Necrotizing Soft Tissue Infections - The Eastern Association for the Surgery of Trauma

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Eastern Association for the Surgery of Trauma

Necrotizing Soft Tissue Infections

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Necrotizing Soft Tissue Infection: Time is Crucial, and the Admitting Service Matters

Kongkaewpaisan N, Hwabejire J, Lee JM, Narueponjirakul N, Meier K, Mendoza A, Saillant N, Rosenthal M, King D, Fagenholz P, Velmahos G, Kaafarani H.

Surg Infect (Larchmt). 2020 Dec;21(10):828-833.

Rationale for Inclusion: This study found that failure to admit patients with NSTI to an ACS service correlates with delayed operative intervention and may lead to higher mortality.

CAVEAT: Small, single center study

Citations - To review the number of citations for this landmark paper, visit Google Scholar.

Impact of a multidisciplinary care bundle for necrotizing skin and soft tissue infections: a retrospective cohort study

Urbina T, Hua C, Sbidian E, Bosc R, Tomberli F, Lepeule R, Winoc-Decousser J, Dessap AM, Chosidow O, de Prost N.

Ann Intensive Care. 2019; 9: 123.

Rationale for Inclusion: This study aimed to assess the impact of a multidisciplinary care bundle on management and outcome of patients with NSTIs. They found that implementation of a bundle was feasible but did not improve survival after adjusting for confounding factors.

CAVEAT: Retrospective study design

Citations - To review the number of citations for this landmark paper, visit Google Scholar.

Factors Affecting Mortality Following Necrotizing Soft-Tissue Infections: Randomized Prospective Study

Barupal SR, Soni ML, Barupal R.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6557049/J Emerg Trauma Shock. 2019 Apr-Jun; 12(2): 108–116.

Rationale for Inclusion: This is a randomized prospective comparative study that found APACHE II to be a significant predictor of mortality among patients with NSTI.

CAVEAT: Single center study; Small number of patients included

Citations - To review the number of citations for this landmark paper, visit Google Scholar.

Higher LRINEC Scores and Escalation of Anesthesia Care in Necrotizing Soft Tissue Infection

Tessler RA, Vanhoy S, Bergus K, Fong C, Bulger EM, Rivara FP, Vavilala MS.

J Surg Res. 2019;238:119-126.

Rationale for Inclusion: Larger study looking at association between LRINEC score and use of vasopressors, invasive monitoring and operative time. Authors found that preoperative LRINEC score is associated with escalations in intraoperative care, and a lower score may predict patients unlikely to require vasopressors or blood transfusions.

CAVEAT: Retrospective study design

Citations - To review the number of citations for this landmark paper, visit Google Scholar.

Efficacy of Wound Coverage Techniques in Extremity Necrotizing Soft Tissue Infections.

Lauerman MH, Scalea TM, Eglseder WA, Pensy R, Stein DM, Henry S.

Am Surg. 2018 Nov 1;84(11):1790-1795.

Rationale for inclusion: Comparing effect of different wound coverage techniques on rate and time to complete closure of wound after debridement.

CAVEAT: Small study.

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Optimal timing of initial debridement for necrotizing soft tissue infection: a practice management guideline from the eastern association for the surgery of trauma.

Gelbard RB, Ferrada P, Yeh DD, Williams BH, Loor M, Yon J, Mentzer C, Khwaja K, Khan MA, Kohli A, Bulger EM, Robinson BRH.

J Trauma Acute Care Surg. 2018 Jul;85(1):208-214.

Rationale for Inclusion: Practice management guideline recommending early operative debridement within 12 hours of suspected diagnosis. Institutional and regional systems should be optimized to facilitate prompt surgical evaluation and debridement.

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Necrotizing soft tissue infections: delayed surgical treatment is associated with increased number of surgical debridements and morbidity.

Kobayashi L, Konstantinidis A, Shackelford S, Chan LS, Talving P, Inaba K, Demetriades D.

J Trauma. 2011 Nov;71(5):1400-5.

Rationale for inclusion: This more recent study found that a delay in surgical intervention >12 hours contributes to higher mortality, septic shock an renal failure, and is associated with an increased number of debridements than patients whose initial debridement is <12 hours after admission. This confirms that early initial debridement leads to improved outcomes in NSTI.

Citations - To review the number of citations for this landmark paper, visit Google Scholar.

Diagnosis of necrotizing soft tissue infections by computed tomography.

Zacharias N, Velmahos GC, Salama A, Alam HB, de Moya M, King DR, Novelline RA.

Arch Surg. 2010 May;145(5):452-5.

Rationale for inclusion: While CT scan should not delay operative intervention for NSTI, this study finds that it may be a useful adjunct for ruling out the diagnosis of a necrotizing infection.

Citations - To review the number of citations for this landmark paper, visit Google Scholar.

Outcome of necrotizing skin and soft tissue infections.

Gunter OL, Guillamondegui OD, May AK, Diaz JJ.

Surg Infect (Larchmt). 2008 Aug;9(4):443-50.

Rationale for inclusion: This study identifies risk factors for mortality, including APACHE II score and lactate levels. It also focuses on the benefit of primary management by an EGS service to facilitate prompt surgical intervention.

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Hyperbaric oxygen as adjuvant therapy in the management of necrotizing fasciitis.

Jallali N, Withey S, Butler PE.

Am J Surg. 2005 Apr;189(4):462-6.

Rationale for inclusion: This literature review does not find consistent evidence to support the routine use of HBO as an adjunctive therapy in the management of NSTI. These findings have since been corroborated in a recent Cochrane review that failed to locate relevant clinical evidence to support or refute the effectiveness of HBOT in the management of necrotizing fasciitis. Good quality clinical trials are needed to define the role of HBOT in the treatment of individuals with necrotizing fasciitis.

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Predictors of mortality and limb loss in necrotizing soft tissue infection.

Anaya DA, McMahon K, Nathens AB, Sullivan SR, Foy H, Bulger E.

Arch Surg. 2005 Feb;140(2):151-7; discussion 158.

Rationale for inclusion: One of the largest cohort studies to determine predictors of mortality that include leukocytosis, elevated creatinine, presence of heart disease, shock and Clostridial infection.

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LRINEC (laboratory risk indicator for necrotizing fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections.

Wong CH, Khin LW, Heng KS, Tan KC, Low CO.

Crit Care Med. 2004 Jul;32(7):1535-41.

Rationale for inclusion: This well cited study discusses one of the most widely used scoring systems to assist with early diagnosis of NSTI. This validated scoring system is based on laboratory values found to be independent predictors of disease and can be used to guide management.

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A simple model to help distinguish necrotizing fasciitis from nonnecrotizing soft tissue infection.

Wall DB, Klein SR, Black S, de Virgilio C.

J Am Coll Surg. 2000 Sep;191(3):227-31.

Rationale for inclusion: Although this is a smaller retrospective review to help distinguish between necrotizing and non-necrotizing infection, the model is simple and highly sensitive with a NPV of 99% for diagnosing necrotizing infection. This tool may be useful when other laboratory parameters (such as those required for the LRINEC score) are not available.

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Aggressive surgical management of necrotizing fasciitis serves to decrease mortality: a retrospective study.

Bilton BD, Zibari GB, McMillan RW, Aultman DF, Dunn G, McDonald JC.

Am Surg. 1998 May;64(5):397-400; discussion 400-1.

Rationale for inclusion: Although this is a smaller retrospective review, the authors found that early surgical debridement leads to a significant reduction in mortality, highlighting the importance of early recognition and expeditious initial debridement in the management of NSTI.

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