Evaluation and Management of Necrotizing Soft Tissue Infections

Bonne, Stephanie; Kadri, Sameer S

doi:10.1016/j.idc.2017.05.011

Cited by 171 publications

(173 citation statements)

References 61 publications

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“…Early resection of necrotic and infected tissue results in a lower microbial load. As a result, the immune system combined with broad spectrum antibiotics has better odds at controlling the infection [1,27]. Thus, time is of the essence.…”

Section: Discussionmentioning

confidence: 99%

Time is of the essence when treating necrotizing soft tissue infections: a systematic review and meta-analysis

et al. 2020

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Background: Although the phrase "time is fascia" is well acknowledged in the case of necrotizing soft tissue infections (NSTIs), solid evidence is lacking. The aim of this study is to review the current literature concerning the timing of surgery in relation to mortality and amputation in patients with NSTIs. Methods: A systematic search in PubMed/MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Controlled Register of Trials (CENTRAL) was performed. The primary outcomes were mortality and amputation. These outcomes were related to the following time-related variables: (1) time from onset symptoms to presentation; (2) time from onset symptoms to surgery; (3) time from presentation to surgery; (4) duration of the initial surgical procedure. For the meta-analysis, the effects were estimated using random-effects meta-analysis models.Result: A total of 109 studies, with combined 6051 NSTI patients, were included. Of these 6051 NSTI patients, 1277 patients died (21.1%). A total of 33 studies, with combined 2123 NSTI patients, were included for quantitative analysis. Mortality was significantly lower for patients with surgery within 6 h after presentation compared to when treatment was delayed more than 6 h (OR 0.43; 95% CI 0.26-0.70; 10 studies included). Surgical treatment within 6 h resulted in a 19% mortality rate compared to 32% when surgical treatment was delayed over 6 h. Also, surgery within 12 h reduced the mortality compared to surgery after 12 h from presentation (OR 0.41; 95% CI 0.27-0.61; 16 studies included). Patient delay (time from onset of symptoms to presentation or surgery) did not significantly affect the mortality in this study. None of the time-related variables assessed significantly reduced the amputation rate. Three studies reported on the duration of the first surgery. They reported a mean operating time of 78, 81, and 102 min with associated mortality rates of 4, 11.4, and 60%, respectively.Conclusion: Average mortality rates reported remained constant (around 20%) over the past 20 years. Early surgical debridement lowers the mortality rate for NSTI with almost 50%. Thus, a sense of urgency is essential in the treatment of NSTI.

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Section: Discussionmentioning

confidence: 99%

Time is of the essence when treating necrotizing soft tissue infections: a systematic review and meta-analysis

et al. 2020

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“…The diagnosis of FG is based on clinical findings because urgent and aggressive surgical treatment with appropriate antibiotics may be lifesaving . Laboratory findings include leukocytosis, electrolyte irregularities, and increased inflammatory markers .…”

Section: Discussionmentioning

confidence: 99%

“…Laboratory findings include leukocytosis, electrolyte irregularities, and increased inflammatory markers . Imaging methods such as computed tomography or magnetic resonance imaging may be helpful for diagnosis and treatment …”

Section: Discussionmentioning

confidence: 99%

“…5 The diagnosis of FG is based on clinical findings because urgent and aggressive surgical treatment with appropriate antibiotics may be lifesaving. 6,7 Laboratory findings include leukocytosis, electrolyte irregularities, and increased inflammatory markers. 8 Imaging methods such as computed tomography or magnetic resonance imaging may be helpful for diagnosis and treatment.…”

Section: Discussionmentioning

confidence: 99%

“…8 Imaging methods such as computed tomography or magnetic resonance imaging may be helpful for diagnosis and treatment. 7 The association of SGLT2 inhibitors with an increased risk of genitourinary infections is well documented. 9 There are a few case reports in the literature that address the association of SGLT2 inhibitors with FG.…”

Section: Discussionmentioning

confidence: 99%

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Fournier's gangrene in a patient on dapagliflozin treatment for type 2 diabetes

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Gürsoy

Kuşkonmaz

et al. 2019

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Necrotizing Soft Tissue Infections

McDermott,

Kao,

Keeley

et al. 2024

JAMA Surg

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ImportanceNecrotizing soft tissue infections (NSTIs) are severe life- and limb-threatening infections with high rates of morbidity and mortality. Unfortunately, there has been minimal improvement in outcomes over time.ObservationsNSTIs are characterized by their heterogeneity in microbiology, risk factors, and anatomical involvement. They often present with nonspecific symptoms, leading to a high rate of delayed diagnosis. Laboratory values and imaging help increase suspicion for NSTI, though ultimately, the diagnosis is clinical. Surgical exploration is warranted when there is high suspicion for NSTI, even if the diagnosis is uncertain. Thus, it is acceptable to have a certain rate of negative exploration. Immediate empirical broad-spectrum antibiotics, further tailored based on tissue culture results, are essential and should be continued at least until surgical debridement is complete and the patient shows signs of clinical improvement. Additional research is needed to determine optimal antibiotic duration. Early surgical debridement is crucial for improved outcomes and should be performed as soon as possible, ideally within 6 hours of presentation. Subsequent debridements should be performed every 12 to 24 hours until the patient is showing signs of clinical improvement and there is no additional necrotic tissue within the wound. There are insufficient data to support the routine use of adjunct treatments such as hyperbaric oxygen therapy and intravenous immunoglobulin. However, clinicians should be aware of multiple ongoing efforts to develop more robust diagnostic and treatment strategies.Conclusions and RelevanceGiven the poor outcomes associated with NSTIs, a review of clinically relevant evidence and guidelines is warranted. This review discusses diagnostic and treatment approaches to NSTI while highlighting future directions and promising developments in NSTI management.

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Evaluation and Management of Necrotizing Soft Tissue Infections

Cited by 171 publications

References 61 publications

Time is of the essence when treating necrotizing soft tissue infections: a systematic review and meta-analysis

Time is of the essence when treating necrotizing soft tissue infections: a systematic review and meta-analysis

Fournier's gangrene in a patient on dapagliflozin treatment for type 2 diabetes

Necrotizing Soft Tissue Infections

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