[Invasive Streptococcal infections - an interdisciplinary challenge]. / Invasive Streptokokken-Infektionen ­ eine interdisziplinäre Herausforderung.

HISTORY AND CLINICAL FINDINGS: We report on a 34-year-old female patient and a 50-year-old male patient, both of whom were admitted to our emergency department with severe septic conditions. MEDICAL EXAMINATIONS: Both patients were resuscitated and exhibited clinical as well as laboratory evidence of a severe bacterial infection. DIAGNOSIS: Both patients had an invasive infection with Group A Streptococcus. The female patient had a Streptococcal sepsis with severe pneumonia, while the male patient had a Streptococcus-induced necrotizing fasciitis of the upper extremity. THERAPY AND COURSE: While the female patient unfortunately died in the emergency department`s resuscitation room despite all intensive medical treatments, the male patient survived after prompt surgical therapy and an extended stay in the intensive care unit. CONCLUSION: Patients with invasive infections caused by Group A Streptococcus can deteriorate rapidly clinically. Prompt diagnosis and initiation of often interdisciplinary treatment are important. Nevertheless, these conditions can be fatal.

Efficacity of hyperbaric oxygen therapy for necrotizing fasciitis in the maxillofacial region: The review of the literature.

Necrotizing fasciitis (NF) is a rare, dangerous, potentially fatal infectious disease of soft tissue. The treatment consists of antibiotic therapy, surgical debridement and subsequent reconstruction. Hyperbaric oxygen (HBO) therapy has been applied in NF patients recently, so our aim was to gather the findings and outcomes for HBO therapy. A PubMed and Google Scholar literature search was conducted regarding the effect of HBO therapy in patients with NF following key words: 'necrotizing fasciitis' AND 'maxillofacial region' OR 'head and neck' AND 'hyperbaric oxygen' OR 'HBO'. A total of 3333 studies have been identified, of which only 16 articles met the inclusion criteria of this review. A conclusion was made, that aggressive combinations of antibiotics and surgical debridement followed by incorporation of HBO therapy, as an adjuvant treatment, in patients with NF and in company by immunoglobulin therapy are showing promising results. In addition, multi-centric studies should be in consideration for further research.

Difficult intubation in a patient with acute epiglottitis and abscess complicated with cervical necrotizing fasciitis: A case report.

INTRODUCTION: Acute epiglottitis is not uncommon and it can cause high mortality due to airway obstruction. Acute epiglottitis complicated with cervical necrotizing fasciitis has rarely been reported, and it is also a life-threatening disease with a fatality rate of 7% to 50%. PATIENT CONCERNS: A 64-year-old woman presented to our hospital with chief complaints of sore throat and cervical swelling, long with foreign body sensation and hoarseness. Endoscopic laryngoscopy showed erythematous and swollen epiglottis with purulent secretions on the surface. Computed tomography (CT) scan showed swollen epiglottis and swelling of the neck with air- and fluid-containing necrotizing tissue. DIAGNOSES: The diagnosis was acute epiglottitis and abscess complicated with cervical necrotizing fasciitis. INTERVENTIONS: With the patient in awake condition, airway access was established by performing intubation with adjunctive use of gum elastic bougie, followed by surgical debridement under general anesthesia; a flap was used for skin coverage and intravenous piperacillin-tazobactam was administered. OUTCOMES: The patient was discharged without complications. CONCLUSION: Gum elastic bougie is a usable tool in difficult intubation. Adequate pre-anesthesia evaluation, patient sedation, and gentle manipulation assured the intubation success in this case.

Necrotizing soft-tissue infection of the upper limb: A single-center study of 24 cases.

