Use of Split-Thickness Skin Grafts and Autologous Skin Cell Suspension in a Case of Extensive Fournier Gangrene.

Fournier gangrene (FG) is a life-threatening necrotizing soft-tissue infection of the perineum and external genitalia, which primarily occurs in obese, diabetic males. The mainstay of treatment is source control via early aggressive surgical excision. Wide surgical excision can result in significant soft tissue defects that can be disfiguring and difficult to close. The most common method of closure is split-thickness skin grafting (STSG). Recently, autologous skin cell suspension (ASCS) technology has been used in addition to STSG to provide better wound healing and closure. This patient experienced excellent wound progression, following FG, through the application of ASCS with STSG, despite challenges related to the wounds, anatomical location, comorbidities, size, and the patient's medical history.

Lower limb salvage in necrotizing burn wound infection: The role of fibular ostectomy and local flaps in a resource-limited setting - A case report and literature review.

INTRODUCTION: Necrotizing burn wound infections following burn injuries are rare. Literature on these cases is also scarce. These infections are life- and limb- threatening unless properly managed. They also pose significant reconstructive challenge, especially in settings lacking microvascular capability. This report describes a limb preservation strategy for limb-threatening necrotizing infection of the leg that complicated a burn injury. Innovative approach was used, utilizing proximal fibular ostectomy, bipedicled local advancement flap and split thickness skin graft. CASE PRESENTATION: A 26-year-old female patient presented to our burn unit after sustaining a contact burn injury from a burning charcoal to her right lateral leg within three days. On the second day of admission, the patient developed significant changes in the appearance of the wound, leading to the diagnosis of necrotizing myofacitis. Emergent debridements were done with the aim of preserving the limb. Subsequent successful, albeit sub-optimal, reconstruction was also achieved despite the lack of microvascular surgical capability in the burn unit. DISCUSSION: This case report and literature review describes a rare limb-threatening necrotizing burn wound infection. The significant reconstructive challenge posed by the defect was addressed using a simple but rarely described reconstructive technique. The importance of limb preservation in LMIC is also emphasized. CONCLUSION: The goal of preserving a limb can be met by using a simple reconstructive technique, despite the lack of microvascular capabilities.

Is Prompt Hyperbaric Oxygen Adjunctive Therapy Able to Reduce Mortality and Amputation in Management of Necrotizing Soft-Tissue Infection?

Background: Necrotizing soft-tissue infection (NSTI) is a rare and serious disease with high morbidity and mortality. Standard therapeutic concepts have included urgent surgical intervention, broad-spectrum antibiotic treatment, and intensive care. Hyperbaric oxygen therapy (HBOT) is used as adjuvant therapy in some centers, but its benefits remain controversial. Methods: A retrospective analysis was conducted in which 98 patients with a clinical diagnosis of NSTI were treated with standard treatments plus HBOT. The clinical outcomes were wound healing, performance status, hospital length, complication rate, recurrence rate, morbidity (amputation rate), and mortality. Primary or secondary outcomes were compared between the time interval of HBOT and the clinical outcomes. Results: The average times from diagnosis of NSTI to initial HBO treatment and from initial surgery to initial HBO treatment were both significantly longer in dead patients than in surviving patients (P = 0.031; P = 0.020). These two time intervals were both significantly longer in amputated patients than in preserved patients (P = 0.031; P = 0.037). Conclusions: Using combined treatment with early surgical debridement combined with HBOT, it is possible to reduce hospital stay, intensive care unit stay, number of debridements, improve complete wound healing rate, and lower amputation and mortality rates among patients with NSTI. The early onset of HBOT soon after diagnosis, especially during critical conditions, is proved to be associated with higher survival and preservation rates.

Squirrel bite-a rare cause of necrotizing soft tissue infection: Case report.

Although squirrel bites are uncommon and generally benign, they have been implicated in the transmission of certain diseases in humans, some of which can be life-threatening. This report discusses the case of a 27-year-old hunter who developed a necrotizing soft tissue infection with vesiculo-bullous skin lesions after a ground squirrel bite.

Necrotizing Soft Tissue Infection Following a Closed Distal Radius Fracture: A Case Report and Literature Review.

Necrotizing soft tissue infections (NSTIs), characterized by extensive soft tissue destruction, are rare but life-threatening. We present a case of a NSTI in a healthy 65-year-old woman following a closed distal radius fracture. The patient presented with severe pain, fever, and lethargy 4 days after her index injury, with physical examination of the right upper limb revealing erythema and swelling to the mid-humeral level and blisters of the fingers and hand. Multiple surgical debridements were required to control the infection, which was caused by Streptococcus pyogenes. This case highlights the rapid progression and devastating consequences of NSTI, which can occur even in the setting of closed injuries in patients without comorbidities. Prompt diagnosis, early surgical intervention, and appropriate antimicrobial therapy are crucial in managing this pathology.Level of Evidence: Level 5.

