Investigating group A Streptococcus antibiotic tolerance in necrotizing fasciitis.

Group A Streptococcus (GAS) necrotizing fasciitis (NF) is a difficult-to-treat bacterial infection associated with high morbidity and mortality despite extensive surgery and targeted antibiotic treatment. Difficult-to-treat infections are often characterized by the presence of bacteria surviving prolonged antibiotic exposure without displaying genetic resistance, referred to as persisters. In the present study, we investigated the presence of GAS persisters in tissue freshly debrided from patients as well as in an in vivo mouse model of NF and examined the phenomenon of antibiotic tolerance. Time-lapse imaging of GAS plated directly upon isolation from NF debrided tissue and an antibiotic challenge-based persisters assay were used to assess the presence of persisters. We show for the first time that GAS recovered directly from freshly debrided NF tissue is characterized by heterogeneous and overall delayed colony appearance time, suggesting the presence of persisters. Acidic pH or nutrient stress exposure, mimicking the NF-like environment in vitro, led to a similar phenotypic heterogeneity and resulted in enhanced survival upon antibiotic challenge, confirming the presence of GAS persisters. GAS persisters might contribute to NF treatment failure, despite extensive surgery and adequate antibiotic treatment.IMPORTANCEDifficult-to-treat and recurrent infections are a global problem burdening society and the health care system alike. Unraveling the mechanisms by which bacteria can survive antibiotic treatment without developing genetic resistance is of utmost importance to lay the foundation for new, effective therapeutic approaches. For the first time, we describe the phenomenon of antibiotic tolerance in group A Streptococcus (GAS) isolated from necrotizing fasciitis (NF) patients. Dormant, non-replicating cells (persisters) are tolerant to antibiotics and their occurrence in vivo is reported in an increasing number of bacterial species. Tailored treatment options, including the use of persisters-targeting drugs, need to be developed to specifically target dormant bacteria causing difficult-to-treat and recurrent infections.

Periorbital necrotizing fasciitis: clinical perspectives on nine cases.

A multicenter review of Periorbital Necrotizing Fasciitis including nine cases, aged 41 to 82, mostly female, and mainly post-traumatic or idiopathic. Streptococcus pyogenes was the most frequent pathogen. Treatment involved debridement alongside antibiotic therapy in all cases. Two cases experienced toxic shock, with no fatalities. Visual outcomes varied from exenteration to preserved visual acuity with minimal aesthetic impact. Early detection and prompt intervention are paramount due to the significant risks associated with this condition, which may lead to severe complications ranging from vision loss to systemic decline or death.

First Case of Necrotizing Fasciitis and Septicemia Caused by Pigmentibacter ruber.

We report the first case of necrotizing fasciitis caused by Pigmentibacter ruber. The isolated strain could not be identified by biochemical characterization or matrix-assisted laser desorption/ionization time-of-flight mass spectrometry but was identified as P. ruber by 16S ribosomal RNA and whole-genome sequencing. Although much remains unknown about the pathogenicity of this bacterial species in humans, it has been shown to cause life-threatening infections such as septicemia and necrotizing fasciitis. Because the isolate was highly resistant to ß-lactams, it was difficult to treat with antimicrobial therapy. Thus, further documentation of cases and analyses are required.

Emphysematous pyelonephritis with progression to necrotising fasciitis of the posterior cervical region and the retropharyngeal space.

A man in his 50s with diabetes presented with backache, left flank pain and fever. On evaluation, he was found to have emphysematous pyelonephritis of the left kidney with a paranephric abscess extending into the posterior abdominal wall and superiorly up to the posterior chest wall and inferiorly extending up to the posterior superior iliac spine. The management involved the initiation of broad-spectrum antibiotics and percutaneous drainage of the abscess. However, as he continued to worsen symptoms-wise, he underwent computed-enhanced CT of the abdomen and thorax. The imaging revealed the presence of a purulent collection in the left lumbar region with an extension along the posterior cervical region and the retropharyngeal space. He underwent a fasciotomy of the lumbar region. The occurrence of emphysematous pyelonephritis along with necrotising fasciitis is uncommon and requires early aggressive management with broad-spectrum antibiotics and adequate drainage. This emphasises the need for early reimaging if the patient does not settle with antibiotics or percutaneous drainage.

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.

Pseudomonas guariconensis Necrotizing Fasciitis, United Kingdom.

We describe a case of necrotizing fasciitis in the United Kingdom in which Pseudomonas guariconensis was isolated from multiple blood culture and tissue samples. The organism carried a Verona integron-encoded metallo-ß-lactamase gene and evidence of decreased susceptibility to ß-lactam antimicrobial agents. Clinicians should use caution when treating infection caused by this rare pathogen.

Defining the Optimal Antibiotic Duration in Necrotizing Skin and Soft Tissue Infections: Clinical Experience from a Quaternary Referral Center.