OBJECTIVES: Necrotizing soft-tissue infection and necrotizing fasciitis of the upper limb are infrequent. Studies are rare, and often include other anatomical regions. The specificities and particularities of this pathology are not well known. The aim of this study was to report diagnosis and treatment aspects. METHODS: A retrospective study was conducted over 10 years on every patient treated for necrotizing fasciitis of the upper limb with clinical, bacteriological and histological confirmation. One hundred ninety-eight items were extracted for each patient concerning clinical, biological, radiological and therapeutic data. RESULTS: During 10 years, 24 patients were diagnosed with necrotizing fasciitis of the upper limb: 18 males, 6 females; mean age, 59.9 years; mean body mass index, 25. Local erythema, pain and fever were the most frequent symptoms. Skin necrosis was present in fewer than 40% of patients. Sixteen cases (66.6%) had prior skin lesions and/or an entry point on the limb. Ten had non-steroidal anti-inflammatory drug prescription before acute symptom onset (42%), requiring intensive care unit admission. Treatment comprised surgical resection, resuscitative measures, antibiotic therapy and reconstructive surgery. Seven patients (30.4%) had 1 session of cutaneous excision, and the others had more than 2. Microbiological analysis found mono-microbial beta-hemolytic group A streptococci (BHGAS) infection in 14 patients (58.4%). Antibiotics were prescribed in 91% of cases before surgery, and in 100% after. The most frequently prescribed substance was clindamycin (18 patients, 75%). Ten patients (42%) stayed in the intensive care unit during treatment. Seventeen patients (70.8%) had thin skin graft reconstruction, including 50% with dermal substitute. Five patients (20.8%) had partial upper limb amputation. Two patients (8.3%) died in the 30 days following diagnosis. CONCLUSIONS: The death rate in necrotizing fasciitis of the upper limb was rather low but the amputation rate was higher than in other locations. This study shows the specific clinical, biological and treatment features of this rare but serious pathology of the upper limb.

[Emergencies in infectious diseases]. / Infektiologische Notfälle.

This article aims to provide an overview of common and high-impact medical emergencies that require prompt and effective infectious diseases management. In the described clinical scenarios of malaria, sepsis, necrotizing fasciitis, and meningitis the authors have emphasized the crucial importance of rapid and accurate diagnosis, as well as appropriate treatment from the perspective of infectious diseases. All of these emergencies demand a high degree of clinical suspicion for accurate diagnosis. Some of them also necessitate the involvement of other medical disciplines, such as neurology in the case of meningitis or surgery for necrotizing fasciitis. Additionally, implementing the right empiric antibiotic regimen or, in the case of malaria, antiparasitic treatment is crucial for improving patient outcomes. As patients with these diagnoses may present at any outpatient department, and efficient and quick management is essential, a deep understanding of diagnostic algorithms and potential pitfalls is of the utmost importance.

[Hyperbaric oxygen therapy and eye disease: Review of the literature]. / Oxygénothérapie hyperbare et maladies oculaires : une revue de la littérature.

Hyperbaric oxygen therapy consists of breathing 100% oxygen continuously or intermittently in a chamber at a pressure equal to or greater than 1.4 absolute atmospheres. Indicated for the emergency treatment of carbon monoxide poisoning and other medical-surgical pathologies such as gas embolism or necrotizing soft-tissue infections, various studies have shown a beneficial effect of hyperbaric oxygen therapy in certain ocular pathologies, notably of microcirculatory origin, such as central retinal artery occlusion or macular edema linked to retinal vein occlusions. In addition, hyperbaric oxygen might represent an alternative treatment for ocular quinine toxicity and might also be useful as an adjuvant to surgery and antibiotics in cases of periorbital necrotizing fasciitis. On the other hand, oxygen in high concentrations has toxic ocular effects due to the production of reactive oxygen derivatives.

[Pediatric necrotizing soft-tissue infections]. / Infections cutanées nécrosantes de l'enfant.

