Necrotizing Soft Tissue Infections: A Review of Diagnosis,Management, and Implications for NP Practice

Skin and soft tissue infections are among the most common diagnoses seen by nurse practitioners practicing in all settings. These infections range from mild, uncomplicated cellulitis to the more severe, complicated diagnosis of necrotizing soft tissue infections (NSTI). For patients presenting with symptoms of skin and soft tissue infections, differentiating NSTIs from less insidious infections is of paramount importance. NSTIs can be difficult to diagnose because the early presentation may be misleadingly straightforward; however, it is essential that NPs carefully consider NSTIs when a patient presents with the following cardinal skin signs: erythema, swelling, and warmth.     

Community-acquired necrotizing soft tissue infections: a review of 122 cases presenting to a single emergency department over 12 years

PURPOSE: To characterize the Emergency Department (ED) presentation of necrotizing soft tissue infections (NSTI) and identify severity markers. Procedures: Retrospective chart review of pathologically diagnosed NSTIs presenting to an urban ED from 1990-2001. Cases were identified from a surgical database, ICD-9 search and prospectively. Five Emergency Physicians (EPs) abstracted data using a standardized form. Severe NSTI was defined by any of the following: death, amputation, intensive care unit (ICU) stay >24 h, >300 cm(2) debrided. Severe and non-severe cases were compared using chi-square, Fisher's exact, and multivariate logistic regression testing. FINDINGS: The 122 cases were characterized by: injection drug use, 80%; fever, 44%; systolic blood pressure (BP) <100 mm Hg, 21%; white blood cell count (WBC) >20 x 10(9)/L, 43%; median time to operation, 8.4 h; mortality, 16%. The managing EP suspected NSTI in 59%. A systolic BP <100 mm Hg, BUN >18 mg/dL, radiographic soft tissue gas, admission to a non-surgical service and clostridial species were independently associated with severe NSTI. CONCLUSIONS: Pathologically defined NSTIs have a wide spectrum of ED presentations and early diagnosis remains difficult.     

Subcutaneous emphysema of the extremities: Be wary of necrotizing fasciitis,but also consider occult rupture or perforation

Not all causes of subcutaneous emphysema are attributable to necrotizing fasciitis. Consider other causes of subcutaneous emphysema in the differential diagnosis.     

Management of Significant and Widespread,Acute Subcutaneous Emphysema: Should We Manage Surgically or Conservatively?

Background

Subcutaneous emphysema of a limb after acute injury is classically associated with gas gangrene. Delayed management can result in amputation and death. Typically caused by a clostridial infection, patients are unwell, with rapidly spreading clinical signs, abnormal laboratory results, and cultures positive. There are reports of widespread subcutaneous emphysema of a limb in well-appearing patients, with blood parameters within normal limits; however, the optimum management of this type of case is unclear.

Objective

Our objectives were to present 4 new cases of acute subcutaneous emphysema in well-appearing patients managed with early surgery, review the literature, and discuss the management decisions in cases of acute subcutaneous emphysema in clinically well patients.

Case reports

Here we present a case series of 4 patients, all with penetrating injuries to the upper limb resulting in widespread subcutaneous emphysema within 24 h of injury. Mean age was 33 years. All were fit and well, with the exception of one with type 1 diabetes, no cardiorespiratory compromise, and no significant derangement of laboratory investigations. X-ray studies showed widespread gas within the soft tissues. All were treated aggressively with immediate surgical fasciotomy of the upper limb, thorough debridement, and washout as required. Gram stains revealed pus cells (polymorphonuclear leucocytes) in all, but organisms in only one case (Gram-positive cocci and bacilli). Prolonged culture grew organisms in all. All patients had a second washout and closure plus 6 weeks of antibiotics. All survived and had fully functioning limbs. Why should an emergency physician be aware of this? We recommend having a low threshold for rapid referral to an appropriate surgical speciality, allowing prompt and radical surgical management of this type of presentation, even in the presence of a well patient.     