Identifying necrotizing soft tissue infection using infectious fluid analysis and clinical parameters based on machine learning algorithms.

Background: Determining the presence of necrotizing soft tissue infection (NSTI) poses a significant hurdle. As of late, there has been a notable increase in the application of artificial intelligence (AI) machine learning techniques in identifying diseases, a shift that can be attributed to their exceptional efficiency, unbiased nature, and high precision. Methods: Information was gathered from a cohort of 13 patients suffering from NSTI, alongside 12 patients with cellulitis. The construction of NSTI diagnostic machine learning models utilized four different algorithms, specifically random forest, k-nearest neighbors (KNN), support vector machine (SVM), and logistic regression. These models were constructed based on 28 distinctive attributes identified through statistical examination. Following this, the diagnostic efficiency of each algorithms was evaluated. A novel random forest model, streamlined for clinical use, was later developed by focusing on 6 attributes that had the most pronounced influence on the accuracy of our initial random forest model. Results: The following data was noted regarding the sensitivity and specificity of the four NSTI diagnostic models:logistic regression displayed 78.2 % and 83.7 %, KNN presented 79.1 % and 87.1 %, SVM showed 83.5 % and 86.3 %, and random forest exhibited 89.6 % and 92.9 %, respectively. In comparison, lactate levels in fluid demonstrated 100 % sensitivity and 76.9 % specificity at an optimal cut-off point of 69.6 mg/dL. Among all four machine learning models, random forest outperformed the others and also showed better results than fluid lactate. A newly constructed random forest model, created using 6 of the 13 identified features, displayed promising results in diagnosing NSTI, having a sensitivity and specificity of 90.2 % and 92.2 %, respectively. Conclusions: Developing a diagnostic model for NSTI employing the random forest algorithm has resulted in a diagnostic technique that is more efficient, cost-effective, and expedient. This approach could provide healthcare practitioners with the tools to identify and manage NSTI with greater efficacy.

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.

Prognostic Factors in Necrotizing Fasciitis: Insights from a Two-Decade, Two-Center Study Involving 209 Cases.

INTRODUCTION: Necrotizing fasciitis (NF) is a critical disease with high morbidity and mortality rates that poses significant challenges in diagnosis and treatment. Prognostic factors for the clinical course of NF remain unclear and are currently under research. This study aims to identify such factors in a large cohort of patients which represents a major comprehensive investigation of prognostic factors for NF. METHODS: Retrospective analysis was conducted on necrotizing fasciitis cases from 2003 to 2023 at two German hospitals. Data included demographics, comorbidities, laboratory findings, infection site, causative microorganisms and outcomes. Statistical analysis involved t-tests, chi-square tests, and ROC analysis. RESULTS: A total of 209 patients were included, with a mortality rate of 18%. Patients were categorized into survivors (n = 171) and non-survivors (n = 38). Non-survivors were significantly older (68.9 ± 13.9 years vs. 55.9 ± 14.3 years; p < 0.01) and exhibited a higher prevalence of peripheral vascular diseases, cancer, and heart, liver, or renal insufficiency. Laboratory findings and scoring results also varied significantly between the two groups. The ROC curve analysis identified age as a predictor of mortality, with an optimal cut-off value of 68.5 years (sensitivity: 60.5%, specificity: 81.9%). Higher age was associated with increased mortality risk. CONCLUSIONS: The patient's age stands out as the primary predictive element for mortality in necrotizing fasciitis. Additionally, we advocate for employing the Laboratory and Anamnestic Risk Indicator for Necrotizing Fasciitis (LARINF-score), which holds substantial prognostic significance and is straightforward to calculate. Considering our findings, crafting a clinical algorithm or scoring mechanism to forecast mortality in NF would be a promising target for future research.

Negative-Pressure Wound Therapy for the Management of Complex Surgical Wounds in a Minority Population.