PEDIATRIC NECROTIZING SOFT-TISSUE INFECTIONS. Necrotizing soft-tissue infections (NSTI) include necrotizing forms of fasciitis, myositis, and cellulitis. In children, these are extremely rare conditions with an estimated annual incidence of less than 0.1/100,000 patients aged 0-18 years in France. Nevertheless, the evolution can be very serious (6% mortality, higher than the mortality observed in paediatric intensive care units [PICU]), whereas the initial local symptoms are poor and can be falsely reassuring. The monitoring of a skin infection must be close in order not to ignore the evolution towards a NSTI. In this case, prompt transfer to a PICU with all the necessary technical facilities and used to the management of these rare conditions must be done. Early initiation of antibiotic treatment and aggressive haemodynamic resuscitation according to the latest Surviving Sepsis Campaign guidelines should be a priority. The paediatric surgeon should be called upon as soon as clinical suspicion arises and participate in the frequent clinical reassessment to determine the optimal time to perform the surgical treatment.

INFECTIONS CUTANÉES NÉCROSANTES DE L'ENFANT. Les infections cutanées nécrosantes comprennent les dermo- hypodermites bactériennes nécrosantes (DHBN) et les fasciites nécrosantes (FN). Chez l'enfant, ce sont des pathologies extrêmement rares, avec une incidence annuelle en France estimée inférieure à 0,1/100 000 patients âgés de 0 à 18 ans. Néanmoins, leur évolution peut être gravissime (mortalité de 6 %, supérieure à la mortalité observée habituellement dans les unités de réanimation pédiatrique [URP]) alors que la symptomatologie locale initiale est pauvre et peut faussement rassurer. La surveillance d'une infection cutanée doit être rapprochée afin de ne pas méconnaître l'évolution vers une DHBN-FN. Dans ce cas, une orientation vers une URP disposant de l'ensemble du plateau technique nécessaire, et surtout habituée à gérer ces situations cliniques, est justifié. L'initiation précoce du traitement antibiotique et la prise en charge hémodynamique agressive en suivant les dernières recommandations de la Surviving Sepsis Campaign doivent être une priorité. Le chirurgien pédiatrique doit être appelé dès la suspicion clinique et participer à la réévaluation pluriquotidienne afin de déterminer le moment optimal pour réaliser le traitement chirurgical.

Contemporary national outcomes of hyperbaric oxygen therapy in necrotizing soft tissue infections.

BACKGROUND: The role of hyperbaric oxygen therapy (HBOT) in necrotizing soft tissue infections (NSTI) is mainly based on small retrospective studies. A previous study using the 1998-2009 National Inpatient Sample (NIS) found HBOT to be associated with decreased mortality in NSTI. Given the argument of advancements in critical care, we aimed to investigate the continued role of HBOT in NSTI. METHODS: The 2012-2020 National Inpatient Sample (NIS) was queried for NSTI admissions who received surgery. 60,481 patients between 2012-2020 were included, 600 (<1%) underwent HBOT. Primary outcome was in-hospital mortality. Secondary outcomes included amputation, hospital length of stay, and costs. A multivariate model was constructed to account for baseline differences in groups. RESULTS: Age, gender, and comorbidities were similar between the two groups. On bivariate comparison, the HBOT group had lower mortality rate (<2% vs 5.9%, p<0.001) and lower amputation rate (11.8% vs 18.3%, p<0.001) however, longer lengths of stay (16.9 days vs 14.6 days, p<0.001) and higher costs ($54,000 vs $46,000, p<0.001). After multivariate analysis, HBOT was associated with decreased mortality (Adjusted Odds Ratio (AOR) 0.22, 95% CI 0.09-0.53, P<0.001) and lower risk of amputation (AOR 0.73, 95% CI 0.55-0.96, P = 0.03). HBO was associated with longer stays by 1.6 days (95% CI 0.4-2.7 days) and increased costs by $7,800 (95% CI $2,200-$13,300), they also had significantly lower risks of non-home discharges (AOR 0.79, 95%CI 0.65-0.96). CONCLUSIONS: After correction for differences, HBOT was associated with decreased mortality, amputations, and non-home discharges in NSTI with the tradeoff of increase to costs and length of stay.

