaric oxygen (HBO) provides optimal care. Part II, a 15-year clinical experience, appears to be the largest English-language series reported using the combined therapy of antibiotics, surgery, and hyperbaric oxygen. One hundred thirty-nine patients (95 males and 44 females), average age, 38 years, were admitted with clostridial myonecrosis. Sixty-seven were in shock at admission and the 27 deaths occurred in this group. One hundred twelve patients (81%) survived the infection. There was a 5% mortality in post-traumatic extremity clostridial myonecrosis. Age and concurrent disease increased the mortality rate, as did delay from time of diagnosis to aggressive combined treatment.