Background: Early initiation of broad-spectrum antibiotic agents is a cornerstone of the care of necrotizing skin and soft tissue infections (NSTI). However, the optimal duration of antibiotic agents is unclear. We sought to characterize antibiotic prescribing patterns for patients with NSTI, as well as associated complications. Patients and Methods: Using an NSTI registry, we characterized antibiotic use at a quaternary referral center. Kaplan-Meier analyses were used to describe overall antibiotic duration and relative to operative source control, stratified by presence of other infections that independently influenced antibiotic duration. Factors associated with successful antibiotic discontinuation were identified using logistic regression. Results: Between 2015 and 2018, 441 patients received antibiotic agents for NSTI with 18% experiencing a complicating secondary infection. Among those without a complicating infection, the median duration of antibiotic administration was 9.8 days (95% confidence interval [CI], 9.2-10.5) overall, and 7.0 days after the final debridement. Perineal NSTI received fewer days of antibiotic agents (8.3 vs. 10.6) compared with NSTI without perineal involvement. White blood cell (WBC) count and fever were not associated with failure of antibiotic discontinuation, however, a chronic wound as the underlying infection etiology was associated with greater odds of antibiotic discontinuation failure (odds ratio [OR], 4.33; 95% CI, 1.24-15.1). Conclusions: A seven-day course of antibiotic agents after final operative debridement may be sufficient for NSTI without any secondary complicating infections, because clinical characteristics do not appear to be associated with differences in successful antibiotic discontinuation.

Mastectomía e injerto cutáneo autólogo por fascitis necrotizante torácica / Mastectomy and skin graft as treatment for thoracic necrotizing fasciitis

Se presenta el caso de una paciente fumadora con hipertensión arterial, diabetes mellitus tipo II en tratamiento con insulina, con control glucémico inadecuado, HS y dislipidemia que ingresó por infección en la mama y la pared torácica izquierda con progresión a fascitis necrotizante. Se intentó inicialmente una actitud quirúrgica conservadora, pero dado el mal control de sus enfermedades de base y la infección rápidamente progresiva, requirió desbridamiento más agresivo con mastectomía y exéresis de músculo afecto. Posteriormente, se realizó un injerto cutáneo mallado en la zona de mastectomía izquierda con zona donante de muslo izquierdo. A pesar de la gravedad del caso, con el tratamiento quirúrgico extenso, antibióticos de amplio espectro y curas diarias, la paciente superó el cuadro séptico y se limitó de ese modo la progresión de la infección. En controles posteriores, la paciente presentó buena evolución clínica. (AU)

Hidradenitis suppurativa is an inflammatory skin disease that affects the folliculopilosebaceous unit. Necrotizing fasciitis of the thoracic wall is a rare entity that affects subcutaneous tissue and deep fascia. It represents a diagnostic and therapeutic emergency requiring broad spectrum antibiotics and extense surgical debridement, with high mortality rates. Other reported cases do not describe fascitis as an infection complicating hidradenitis, as the case of our patient. We present a case of a patient with a history of hidradenitis suppurativa, smoking, hypertension, diabetes mellitus with poor glycemic control, and dyslipidemia, admitted to our hospital with left breast and thoracic wall infection, with progression to necrotizing fascitis. Initially a preservative surgery was attempted but given the patient's comorbidities and the rapidly progressive infection, a mastectomy was required. In second time surgery, an autologous skin graft was performed. Despite the severity of the case, the patient overcame the infection after extensive surgical debridement, broad spectrum antibiotics and daily cures. In follow-up controls the patient presented good clinical condition. (AU)

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.

Saksenaea vasiformis infection: Extensive abdominal wall necrotizing fasciitis with systematic review and analysis of 65 cases.

INTRODUCTION: Saksenaea vasiformis is a rarely reported Mucorales causing mucormycosis in both immunocompromised and immunocompetent individuals. Due to few reported cases, the clinical characteristics and optimal management strategy for this rare agent are not clearly described. METHODS: We systematically reviewed Medline, EmBase and CINHAL for studies on S. vasiformis infections reported until 1 January 2022 and 57 studies (63 patients) were retrieved. Additionally, one more case of extensive abdominal wall necrotizing fasciitis managed by our team was also included. The clinical and demographic characteristics and outcomes were extracted and analysed. RESULTS: Out of the 65 included cases, the majority were reported from India (26.6%). The most common risk factors for infection were accidental trauma wounds (31.3%), health-care-related wounds (14.1%) and animal/insect bites (12.5%). Most common clinical presentation was subcutaneous mucormycosis (60.9%) followed by rhino-orbito cerebral mucormycosis (14%), necrotizing fasciitis (10%), disseminated infection (9.3%), pulmonary mucormycosis (3.2%) and osteomyelitis (1.6%). Mortality was observed in 24 (37.5%) patients and health care related injuries were significantly associated with higher mortality (p = .001). The use of posaconazole (p = .019) and the use of surgical management (p = .032) was associated with significantly better survival. DISCUSSION: In this study, we describe the largest compendium of mucormycosis due to S. vasiformis, which can be useful in increasing awareness regarding this rare Mucorales and guiding patient management.

[Necrotizing fasciitis].

Necrotizing soft tissue infections (NSTI) is a serious infection with a mortality of up to 25% at three months. This review gives an overview of the diagnosis and treatment of NSTI. The prognosis is dependent on rapid surgical treatment, aggressive, prompt removal of infected tissue, broad spectrum antibiotic treatment and supportive care. In cases with suspected or verified infection with Streptococcus pyogenes, adjuvant therapy with immunoglobulins can be considered.

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.

Household Transmission of Group A Streptococcus Necrotizing Fasciitis.

A healthy 40-year-old woman was diagnosed with necrotizing fasciitis 2 days after her husband's death from the same infectious process. Prompt identification and immediate surgical intervention prevented a similar result in this patient. Additional investigation into both patients' medical records found the inciting organism to be group A streptococcus. Although the exact mechanism of inoculation is unknown, the spread of this infection within a household prompts the question of whether antibiotic prophylaxis should be given among close contacts in future cases of necrotizing fasciitis.