Necrotizing Fasciitis in the Adult Patient: Implications for Nurse Practitioners

Necrotizing fasciitis is a life-threatening skin and soft tissue infection associated with high morbidity and mortality in adult patients. Nurse practitioners in both outpatient and inpatient settings should be vigilant for the hallmark signs and symptoms, such as pain out of proportion to the wound appearance and gray or “dishwasher”-colored discharge from the wound. Prompt recognition of these signs and symptoms, rapid surgical debridement, and early initiation of broad-spectrum antimicrobial management are necessary for optimizing patient outcomes and reducing hospital length of stay, cost, morbidity, and mortality.     

“Synchronous” Multifocal Necrotizing Fasciitis

Background

Necrotizing fasciitis (NF) is an infection of the soft tissue, and is fatal if not promptly and aggressively treated. Although it is rare, it is not exceptional; nevertheless, its presentation may be misleading and may delay the diagnosis. We highlight the possible synchronous development of NF in multiple noncontiguous areas.

Case Report

A 44-year-old diabetic man with no history of trauma complained of nonspecific lower back pain, which he treated with analgesics and oral antibiotics. Erythema at the left arm appeared, and the general condition worsened. The patient was admitted to the Emergency Department, and NF was diagnosed at the right gluteus and left arm.

Conclusion

“Synchronous” multifocality is not an expected presentation of NF, and it complicates the diagnosis and delays treatment, with a potentially negative impact on outcome.     

坏死性筋膜炎合并溶血性贫血1例报道并文献复习

坏死性筋膜炎(NF)是临床上较为罕见的一种感染性疾病,发病后进展迅速,可在短时间内累及全身多个器官,严重者引起脓毒性休克,如治疗不及时则死亡率及致残率极高。为进一步探讨NF的诊断及治疗,本文分析1例收治于江苏省中医院,同时具有溶血性贫血及糖尿病等基础疾病,且长期服用激素药物的NF患者的病历资料,并复习近年来国内外相关文献,作如下报道。     

Sonographic Findings in Necrotizing Fasciitis

Necrotizing fasciitis is a rare but serious disease, and early diagnosis is essential to reducing its substantial morbidity and mortality. The 2 cases presented show that the key clinical and radiographic features of necrotizing fasciitis exist along a continuum of severity at initial presentation; thus, this diagnosis should not be prematurely ruled out in cases that do not show the dramatic features familiar to most clinicians. Although computed tomography and magnetic resonance imaging are considered the most effective imaging modalities, the cases described here illustrate how sonography should be recommended as an initial imaging test to make a rapid diagnosis and initiate therapy.     

Management of necrotizing skin and soft tissue infections

Although rare, necrotizing skin and soft tissue infections can be devastating infections that are difficult to diagnose and challenging to manage. Clinical presentation is often insidious, and a low index of suspicion is critical. Various diagnostic tools, such as scoring systems or imaging techniques, have been introduced, but none is convincingly superior to sound clinical judgment. Early diagnosis allows early adequate therapy that includes antibiotic therapy, critical care support, specific interventions such as intravenous immunoglobulin in selected patients and, most importantly, early source control. Empirical antibiotic therapy should cover a broad range of both Gram-negative and Gram-positive aerobic and anaerobic microorganisms, and clindamycin is recommended when group A Streptococcus is a suspected pathogen.     

Necrotizing fasciitis: early sonographic diagnosis

Necrotizing fasciitis is a rare, but potentially fatal bacterial infection of the soft tissues. Establishing the diagnosis at the early stages of the disease remains the greatest challenge. We report a case of necrotizing fasciitis involving the upper extremity. Sonography revealed subcutaneous emphysema spreading along the deep fascia, swelling, and increased echogenicity of the overlying fatty tissue with interlacing fluid collections. The patient responded well to early surgical debridement and parenteral antibiotics.     

Neglected peritonsillar abscess resulting in necrotizing soft tissue infection of the neck and chest wall

Necrotizing soft tissue infection (NSTI) of the neck and chest wall resulting from neglected peritonsillar abscess is a relatively rare but highly lethal surgical condition which has received little attention in the literature. The case of a 54-year-old male patient affected by this unusual infection is reported. Our recent experience and literature data suggest that NSTI resulting from peritonsillar abscess is rapidly spreading and life threatening. High index of suspicion, early diagnosis, broad-spectrum antibiotics and aggressive surgical debridement are essential to its successful treatment.     

