Scarce evidence of efficacy of hyperbaric oxygen therapy in necrotizing soft tissue infection: a systematic review

Thrane, Jens Faunø; Ovesen, Therese

doi:10.1080/23744235.2019.1597983

Cited by 21 publications

(13 citation statements)

References 42 publications

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“…Other authors recommend the use of HBOT in NSTI 11,62 . However, in a literature review on the efficacy of HBOT in necrotizing soft tissue infections, Faunø et al found "poor and biased" evidence and the need for randomized controlled trials 63 . The same conclusion was drawn by Anheuser et al, who carried out a retrospective multicenter analysis of the influence of HBO on Fournier's gangrene 64 .…”

Section: Hyperbaric Oxygen Therapymentioning

confidence: 99%

Clostridial Gas Gangrene ‐ A Rare but Deadly Infection: Case series and Comparison to Other Necrotizing Soft Tissue Infections

Leiblein

Wagner

Adam

et al. 2020

Orthopaedic Surgery

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Objective: Clostridial gas gangrene (GG) or clostridial myonecrosis is a very rare but life-threatening necrotizing soft tissue infection (NSTI) caused by anaerobic, spore-forming, and gas-producing clostridium subspecies. It is the most rapidly spreading and lethal infection in humans, also affecting muscle tissue. The high mortality, of up to 100%, in clostridial GG is mediated by potent bacterial exotoxins. Necrotizing fasciitis (NF) is an important differential diagnosis, most often caused by group A streptococci, primarily not affecting musculature but the subcutaneous tissue and fascia. In the early stages of the infection, it is difficult to distinguish between GG and NF. Therefore, we compare both infection types, identify relevant differences in initial clinical presentation and later course, and present the results of our patients in a retrospective review. Methods: Patients diagnosed with GG from 2008 to 2018 in our level one trauma center were identified. Their charts were reviewed retrospectively and data analyzed in terms of demographic information, microbiological and histological results, therapeutic course, outcome, and mortality rates. The laboratory risk indicator for NF (LRINEC) score was applied on the first blood work acquired. Results were compared to those of a second group diagnosed with NF. Results: Five patients with GG and nine patients with NF were included in the present study. Patients with GG had a mortality rate of 80% compared to 0% in patients with NF. In eight patients with NF, affected limbs could be salvaged; one NF underwent amputation. LRINEC did not show significant differences between the groups; however, C-reactive protein was significantly increased (P = 0.009) and hemoglobin (Hb) was significantly decreased (P = 0.02) in patients with GG. Interleukin-6 and procalcitonin levels did not show significant difference. Patients with GG were older (70.2 vs 50 years). Of the isolated bacteria, 86% were sensitive to the initial calculated antibiotic treatment with ampicillin-sulbactam or imipenem plus metronidazole plus clindamycin. Conclusion: Both GG and NF need full-scale surgical, antibiotic, and intensive care treatment, especially within the first days. Among patients with NSTI, those with clostridial GG have a significantly increased mortality risk due to early septic shock caused by clostridial toxins. In the initial stages, clinical differences are hardly detectable. Immediate surgical debridement is the key to successful therapy for NSTI and needs to be performed as early as possible. However, patients should be treated in a center with an experienced interdisciplinary intensive care team based on a predetermined treatment plan.

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Section: Hyperbaric Oxygen Therapymentioning

confidence: 99%

Clostridial Gas Gangrene ‐ A Rare but Deadly Infection: Case series and Comparison to Other Necrotizing Soft Tissue Infections

Leiblein

Wagner

Adam

et al. 2020

Orthopaedic Surgery

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“…This may lead to some bias in the analysis, but prospective randomized studies would not be ethical for this condition as this method is already classically used and leads to benefits; thus, depriving patients of treatment would not be recommended. 54 Another aspect that may have influenced and caused some bias in the results is the fact that not all patients were operated on by the same surgeon and in the same department, which may lead to differences. However, groups I and II were similar in terms of age, comorbidities and anatomical severity classification.…”

