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.

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.

Cervical necrotizing fasciitis caused by oral cavity infection: a case report considering therapeutic approach and its morphofunctional implications / Fascitis necrosante cervical causada por infección de la cavidad oral. Reporte de un caso considerando el abordaje terapéutico y sus implicaciones morfofuncionales

SUMMARY: Cervical necrotizing fasciitis (NF) is a rare complication of oral cavity infection with high morbi-mortality. Given its low prevalence, adequately reporting cases of NF, its therapeutic management, and associated morphofunctional modifications to the clinical and scientific community is pivotal. To that end, we herein describe a case of cervical NF in a 60-year-old patient with comorbidities and patient presented large, painful cervical swelling associated with a necrotic ulcer lesion in the anterior neck region. Intraoral examination indicated a periodontal abscess in the right mandibular area, while computed tomography indicated the lesion's extension from the right mandibular to the submandibular region. Following empirical intravenous antibiotic treatment, a broad surgical debridement was performed, and the foci of oral infection were removed. Debridement revealed communication between deep and superficial anatomical regions in the submandibular area, where we subsequently placed a Penrose drain. Biopsies showing acute inflammatory infiltrate associated with necrotic and hemorrhagic regions confirmed the diagnosis of NF. When an antibiogram revealed resistance to the empirical treatment, the antibiotic scheme was replaced with an adequate alternative. After a second debridement, we closed the defect with fascio-mucocutaneous advancement flaps with a lateral base while maintaining suction drainage. Having reacted positively, the patient was discharged 10 days after the operation. Despite an extensive morphofunctional change generated in the treated area, the patient showed no difficulties with breathing, phonation, swallowing, or mobilizing the area during control sessions. Altogether, this report contributes to the highly limited literature describing morphological aspects that can facilitate or delay the spread of infection or the morphofunctional disorders associated with the size and depth of surgical interventions for cervical NF, information that is relevant for the comprehensive, long-term prognosis of the treatment of NF.

La fascitis necrosante (FN) cervical es una rara complicación de una infección proveniente de la cavidad bucal asociada a una alta morbimortalidad. Por lo anterior, es fundamental informar a la comunidad clínica y científica los casos de FN, su manejo terapéutico y las modificaciones morfofuncionales asociadas. Se describe un caso de FN cervical en una paciente de 60 años quien presentó una gran tumefacción dolorosa asociada a una lesión ulcerosa necrótica en la región anterior del cuello. El examen intraoral mostró un absceso periodontal en el área mandibular derecha y la tomografía computarizada mostró la extensión de la lesión hacia la región submandibular. Tras el tratamiento antibiótico empírico, se realizó un desbridamiento quirúrgico extenso y se extirparon los focos de infección oral. El desbridamiento reveló comunicación entre las regiones anatómicas profundas y superficiales del área submandibular, donde se colocó un drenaje Penrose. Las biopsias mostraron un infiltrado inflamatorio agudo asociado con regiones necróticas y hemorrágicas, confirmando el diagnóstico de FN. El antibiograma reveló resistencia al tratamiento empírico, por lo que el esquema antibiótico se sustituyó. Tras un segundo desbridamiento, se cerró el defecto con colgajos de avance fascio-mucocutáneos de base lateral manteniendo drenaje aspirativo. El positivo progreso del paciente permitió su alta 10 días después. Aun cuando se generó una gran modificación morfofuncional en el área tratada, la paciente no presentó dificultades para respirar, hablar, deglutir o movilizar el área cervical intervenida durante las sesiones de control. Este informe contribuye a la limitada literatura que describe los aspectos morfológicos que pueden facilitar o retrasar la propagación de la FN y las consecuencias asociadas a los trastornos morfofuncionales provocadas por el tamaño y profundidad de las intervenciones quirúrgicas requeridas por la FN, información relevante para el pronóstico integral a largo plazo del tratamiento de la FN.