Naja atra snakebite in Taiwan

Background: Naja atra snakebite is uncommon in Taiwan and causes distinct effects on its victims. Although the Taiwan government produces its own specific antivenom, little information on the management of N. atra snakebite is available.

Materials and methods: We retrospectively evaluated 183 patients admitted to two medical centers. Of these, 45 were identified as definite cases of N. atra snakebite, 86 as suspected cases, and 52 as clinical cases. Demographic data, symptomatology, and management were compared between these case groups.

Results: Symptomatology and management were similar in the three groups. Among the 183 patients, 10 (5.5%) were asymptomatic and nine (4.9%) had transient and partial ptosis or body weakness. The principal effects were local tissue swelling and pain in 173 patients (94.5%), followed by clinically suspected wound infection in 148 (80.9%), skin necrosis in 120 (65.6%), necrotizing soft tissue infection in 77 (42.1%), fever in 59 (32.2%), and gastrointestinal effects in 53 (29%). The median total dose of specific antivenom needed to treat N. atra envenoming was 10 vials. In the envenomed patients, debridement was required in 74 patients (42.8%), fasciotomy/fasciectomy in 46 (26.6%), and finger or toe amputation in seven (4%). The first operation was performed at a median of 3.5 days after the bite.

Discussion and conclusions: Based on these typical manifestations, clinical diagnosis of N. atra snakebites may be feasible and practical. In contrast to other snakes of Elapidae family, N. atra bite did not cause serious neurological effects. Early surgical consultation should be obtained because half of the patients underwent surgery due to infectious complications. Acute compartment syndrome was the surgical indication in rare cases; however, overestimation of the incidence may have occurred. This syndrome should be confirmed by serial intracompartmental pressure monitoring instead of only physical examination, and a sufficient dose of antivenom should be given prior to surgical decompression.     

A Case of Necrotizing Fasciitis with a LRINEC Score of Zero: Clinical Suspicion Should Trump Scoring Systems

Background

Necrotizing fasciitis (NF) is a potentially lethal infection involving the skin, subcutaneous tissue, and fascia. The Laboratory Risk Indicator for Necrotizing fasciitis (LRINEC) score has been proposed as a way of using abnormal laboratory values to distinguish between severe cellulitis and necrotizing fasciitis.

Objectives

The utility of the LRINEC system, including a review of current literature on this scoring system, is discussed.

Case Report

A case of a 37-year-old man is presented. As part of the diagnostic work-up, appropriate laboratory tests necessary to calculate a LRINEC score were obtained. Despite a LRINEC score of 0, NF was later confirmed at surgery.

Conclusions

Although the LRINEC score has been proposed as a robust way of identifying patients with early NF, it failed to detect NF in the patient reported here. NF should thus remain primarily a disease of clinical suspicion, and this suspicion should trump the LRINEC score.     

Atraumatic Clostridial myonecrosis: case report and literature review

Clostridial myonecrosis (CM) is a rare, life-threatening infection that is most often associated with recent surgery or skeletal muscle trauma. It usually affects patients with some degree of underlying immunocompromise or vascular insufficiency. Occasionally, CM can occur at remote sites, with seeding from a gastrointestinal source in the setting of malignancy. We report a case of a 75-year-old man who developed rapidly progressive myonecrosis in the right shoulder, without prior trauma, caused by Clostridium septicum. On autopsy, this patient was found to have previously undiagnosed radiation colitis with ulcerations and abscess formation, secondary to recent prostate cancer radiation therapy. Although several case reports discuss CM in the setting of bowel malignancy, our case illustrates that non-malignant bowel inflammation may be a sufficient source for the infection. Clinical features of this uncommon disease are discussed, and the relevant literature is reviewed with regard to Clostridium septicum as an etiologic agent.     