[Analysis of clinical data of necrotizing fasciitis secondary to intestinal fistulas and screening the mortality risk factors].

Objective: To analyze the clinical data and to screen the mortality risk factors of necrotizing fasciitis (NF) secondary to intestinal fistulas (NFsIF). Methods: This study was a retrospective observational study. The data of all NFsIF cases who met the inclusion criteria and were admitted into Shandong Provincial Hospital Affiliated to Shandong First Medical University (hereinafter referred to as our unit) from January 2000 to October 2023, and in PubMed, Web of Science, Scopus, China National Knowledge Infrastructure, and Chinese Medical Journal Network databases from its establishment to October 2023 were retrieved and screened. Based on clinical outcomes, the cases were divided into survival group (47 males and 24 females) and death group (16 males and 7 females), and the mortality rate was calculated. Clinical data of patients in the two groups including age, underlying diseases (most related to NF), symptom duration before presentation, white blood cell count, causes of NF, signs of peritonitis, scope of NF involvement, and intestinal management and wound management measures were compared and analyzed to screen the risk factors of death in 94 patients with NFsIF. Results: A total of 94 valid cases were collected, including 90 patients reported in the literature and 4 patients admitted to our unit, with the mortality rate of patients being 24.5% (23/94). Univariate analysis showed that there were no statistically significant differences in age, underlying diseases, symptom duration before presentation, white blood cell count, causes of NF, signs of peritonitis, scope of NF involvement between patients in the two groups (P>0.05); there were statistically significant differences in intestinal treatment and wound treatment between the two groups (with χ2 values of 17.97 and 8.33, respectively, P<0.05). Multivariate logistic regression analysis showed that both intestinal treatment measures and wound treatments measures were independent risk factors for death in 94 NFsIF patients, among which first-stage colostomy+late-stage reconstruction and negative presssure therapy had higher protective effects (with odds ratios of 0.05 and 0.27, respectively, 95% confidence intervals of 0.01-0.33 and 0.08-0.88, respectively, P<0.05). Conclusions: The mortality risk of patients with NFsIF is high. Based on comprehensive treatments, active intestinal and wound treatment may be the key to avoid death, with first-stage colostomy+late-stage reconstruction and negative pressure therapy having higher protective effects.

[Hand infections]. / Infections de la main.

HAND INFECTIONS. Hand and finger infections are very common. They result from the inoculation of a germ through the skin barrier. They can range from simple paronychia to extremely serious necrotizing fasciitis. Certain infections, such as those resulting from bites, have their own specific characteristics, which will determine how they are managed. While management can be medical in the early stages, it is important not to ignore the need for surgical treatment, otherwise serious complications may arise, leading to functional and aesthetic sequelae. Delays in treatment cannot be made up. Any infectious lesion can be potentially serious and must be treated in an appropriate department if there is the slightest doubt.

INFECTIONS DE LA MAIN. Les infections de la main et des doigts sont très fréquentes. Elles résultent de l'inoculation d'un germe à travers la barrière cutanée. Elles vont du simple panaris à la gravissime fasciite nécrosante. Certaines infections, comme celles faisant suite aux morsures, ont des caractéristiques propres dont dépend la prise en charge. Si elle peut être médicale au stade initial, il est important de ne pas méconnaître le moment du traitement chirurgical sous peine de voir survenir des complications graves responsables de séquelles fonctionnelles et esthétiques. Le retard à la prise en charge ne peut être rattrapé. Toute lésion infectieuse peut être potentiellement grave et, au moindre doute, doit être prise en charge dans un service adapté.

Does Negative Pressure Wound Therapy Impact the Outcome for Patients With Necrotizing Soft Tissue Infection Infected With Anaerobic Bacteria?