[Invasive group A streptococcal infections in the Netherlands]. / Invasieve groep A-streptokokkeninfecties in Nederland.

Group A streptococcal (GAS) infections are caused by the Gram-positive bacterium Streptococcus pyogenes. Infection can occur via droplet infection from the throat and via (in)direct contact with infected people. GAS can cause a wide variety of diseases, ranging from superficial skin infections, pharyngitis and scarlet fever, to serious invasive diseases such as puerperal sepsis, pneumonia, necrotising soft tissue infections (NSTI) (also known as necrotising fasciitis/myositis), meningitis and streptococcal toxic shock syndrome (STSS). In invasive GAS infections, the bacteria has penetrated into a sterile body compartment (such as the bloodstream, deep tissues, or the central nervous system). Invasive GAS infections are rare but serious, with high morbidity and mortality. Since March 2022, the National Institute for Public Health and the Environment (RIVM) reported a national increase in notifiable invasive GAS infections (NSTI, STSS and puerperal fever). Particularly NSTI has increased compared to the years before the SARS-CoV-2 pandemic. Remarkably, the proportion of children aged 0 to 5 years with invasive GAS-infections is higher in 2022 than in the previous years (12% compared to 4%). While seasonal peaks occur, the current elevation exceeds this variation. To promote early recognition and diagnosis of invasive GAS infections different clinical cases are presented.

Pathophysiological Considerations in Periorbital Necrotizing Fasciitis: A Case Report.

BACKGROUND: Periorbital necrotizing fasciitis (PNF) is a rare complication of bacterial infection, associated with irreversible inflammatory destruction of soft tissues like subcutaneous tissue and superficial fascia. PNF can cause visual loss, septic shock and death within hours to days. Since the infection progresses rapidly from a local disease to septic shock, prompt identification and decisive interventions are mandatory. AIM: Considering pathophysiology, differential diagnosis, and treatment options, we report a case of PNF and its outcome. METHODS: A 69 years old male with febrile periorbital swelling had been diagnosed with bilateral PNF, caused by dual infection with Streptococcus pyogenes (S. pyogenes) and Staphylococcus aureus (S. aureus) based on conjunctival swabs. RESULTS: The superantigens produced by S. pyogenes have been identified as key to the rapid dissemination of infection and severity of systemic manifestations. CONCLUSION: A combination of intravenous antibiotics and regular surgical debridements resulted in a beneficial outcome in our patient.

Necrotizing fasciitis: A highly fatal infection.

BACKGROUNDS: Necrotizing fasciitis is a severe bacterial infection characterized by involvement of all skin's layers, including the superficial fascia. Diagnosis and treatment must be as quick as possible. Once suspected, extensive surgical debridement is required. METHODS: All necrotizing fasciitis, managed in our hospital in Dijon, during the period from January 2011 to May 2021, were retrospectively analyzed. Demographics characteristics of patients, biological parameters, and type of bacteria were collected. Statistical analysis was performed on the cost of hospitalization, as well as on the death rate between type I and II NF and the speed of management. Student's t-test and Chi2 test were performed with a significant level P<0.05. FINDINGS: A total of 65 patients were included over the period. The mean age was 68.8 years. The average length of stay was 32.4 days, with an average cost of 79,305 €. The main locations were the lower limbs (57%) and the perineum (35%). Cost of hospitalization did not differ between type I and II (P=0.21), unlike mortality rate (P=0.003). Furthermore, the mortality rate according to the speed of management did not vary in our series (P=0.45). CONCLUSION: Necrotizing fasciitis is quickly fatal if left untreated. Early diagnosis, combined with surgical debridement and probabilistic antibiotic therapy are required. Our study shows the impact of necrotizing fasciitis in terms of cost to society and the importance of prevention of certain risk factors. A global management of the patient is necessary to increase the survival rate.

Necrotizing fasciitis - two case reports and literature review.