Introduction Negative-pressure wound therapy (NPWT) has been used for decades as an established treatment modality for complex wounds, now commonplace in hospitals and various clinical and outpatient settings. Several studies have noted improved healing outcomes with this device, but the current state of literature is in debate on both clinical and economic effectiveness. The use of NPWT can become expensive, largely because of the complexity of wounds and the need for outpatient management, from which a majority of the benefit is derived. This creates a disparity in access to this therapy. A lack of insurance and limited access to healthcare that is present in minority populations contribute to this inequality. Methods We reviewed the clinical courses of eight patients who were treated with NPWT at a single acute care facility in an underserved area caring for a minority population. Results We describe several different anatomic wounds along with details including the size of wounds, number of debridements, length of hospital stay, duration of treatment, and ensuing courses of the minority patients who received NPWT for the entire duration of their wound care course. Conclusions This case series demonstrates desirable wound healing outcomes with the use of NPWT in the minority population. The authors draw attention to the outpatient benefit of this device that may be lost in those with limited insurance in minority populations and seek to encourage further studies in this population in resource-limited settings to determine its true clinical effectiveness.

A case of necrotizing fasciitis initially misdiagnosed as cellulitis.

INTRODUCTION AND IMPORTANCE: Necrotizing Fasciitis (NF) is a life-threatening, rapidly progressive infection of the skin and underlying soft tissues. Bacterial pathogens induce a toxic-shock reaction that reduces vascular flow, causing thrombosis, sepsis, and tissue necrosis. Treatment consists of immediate IV antibiotics and oftentimes surgical intervention. We present a case of acute NF that was misdiagnosed as cellulitis. CASE PRESENTATION: A 17-year-old male was transferred to an emergency department from a rural hospital for further management of right lower extremity cellulitis and suspected sepsis. On examination, there was an ulcerated lesion on his right lower leg. Within 4 h, the patient underwent fasciotomy and debridement. The patient was hospitalized for 10 days, received a 3-week-course of Cefazolin, and underwent a meshed split-thickness skin graft. By the end of his hospital stay, he showed significant clinical improvement. CLINICAL DISCUSSION: Misdiagnosis of NF will almost always lead to a poorer prognosis. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score is used to differentiate NF from other soft tissue infections. Yet, other diagnostic clues such as presentation or pain out of proportion to physical findings may be more relevant clinical indicators for a NF diagnosis. Moreover, though imaging findings of NF may be relevant, surgical fascial examination must not be delayed for the purpose of imaging. It is also important to note that cellulitis and NF do share a disease spectrum. CONCLUSION: A life-threatening NF infection may seem to be a benign-appearing case of cellulitis, and thus early detection is vital.

Diabetic Foot Infections in the Emergency Department.

Diabetic foot infection (DFI) is among the most common diabetic complications requiring hospitalization. Prompt emergency department diagnosis and evidence-based management can prevent eventual amputation and associated disability and mortality. Underlying neuropathy, arterial occlusion, immune dysfunction, and hyperglycemia-associated dehydration and ketoacidosis can all contribute to severity and conspire to make DFI diagnosis and management difficult. Serious complications include osteomyelitis, necrotizing infection, and sepsis. Practice guidelines are designed to assist frontline providers with correct diagnosis, categorization, and treatment decisions. Management generally includes a careful lower extremity examination and plain x-ray, obtaining appropriate tissue cultures, and evidence-based antibiotic selection tailored to severity.

Low attenuation areas in necrotizing soft tissue infection.

Necrotizing Soft Tissue Infection can be challenging to differentiate from abscesses based on computed tomography imaging findings only, so it is crucial to perform surgical debridement as early as possible.

The clinical characteristics and risk factors for necrotizing soft tissue infection in children.

Importance: Necrotizing soft tissue infection (NSTI) is a serious infectious disease. However, the early clinical manifestations and indicators of NSTI in children are still unclear. Objective: The purpose of this study was to analyze the clinical characteristics and risk factors of NSTI in pediatric patients. Methods: A total of 127 children with skin and soft tissue infection (SSTI) were treated at our hospital and divided into two groups: the NSTI group and the non-NSTI group, based on their discharge diagnosis from January 2011 to December 2022. Then, we collected and analyzed the clinical characteristics and risk factors of all patients, including sex and age, disease inducement, admission temperature, local skin manifestations, infection site, the presence of sepsis, bacterial culture, and laboratory indicators. Results: In our study, there was a statistical difference in the age distribution and disease inducement between NSTI and non-NSTI groups. The occurrence of local skin manifestations (blisters/bullae and ecchymosis) and the presence of sepsis significantly increased in the NSTI group compared to the non-NSTI group. Additionally, only the platelet count on laboratory tests was statistically different between the NSTI and non-NSTI groups. Finally, the logistic regression analysis suggested that local skin manifestations such as blisters/bullae, and ecchymosis, as well as the presence of sepsis, were identified as risk factors for NSTI. Interpretation: Children with SSTI and skin manifestations such as blisters/bullae, ecchymosis, and the presence of sepsis are at a higher risk of developing NSTI. These symptoms serve as useful indicators for early detection of NSTI.