Background: A notable improvement in the treatment of necrotizing soft tissue infections (NSTIs) is the development of negative pressure wound therapy (NPWT). Clinicians are still debating whether NPWT is as successful as conventional wet-to-dry dressings at removing bacteria. Recent research has revealed potential oxygen deprivation effects of NPWT in underlying wound tissues, although clinical trials regarding the effects of reduced oxygen on anaerobic bacterial soft tissue infections remain noticeably lacking. Hypothesis: We hypothesized that NPWT-treated patients with NSTIs who were solely infected by anaerobic bacteria would have worse outcomes than those who were infected with other bacterial species. Patients and Methods: Our study included a retrospective examination of the 2008-2022 period of our Acute and Critical Care Surgery database. Patients who had been identified as having necrotizing fasciitis, Fournier gangrene, or gas gangrene and who had their conditions verified by positive wound cultures acquired during the initial debridement and subsequently received NPWT made up the study cohort. Comorbidities, surgical techniques, and clinical results were all covered by the data. Based on their wound infections, patients were divided into two groups: those with exclusively anaerobic NSTIs and those with different bacterial groups (such as polymicrobial and aerobic). Multiple regression, χ2 analysis, and analysis of variance (ANOVA) were among the analytical methods used. Results: One hundred twelve patients with NSTI who had received NPWT comprised the study cohort. Sixteen of these patients (14.3%) had NSTIs that were exclusively anaerobic, whereas the remaining 96 (85.7%) had NSTIs that were mixed aerobic, facultative, or polymicrobial. Between the two groups, there was no difference in the initial wound size. Patients with anaerobic NSTI who underwent NPWT showed a statistically significant increase in the number of debridements (3 [interquartile range {IQR},1-9] vs. 2 [IQR, 1-4]; p = 0.012) and an increased 100-day re-admission rate (37.5% vs. 12.5%; p = 0.012) when compared with patients with non-anaerobic NSTI. The 100-day re-admission rate increased three-fold in NPWT-treated anaerobic NSTIs, according to a logistic regression analysis (odds ratio [OR], 3.63; 95% confidence interval [CI], 1.06-12.44; p = 0.04). Conclusions: In contrast to patients with other bacterial strains, our data show that patients with NSTI treated with NPWT who only have anaerobic bacterial infections have a larger number of debridements and are much more likely to require re-admission within 100 days. We call for additional prospective studies to be conducted to identify additional risk factors and consider alternate treatment options for individuals with exclusively anaerobic NSTIs in light of these findings.

Characterization of patients with odontogenic necrotizing soft tissue infections in the head and neck area. A retrospective analysis.

OBJECTIVE: Necrotizing soft-tissue infection (NSTI) in the head and neck area may develop from odontogenic infections. The aim of this study was to characterize patients with NSTI in the head and neck with odontogenic origin in a well-defined prospectively collected cohort. MATERIAL AND METHODS: Patients with NSTI in the head and neck, hospitalized between 2013 and 2017 at Copenhagen University Hospital and registered in the Scandinavian INFECT database were included. Medical records of identified patients and from the INFECT database were screened for a defined set of data including the primary focus of infection, comorbidities, predisposing factors, clinical and radiographic diagnostics, course of treatment, and treatment outcome. RESULTS: Thirty-five patients with NSTI in the head and neck area were included in the study. A total of 54% had odontogenic origin, primarily from mandibular molars, and 94% had radiographic signs of infectious oral conditions. Overall, comorbidities were reported in 51% with cardiovascular disease being the most prevalent. In 20%, no comorbidities or predisposing conditions could be identified. The overall 30-day mortality rate was 9%. CONCLUSIONS: More than half of NSTI cases in the head and neck region had an odontogenic origin, and special attention should be paid to infections related to mandibular molars.

Necrotizing fasciitis: an update on epidemiology, diagnostic methods, and treatment.