<b><br>Introduction:</b> Necrotizing fasciitis (NF) is a rare, rapidly progressing infection of the skin and subcutaneous tissue. NF can lead to massive tissue necrosis, resulting in sepsis, septic shock and death. In this disease, it is important to quickly diagnose and implement appropriate treatment.</br> <b><br>Aim:</b> Analysis of the diagnostic and therapeutic process in two clinical cases and a review of the literature on the methods of diagnosis and treatment of necrotizing fasciitis.</br> <b><br>Material and methods:</b> The medical data of two patients hospitalized in the St Alexander Hospital in Kielce from December 2022 to June 2023 due to necrotizing fasciitis were analyzed. Also literature search across PubMed, Medline and Research Gate databases from 2000 up to 2023 was performed. We reviewed English literature according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. The following keywords were used: necrotizing fasciitis, etiopathogenesis, pathophysiology, management.</br> <b><br>Results:</b> The research group consisted of two male patients with NF after trauma, in different parts of the body. Based on the clinical examination, the results of laboratory and imaging tests, a diagnosis was made and appropriate treatment was initiated. Despite the applied treatment, one patient died as a result of progressive multiple organ failure.</br> <b><br>Conclusions:</b> Despite advances in diagnosis and treatment, including universal access to antibiotics, necrotizing fasciitis still cause high mortality. The microbiological complexity of the majority of cases and non-specific symptoms make the diagnostic and therapeutic process difficult. Taking into account necrotizing fasciitis each time in the differential diagnosis of inflammation of the skin and subcutaneous tissue, especially based on trauma, will allow to reduce morbidity and mortality in this disease.</br>.

[A human bite wound caused a severe life threatening infection]. / Een mensenbeet met desastreuze gevolgen.

Within 24 hours after a human bite trauma, a 34-year-old male patient became septic and ended up at an intensive care unit. The combination of a local damage of the skin or mucosa, aggressive micro-organisms, local host factors, and some bad luck resulted in necrotizing fasciitis for this patient. This is a very rapid progressive infection which can spread via fat tissue and the muscle fascia. The occurrence of extensive necrosis releases a lot of cytokines and acute-phase proteins, resulting in a systemic reaction. The consequential vasodilatation makes it necessary for the heart to pump harder in order to maintain the circular volume. The patient will soon become septic and hemodynamically unstable. This can also lead to multiple organ failure with potentially fatal consequences. Because necrotizing fasciitis can be caused by commensal bacteria, even young healthy patients are at risk for this invasive life threatening disease. Early recognition of the clinical manifestations can prevent a fatal outcome.

The development of surgical risk score and evaluation of necrotizing soft tissue infection in 161 Naja atra envenomed patients.

BACKGROUND: Naja atra bites cause wound necrosis, secondary infection, and necrotizing soft tissue infection (NSTI) requiring repetitive surgeries. Little information is known about the predictors for surgery after these bites. MATERIALS AND METHODS: We retrospectively evaluated 161 patients envenomed by N. atra, 80 of whom underwent surgery because of wound necrosis and infection. We compared the patients' variables between surgical and non-surgical groups. To construct a surgical risk score, we converted the regression coefficients of the significant factors in the multivariate logistic regression into integers. We also examined the deep tissue cultures and pathological findings of the debrided tissue. RESULTS: A lower limb as the bite site, a ≥3 swelling grade, bullae or blister formation, gastrointestinal (GI) effects, and fever were significantly associated with surgery in the multivariate logistic regression analysis. The surgical risk scores for these variables were 1, 1, 2, 1, and 2, respectively. At a ≥3-point cutoff value, the model has 71.8% sensitivity and 88.5% specificity for predicting surgery, with an area under the receiver operating characteristic curve of 0.88. The histopathological examinations of the debrided tissues supported the diagnosis of snakebite-induced NSTI. Twelve bacterial species were isolated during the initial surgery and eleven during subsequent surgeries. DISCUSSION AND CONCLUSIONS: From the clinical perspective, swelling, bullae or blister formation, GI effects, and fever appeared quickly after the bite and before surgery. The predictive value of these factors for surgery was acceptable, with a ≥3-point risk score. The common laboratory parameters did not always predict the outcomes of N. atra bites without proper wound examination. Our study supported the diagnosis of NSTI and demonstrated the changes in bacteriology during the surgeries, which can have therapeutic implications for N. atra bites.