器具辅助软组织松解术联合体外冲击波疗法治疗足底筋膜炎的短期疗效观察

目的 探讨器具辅助软组织松解术（instrument-assisted soft tissue mobilization, IASTM）联合体外冲击波疗法（extracorporeal shock wave therapy, ESWT）对足底筋膜炎（plantar fasciitis, PF）的短期疗效。方法 选择2019年5月至2021年4月在复旦大学附属中山医院康复医学科就诊的足底筋膜炎患者41例,随机分为对照组（n=20）和观察组（n=21）。对照组仅接受ESWT治疗,观察组接受IASTM与ESWT联合治疗。所有患者分别于治疗前、治疗4周后采用视觉模拟评分（visual analogue scale, VAS）、无痛承重负荷（painless weight-bearing load, PWBL）以及足踝功能评估（foot and ankle ability measure, FAAM）中的日常生活活动(activities of daily living, ADL)分量表评估2组治疗效果并比较。结果 治疗后,对照组和观察组的VAS评分分别由（5.58±1.92）分和（5.63±1...     

Case report of open appendectomy in treating acute perforated appendicitis with necrotizing fasciitis of the abdominal wall: A rare complication of a common disease

Acute appendicitis can be associated with uncommon complications such as necrotizing fasciitis. We present a case of a 37‐year‐old woman referred to our hospital with a 1‐week history of significant weakness, anorexia, and mild abdominal pain. According to laboratory and radiographic data, the patient was diagnosed with perforated appendicitis and gangrene.     

Cutaneous diphtheria complicated oncologic reconstruction surgery in osteosarcoma

Diphtheria is an uncommon bacterial infection of the upper respiratory tract. We described a surgical site infection in a young adolescent female on maintenance chemotherapy. Corynebacterium diphtheriae was recovered from the wound, and she was treated with antibiotics and antitoxin. Cutaneous diphtheria should be considered in immunocompromised patients receiving chemotherapy.     

135例小儿腹腔细菌感染谱的分析

目的：分析儿童腹腔感染的细菌感染谱和治疗结果。方法：用纸片扩散法对分离的细菌进行药敏试验，并判断细菌耐药性，评价预后。结果：共分离得到致病菌158株，儿童腹腔感染以G菌为主，出现了超广谱β内酰胺酶（EASBLs）阳性菌，常用抗生素均出现耐药菌株。手术治疗仍是有效手段。结论：儿童腹腔感染的治疗需手术和抗生素治疗共同进行。抗生素治疗需注意耐药性。     

ABSCESS: Applied Bedside Sonography for Convenient Evaluation of Superficial Soft Tissue Infections

Objectives: Soft tissue infections are a common presenting complaint in the emergency department (ED). The authors sought to determine the utility of ED bedside ultrasonography (US) in detecting subcutaneous abscesses. Methods: Between August 2003 and November 2004, a prospective, convenience sample of adult patients with a chief complaint suggestive of cellulitis and/or abscess was enrolled. US was performed by attending physicians or residents who had attended a 30‐minute training session in soft tissue US. The treating physician recorded a yes/no assessment of whether he or she believed an abscess was present before and after the US examination. Incision and drainage (I + D) was the criterion standard when performed, while resolution on seven‐day follow‐up was the criterion standard when I + D was not performed. Results: Sixty‐four of 107 patients had I + D–proven abscess, 17 of 107 had negative I + D, and 26 of 107 improved with antibiotic therapy alone. The sensitivity of clinical examination for abscesses was 86% (95% confidence interval [CI] = 76% to 93%), and the specificity was 70% (95% CI = 55% to 82%). The positive predictive value was 81% (95% CI = 70% to 90%), and the negative predictive value was 77% (95% CI = 62% to 88%). The sensitivity of US for abscess was 98% (95% CI = 93% to 100%), and the specificity was 88% (95% CI = 76% to 96%). The positive predictive value was 93% (95% CI = 84% to 97%), and the negative predictive value was 97% (95% CI = 88% to 100%). Of 18 cases in which US disagreed with the clinical examination, US was correct in 17 (94% of cases with disagreement, χ²= 14.2, p = 0.0002). Conclusions: ED bedside US improves accuracy in detection of superficial abscesses.