PURPOSE OF REVIEW: The aim of this review is to discuss the latest evidence of epidemiology, diagnostic methods, and treatment of necrotizing soft tissue infections (NSTIs) with a particular focus on necrotizing fasciitis (NF). RECENT FINDINGS: NSTIs have been historically referred to as NF but encompass a broader range of infections, with variable rates ranging from 0.86 to 32.64 per 100 000 person-years, influenced by factors such as climate and seasonal variations. They have diverse microbiological profiles categorized into different types based on the involved pathogens, including polymicrobial or monomicrobial infections caused by organisms such as group A streptococcus (GAS), Staphylococcus aureus , some Gram-negative pathogens, and filamentous fungi following trauma and natural disasters. Diagnosis relies on clinical symptoms and signs, laboratory markers, and imaging. However, the gold standard for diagnosis remains intraoperative tissue culture. Treatment involves repeated surgical debridement of necrotic tissues in addition to intravenous antibiotics. Adjuvant therapies with intravenous immunoglobulin (IVIG) and hyperbaric oxygen therapy (HBOT) might have a role. Soft tissue reconstruction may be necessary following surgery. SUMMARY: Prompt diagnosis and proper medical and surgical management of NSTI will improve outcomes.

Pathogens and their resistance behavior in necrotizing fasciitis.

BACKGROUND: Necrotizing fasciitis (NF) is a rare but life-threatening condition in which extensive soft tissue destruction can occur very quickly if left untreated. Therefore, timely broad-spectrum antibiotic administration is of prognostic importance in addition to radical surgical debridement. AIM: This study evaluates the cases of NF in our hospital during the last ten years retrospectively with respect to the pathogens involved and their antimicrobial resistance. This approach aims to provide guidance regarding the most targeted initial antibiotic therapy. METHODS: We performed a retrospective microbiological study evaluating pathogen detection and resistance patterns including susceptibility testing of 42 patients with NF. RESULTS: Type 1 NF (polymicrobial infection) occurred in 45% of the patients; 31% presented type 2 NF (monomicrobial infection). The most common pathogens detected were E. coli, staphylococci such as Staphylococcus aureus and Staphylococcus epidermidis, Proteus mirabilis, enterococci, and streptococci such as Streptococcus pyogenes. Twelve percent presented an additional fungus infection (type 4). Ten percent showed no cultivation. Two percent (one patient) presented cocci without specification. CONCLUSION: Most pathogens were sensitive to antibiotics recommended by guidelines. This confirms the targeting accuracy of the guidelines. Further studies are necessary to identify risk factors associated with multidrug resistant infections requiring early vancomycin/meropenem administration.

Vacuum-assisted closure of a tissue deficit of the submental area in a patient with a necrotizing soft tissue odontogenic infection.

Odontogenic infections can rarely progress to necrotizing soft tissue infections. Cervical necrotizing fasciitis (CNF) is a rare but fulminant infection that spreads along the fascial planes, including connective tissue, muscle, and subcutaneous fat, and is typified by necrosis of the skin and other adjacent tissues. This article aims to present the treatment of a patient with submental skin and soft tissue necrosis due to an odontogenic infection and the subsequent management of the tissue deficit with a vacuum-assisted closure (VAC) system. The patient presented with extensive skin necrosis in the submental area and was immediately hospitalized, and management of the odontogenic infection was performed. When the patients' infection had been sufficiently controlled, a wound VAC device was placed in the deficit. The VAC device was removed after 12 days, and the patient was discharged. In conclusion, VAC can be used to manage tissue deficits with good aesthetic results.

Necrotizing Soft-Tissue Infections: A Case-Based Review.

GENERAL PURPOSE: To review the assessment and management of necrotizing fasciitis. TARGET AUDIENCE: This continuing-education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Identify the etiologic pathogens for necrotizing fasciitis.2. Summarize assessment guidelines for patients who present with signs of necrotizing fasciitis.3. Explain recommended treatment protocols for patients who have necrotizing fasciitis.

Necrotizing fasciitis is a rapidly progressive soft-tissue infection with tissue necrosis and a high mortality rate. This case-based review provides an overview of an approach to the diagnosis and management of necrotizing fasciitis for clinicians.