Prognostic Role of Subsequent Thrombocytopenia in Necrotizing Fasciitis Without Liver Disease.

BACKGROUND: Necrotizing fasciitis (NF) is a life-threatening disease with a fulminant presentation. Although early diagnosis can be aided by combining physical examination, the Laboratory Risk Indicator for Necrotizing Fasciitis score, and computed tomography, a mortality rate of 30% is still reported. In the modern times, an economical and efficient biomarker for predicting mortality in NF patients is still lacking. Platelet count is typically measured in routine blood tests and aids in predicting disease severity. We aimed to clarify the role of platelet count as a predictive factor for aspects of prognosis, such as mortality and surgical outcomes, in patients with NF. METHODS: We identified 285 patients with NF between 2018 and 2020 in a single medical center in southern Taiwan. Medical records were collected for the evaluation of patients with thrombocytopenia. Univariate and multivariate analyses were performed for different outcomes. RESULTS: We included 115 patients with confirmed diagnoses of NF. Twelve patients died with a mortality rate of 10.4%. Patients with thrombocytopenia exhibited a higher mortality rate (20.9% vs 4.2%, P = 0.006), more shock episodes (51.2% vs 11.1%, P < 0.001), higher intensive care unit admission rate (46.5% vs 13.9%, P < 0.001), and longer hospital length of stay (37.49 ± 24.12 days vs 28.82 ± 14.63 days, P = 0.037) than those without thrombocytopenia. All patients infected with Vibrio species exhibited thrombocytopenia. In multivariate analysis, independent risk factors for mortality were thrombocytopenia (odds ratio, 4.57; 95% confidence interval, 1.08-19.25) and single gram-negative bacterial culture from the wound (odds ratio 6.88; 95% confidence interval, 1.58-29.96). CONCLUSIONS: In patients with NF and subsequent thrombocytopenia, a higher mortality rate, greater numbers of shock episodes, higher demand for intensive care unit, and longer hospital length of stay were observed than in those without thrombocytopenia. In patients with NF, platelet count is a valuable and economic indicator of prognosis. Once thrombocytopenia developed in patients with necrotizing fasciitis, aggressive antibiotic treatment and surgical management are required to improve the chances of recovery.

A rare cause of bacteremia due to Porphyromonas asaccharolytica in a patient with necrotizing fasciitis.

Porphyromonas species are Gram-negative anaerobic bacilli mainly involved in human periodontal diseases. We report an uncommon case of bacteremia due to P. asaccharolytica in a patient with necrotizing fasciitis. A 52-year-old woman with a history of diabetes mellitus was admitted for an extensive necrotizing lesion on the left lower limb. After she developed septic shock, two sets of blood cultures were taken. Anaerobic bottles yielded a pure culture of a microorganism initially identified as P. uenonis by MALDI-TOF MS but with a low log score, and a gene sequencing technique was therefore applied, identifying the isolate as P. asaccharolytica. Only resistance to penicillin and clindamycin was documented. Treatment with meropenem was administered, and the patient was discharged following her recovery.

Streptolysin O concentration and activity is central to in vivo phenotype and disease outcome in Group A Streptococcus infection.