A Cross-Sectional Analysis of Pediatric Necrotizing Soft Tissue Infection Cases and Racial Disparities From the 2016 to 2020 National Inpatient Sample.

INTRODUCTION: The incidence, treatment, and outcomes of necrotizing soft tissue infections (NSTIs) and associated racial disparities have been described in adults, but research in the pediatric population is limited. The purpose of this study is to provide a nationally representative characterization of pediatric NSTI and determine the presence of any racial disparities. METHODS: The National Inpatient Sample was analyzed from 2016 through 2020. Patients aged less than 20 y with a diagnosis of necrotizing fasciitis, Fournier's gangrene, or gas gangrene (based on International Classification of Diseases, Tenth Revision, Clinical Modification codes) were included for analysis. RESULTS: A total of 355 patients were identified. Black and Hispanic patients accounted for the most admissions in 2016 and 2018, respectively (P = 0.024). Compared to White patients, more Black patients were insured by Medicaid (P = 0.037) and were in the first zip code-based income quartile (P = 0.005). The leading infection overall was necrotizing fasciitis and most patients (81.7%) underwent a surgical procedure by the first calendar day after admission. Although the proportion of Black patients undergoing subcutaneous tissue and fascia excisions was more than that of White patients (P = 0.005), there were no significant differences by race in the time to first procedure, the total number of procedures, or number of postoperative complications. Our amputation and mortality rates were low and unreportable, but there were no differences by race. CONCLUSIONS: NSTI is rare in the pediatric population and mortality is low. Black patients are disproportionately diagnosed, but these disparities do not extend to disease treatment or outcomes.

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.

Increase in Streptococcal Necrotizing Fasciitis During and After the Coronavirus Disease 2019 Pandemic.

Background: Necrotizing fasciitis (NF) is a life-threatening and rare condition. However, we report and analyze a remarkably high number of NF cases during the coronavirus disease 2019 (COVID-19) pandemic and especially in the first months after the COVID-19 pandemic. Patients and Methods: We conducted a retrospective analysis of 17 cases of NF treated in our clinic between January and May 2023. Data were collected on demographics, comorbidities, risk factors, laboratory findings, and clinical outcomes. For each individual case two risk indicating scores, the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) and Laboratory and Anamnestic Risk Indicator for Necrotizing Fasciitis (LARINF) were calculated. Results: In the pandemic years 2021 and 2022 there were 21 and 30 patients with NF, respectively, treated in our clinic. Of the 17 included NF cases in this study from January until May 2023, 16 cases required intensive care unit (ICU) admission, six cases required limb amputation, and four cases resulted in death. The microbiologic examination revealed seven cases of polymicrobial infections, eight cases of monomicrobial infections primarily caused by Streptococcus pyogenes, and two cases without microbial growth. The LRINEC score showed a sensitivity of 82%, whereas the LARINF score demonstrated a sensitivity of 100% for identifying cases of NF. Conclusions: This study highlights a notable increase in NF during and after the COVID-19 pandemic, predominantly associated with Streptococcus pyogenes-induced infections. These cases demonstrate a highly aggressive nature, leading to limb amputation or death in more than half of the cases.

Negative Pressure Wound Therapy With and Without Instillation in Necrotizing Soft Tissue Infections.

Background: Necrotizing soft tissue infections (NSTIs) are rare but deadly infections that require early and often extensive surgical debridement. After debridement, patients frequently have substantial morbidity because of large, open wounds. Hypothesis: Negative pressure wound therapy with instillation (NPWTi) results in higher wound closure rates compared with traditional negative pressure wound therapy (NPWT) or wet to dry dressings (moist wound care dressing). Patients and Methods: A prospectively maintained Acute and Critical Care Surgery database spanning 2008-2018 was queried for patients with a diagnosis of necrotizing fasciitis, Fournier gangrene, or gas gangrene. Data were collected on patient comorbidities, operative management, and clinical outcomes. Patients were stratified by use of moist wound care dressing, traditional NPWT, or NPWTi. Data were analyzed using analysis of variance (ANOVA), χ2, and logistic regression. Results: During the 10-year study period, patients were treated for NSTI; 173 were managed with moist wound care dressing, 150 with NPWT, and 48 with NPWTi. Patients were similar in terms of demographics, body mass index (BMI), diabetes mellitus, and smoking rates. Overall, complication rates were not substantially different, but mortality was higher in the moist wound care dressing group (16.2% vs. 10.7% NPWT vs. 2.1% NPWTi; p = 0.02). In the moist wound care dressing group, 81.5% of patients had an open wound at discharge compared with 52.7% of the NPWT group and only 14.6% of the NPWTi group (p < 0.001). On multivariable regression, NPWTi was associated with closure rates five times higher than the NPWT group (odds ratio [OR], 5.28; 95% confidence interval [CI], 2.40-11.61; p < 0.001) after controlling for smoking status, intravenous drug use, number of operations, and involvement of the most common region of the body. Conclusions: Negative pressure wound therapy with instillation is associated with higher rates of wound closure without increasing complication rates in patients with NSTI compared with traditional NPWT or moist wound care dressing. Although prospective studies are needed, this indicates the potential to improve patient quality of life through reduced pain and outpatient home health needs.