Section: Discussionmentioning

confidence: 99%

Hyperbaric oxygen therapy decreases mortality due to Fournier’s gangrene

Féres

Feitosa

Rocha

et al. 2021

Medical Gas Research

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There is no consensus about the role of adjunctive hyperbaric oxygen therapy (HBOT) in the management of Fournier’s gangrene. The aim of this study was to compare the evolution of patients with Fournier’s gangrene treated with all classical measures with and without adjuvant HBOT. A retrospective comparative study regarding the evolution of patients treated for Fournier’s gangrene was conducted in two periods. In period I, from 1990 to 2002, patients received standard treatments for Fournier’s gangrene, which consisted of surgical debridement, antibiotic therapy and intensive care. In period II, from 2012 to 2019, adjunctive HBOT was added to the classical management strategy. All patients were assigned into four groups according to the anatomical severity classification and the area affected after the first debridement. This classification ensured that the groups could be comparable. The total number of patients in this study was 197, and these patients were divided into control group (118/59.9%) and HBOT group (79/40.1%). The mean age, comorbidities, and anatomical severity classification were similar between the two groups. In period I, 34 out of 118 (28.8%) patients died, while in the HBOT group, 3 out of 77 (3.7%) patients died ( P < 0.001). The use of adjuvant HBOT in combination with classical treatment was associated with reduced mortality. This study was approved by the Institutional Review Board and the Ethics Committee of Ribeirão Preto Medical School, University of São Paulo, Brazil (No. 08/2018) on May 2, 2018.

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“…Many studies investigating its impact on outcome of NSTI demonstrated positive effects [21][22][23][24][25][26][27][28][29], whereas others did not show significant benefit [30][31][32][33][34]. Past systematic reviews provided only limited evidence on the clinical advantages of HBOT and had difficulties performing reliable meta-analyses due to shortcomings in the design and limited cohort sizes of included studies, high risk of confounding, substantial study heterogeneity and poor concordance of inclusion criteria [4,5,35,36]. According to the latest meta-analysis, HBOT improves the odds for survival of NSTI [11].…”

Section: Impact Of Hbotmentioning

confidence: 99%

“…Furthermore, high oxygen levels ameliorate tissue regeneration and improve the efficacy of antibiotics, especially in biofilm forming microbes [ 3 ]. However, evidence for the benefits of HBOT in terms of survival and clinical outcome of patients with NF and FG is still limited [ 4 , 5 ].…”

Section: Introductionmentioning

confidence: 99%

Outcome of necrotizing fasciitis and Fournier's gangrene with and without hyperbaric oxygen therapy: a retrospective analysis over 10 years

et al. 2022

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Background Necrotizing soft tissue infections (NSTI) require immediate radical debridement, broad-spectrum antibiotics and intensive care. Hyperbaric oxygen therapy (HBOT) may be performed adjunctively, but unequivocal evidence for its benefits is still lacking. Methods We performed a retrospective single-center study including 192 patients with necrotizing fasciitis or Fournier's gangrene to assess in-hospital mortality and outcome dependent on patient, disease and treatment characteristics with or without HBOT. Results The in-hospital mortality rate was 27.6%. Factors associated with increased mortality according to multivariate analysis were higher age, affection of multiple or problem localizations (odds ratio (OR) = 2.88, P = 0.003), ineligibility for HBOT despite clinical indication (OR = 8.59, P = 0.005), pathogens in blood cultures (OR = 3.36, P = 0.002), complications (OR = 10.35, P < 0.001) and sepsis/organ dysfunction (OR = 19.58, P < 0.001). Factors associated with better survival included vacuum-assisted wound closure (OR = 0.17, P < 0.001), larger number of debridements (OR = 0.83, P < 0.001) and defect closure with mesh graft (OR = 0.06, P < 0.001) or flap (OR = 0.09, P = 0.024). When participants were stratified into subgroups without requirement of HBOT (n = 98), treated with HBOT (n = 83) and ineligible for HBOT due to contraindications (n = 11), the first two groups had similar survival rates (75.5% vs. 73.5%) and comparable outcome, although patients with HBOT suffered from more severe NSTI, reflected by more frequent affection of multiple localizations (P < 0.001), sepsis at admission (P < 0.001) and intensive care treatment (P < 0.001), more debridements (P < 0.001) and a larger number of antibiotics (P = 0.001). In the subgroup ineligible for HBOT, survival was significantly worse (36.4%, P = 0.022). Conclusion These results point to a benefit from HBOT for treatment of NSTI in critically ill patients.

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Scarce evidence of efficacy of hyperbaric oxygen therapy in necrotizing soft tissue infection: a systematic review

Cited by 21 publications

References 42 publications

Clostridial Gas Gangrene ‐ A Rare but Deadly Infection: Case series and Comparison to Other Necrotizing Soft Tissue Infections

Clostridial Gas Gangrene ‐ A Rare but Deadly Infection: Case series and Comparison to Other Necrotizing Soft Tissue Infections

Hyperbaric oxygen therapy decreases mortality due to Fournier’s gangrene

Outcome of necrotizing fasciitis and Fournier's gangrene with and without hyperbaric oxygen therapy: a retrospective analysis over 10 years

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