Group A Streptoccocus (GAS) is among the most diverse of all human pathogens, responsible for a range of clinical manifestations, from mild superficial infections such as pharyngitis to serious invasive infections such as necrotising fasciitis and sepsis. The drivers of these different disease phenotypes are not known. The GAS cholesterol-dependent cytolysin, Streptolysin O (SLO), has well established cell and tissue destructive activity. We investigated the role of SLO in determining disease outcome in vivo, by using two different clinical lineages; the recently emerged hypervirulent outbreak emm type 32.2 strains, which result in sepsis, and the emm type 1.0 strains which cause septic arthritis. Using clinically relevant in vivo mouse models of sepsis and a novel septic arthritis model, we found that the amount and activity of SLO was vital in determining the course of infection. The emm type 32.2 strain produced large quantities of highly haemolytic SLO that resulted in rapid development of sepsis. By contrast, the reduced concentration and lower haemolytic activity of emm type 1.0 SLO led to translocation of bacteria from blood to joints. Importantly, sepsis associated strains that were attenuated by deletion or inhibition of SLO, then also translocated to the joint, confirming the key role of SLO in determining infection niche. Our findings demonstrate that SLO is key to in vivo phenotype and disease outcome. Careful consideration should be given to novel therapy or vaccination strategies that target SLO. Whilst neutralising SLO activity may reduce severe invasive disease, it has the potential to promote chronic inflammatory conditions such as septic arthritis.

Bacteriology and mortality of necrotizing fasciitis in a tertiary coastal hospital with comparing risk indicators of methicillin-resistant Staphylococcus aureus and Vibrio vulnificus infections: a prospective study.

BACKGROUND: Vibrio vulnificus has been reported as the leading causative pathogen of necrotizing fasciitis (NF) and related fatality in the coastal area. Necrotizing fasciitis caused by methicillin-resistant Staphylococcus aureus (MRSA) and V. vulnificus have high mortality rates. The purpose of this prospective study was to clarify the clinical characteristics between death and survival NF patients, to investigate bacteriologic profile and mortality of NF patients, and to compare risk indicators of MRSA and V. vulnificus NF patients. METHODS: This prospective study was conducted in 184 consecutive NF patients over a period of three years in a tertiary coastal hospital. Differences in mortality, laboratory findings, microbiology and clinical outcomes were compared between the death and survival groups, and the V. vulnificus and MRSA subgroups. RESULTS: Twenty patients died, resulting in a mortality rate of 10.9%, and there were 108 patients with a monomicrobial infection (58.7%). The death group had a significantly higher incidence of shock at emergency room and bacteremia than did the survival group. Vibrio species (40 cases) and S. aureus (31 cases) were the two major pathogens. Significant differences with respect to hepatic dysfunction, shock, the event with seawater or seafood contact, bacteremia, C-reactive protein, mean platelet counts, and the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score were observes between V. vulnificus and MRSA groups. CONCLUSIONS: NF patients with both hepatic dysfunction and diabetes mellitus, bacteremia and shock have significantly higher mortality. We should be aware of the increasing incidence of monomicrobial NF and higher mortality rates of Gram-negative pathogens in the warm coastal area. LRINEC score is not a suitable diagnostic indicator for V. vulnificus NF, which is more rapidly progressive and fulminant than MRSA NF. NF needed team works by early suspicion, immediate surgical intervention and aggressive care, which can successfully decrease mortality.

Emergency hip disarticulations for severe necrotising fasciitis of the lower limb: a series of rare cases from a rural district general hospital.

Hip disarticulation is the removal of the entire lower limb through the hip joint by detaching the femur from the acetabulum. This major ablative procedure is rarely performed for infection but may be required in severe necrotising fasciitis. We present a single centre retrospective review of all cases of emergency hip disarticulations in patients with necrotising fasciitis between 2010 and 2020. All five patients included in the review presented with acute lower limb pain and sepsis. Three patients had comorbidities predisposing them to necrotising fasciitis. Three were deemed to be high risk and two were at intermediate risk of developing necrotising fasciitis. There were two deaths in the postoperative period. Of the three survivors, two required revision surgery for a completion hindquarter amputation and one for flap closure. All three survivors had good functional outcomes after discharge from hospital. Despite its associated morbidity, emergency amputation of the entire lower limb is a life-saving treatment in cases of rapidly progressing necrotising fasciitis and should be considered as a first-line option in managing this condition.