Reduced interleukin-18 secretion by human monocytic cells in response to infections with hyper-virulent Streptococcus pyogenes.

BACKGROUND: Streptococcus pyogenes (group A streptococcus, GAS) causes a variety of diseases ranging from mild superficial infections of the throat and skin to severe invasive infections, such as necrotizing soft tissue infections (NSTIs). Tissue passage of GAS often results in mutations within the genes encoding for control of virulence (Cov)R/S two component system leading to a hyper-virulent phenotype. Dendritic cells (DCs) are innate immune sentinels specialized in antigen uptake and subsequent T cell priming. This study aimed to analyze cytokine release by DCs and other cells of monocytic origin in response to wild-type and natural covR/S mutant infections. METHODS: Human primary monocyte-derived (mo)DCs were used. DC maturation and release of pro-inflammatory cytokines in response to infections with wild-type and covR/S mutants were assessed via flow cytometry. Global proteome changes were assessed via mass spectrometry. As a proof-of-principle, cytokine release by human primary monocytes and macrophages was determined. RESULTS: In vitro infections of moDCs and other monocytic cells with natural GAS covR/S mutants resulted in reduced secretion of IL-8 and IL-18 as compared to wild-type infections. In contrast, moDC maturation remained unaffected. Inhibition of caspase-8 restored secretion of both molecules. Knock-out of streptolysin O in GAS strain with unaffected CovR/S even further elevated the IL-18 secretion by moDCs. Of 67 fully sequenced NSTI GAS isolates, 28 harbored mutations resulting in dysfunctional CovR/S. However, analyses of plasma IL-8 and IL-18 levels did not correlate with presence or absence of such mutations. CONCLUSIONS: Our data demonstrate that strains, which harbor covR/S mutations, interfere with IL-18 and IL-8 responses in monocytic cells by utilizing the caspase-8 axis. Future experiments aim to identify the underlying mechanism and consequences for NSTI patients.

No role for standard imaging workup of patients with clinically evident necrotizing soft tissue infections: a national retrospective multicenter cohort study.

PURPOSE: To assess the diagnostic contribution of different imaging studies to diagnose necrotizing soft tissue infections (NSTIs) and the time to surgery in relation to imaging with the hypothesis that imaging studies may lead to significant delays without being able to sufficiently dismiss or confirm the diagnosis since a NSTI is a surgical diagnosis. METHODS: A retrospective multicenter cohort study of all NSTI patients between 2010 and 2020 was conducted. The primary outcome was the number of cases in which imaging contributed to or led to change in treatment. The secondary outcomes were time to treatment determined by the time from presentation to surgery and patient outcomes (amputation, intensive care unit (ICU) admission, length of ICU stay, hospital stay, and mortality). RESULTS: A total of 181 eligible NSTI patients were included. The overall mortality was 21% (n = 38). Ninety-eight patients (53%) received imaging in the diagnostic workup. In patients with a clinical suspicion of a NSTI, 81% (n = 85) went directly to the operating room and 19% (n = 20) underwent imaging before surgery; imaging was contributing in only 15% (n = 3) by ruling out or determining underlying causes. In patients without a clinical suspicion of a NSTI, the diagnosis of NSTI was considered in 35% and only after imaging was obtained. CONCLUSION: In patients with clinically evident NSTIs, there is no role for standard imaging workup unless it is used to examine underlying diseases (e.g., diverticulitis, pancreatitis). In atypical presenting NSTIs, CT or MRI scans provided the most useful information. To prevent unnecessary imaging and radiation and not delay treatment, the decision to perform imaging studies in patients with a clinical suspicion of a NSTI must be made extremely careful.

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.