A rare case of necrotizing fasciitis of the abdominal wall due to Hungatella effluvii and Streptococcus constellatus.

We report a rare case of necrotizing fasciitis of the abdominal wall caused by Hungatella effluvii and Streptococcus constellatus. Necrotizing fasciitis has high mortality, so early diagnosis and aggressive treatment are essential for good clinical outcome. Identification of the microbial contribution to these infections is crucial for targeted antibiotic treatment.

Necrotizing fasciitis secondary to lake water inoculation with Aeromonas sobria: A case report.

RATIONALE: Necrotizing fasciitis (NF) is a rapidly progressing bacterial soft tissue infection with a high mortality rate. It is characterized by significant soft tissue destruction with associated sepsis. The mainstay of treatment is coverage with appropriate broad-spectrum antibiotic therapy and emergent surgical debridement. PATIENT CONCERNS: A previously healthy 66-year-old female presented with a deep laceration to her right, posterior calf with subsequent contamination with lake water. After the wound was irrigated and closed, the patient developed NF. DIAGNOSIS: Laceration of the right lower extremity complicated by NF secondary to Aeromonas sobria. INTERVENTIONS: The patient underwent emergent surgical debridements with intravenous broad-spectrum antibiotics and negative pressure wound therapy. The lower extremity was reconstructed with split-thickness skin grafts. OUTCOMES: The patient's initial penetrating trauma was closed in the emergency room, and the patient was discharged home with antibiotics. She returned the next day with unstable vitals and was admitted to the intensive care unit. Her condition continued to deteriorate, and she underwent serial surgical debridements. Her condition improved and was discharged home after 13 days in the hospital. LESSONS LEARNED: Close monitoring for NF is important for tissue infections sustained in aquatic environments. Timely identification and surgical management of NF increases overall survival.

Friends or enemies? The complicated relationship between Pseudomonas aeruginosa and Staphylococcus aureus.

Pseudomonas aeruginosa (Pa) and Staphylococcus aureus (Sa) are opportunistic pathogens that are most commonly co-isolated from chronic wounds and the sputum of cystic fibrosis patients. Over the last few years, there have been plenty of contrasting results from studies involving P. aeruginosa and S. aureus co-cultures. The general concept that P. aeruginosa outcompetes S. aureus has been challenged and there is more evidence now that they can co-exist. Nevertheless, it still remains difficult to mimic polymicrobial infections in vitro and in vivo. In this review, we discuss recent advances in regard to Pa-Sa molecular interactions, their physical responses, and in vitro and in vivo models. We believe it is important to optimize growth conditions in the laboratory, determine appropriate bacterial starting ratios, and consider environmental factors to study the co-existence of these two pathogens. Ideally, optimized growth media should reflect host-mimicking conditions with or without host cells that allow both bacteria to co-exist. To further identify mechanisms that could help to treat these complex infections, we propose to use relevant polymicrobial animal models. Ultimately, we briefly discuss how polymicrobial infections can increase antibiotic tolerance.

Rapidly fatal necrotizing soft tissue infection due to Clostridium sordellii in an injection drug user.

Clostridium sordellii infections are known to be associated with high morbidity and mortality. To date, only a small number of cases with necrotizing soft tissue infection due to C. Sordellii have been reported. We report a case presented with necrotizing soft tissue infection of the right upper extremity caused by C. sordellii in a patient with known use of injected heroin. Despite broad spectrum antibiotics and surgical debridement, the patient's clinical course became rapidly fatal, within 24 h of admission. C. sordellii necrotizing soft tissue infections are particularly virulent. Even in the context of appropriate surgical debridement, these infections can be rapidly fatal. This case highlights the importance of high suspicion for C. sordellii as potential pathogen of necrotizing soft tissue infection in injection drug users.