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Necrotizing soft tissue infection — Clinical Guidelines

Overview

Necrotizing soft tissue infections (NSTIs) are severe, rapidly progressing infections characterized by necrosis of soft tissues, often requiring urgent surgical intervention and aggressive management to mitigate high morbidity and mortality rates 1 2 5.

Diagnosis

Clinical Presentation: Erythema, edema, bullae formation, cutaneous anesthesia, ecchymosis, tense edema, gas formation, and pain disproportionate to physical findings 2.

Laboratory Tests: Elevated inflammatory markers, metabolic acidosis, and hypoxemia may be present 5.

Imaging: CT scans can reveal signs of infection and extent of tissue involvement 5.

Scoring Systems: LRINEC score can aid in early identification and risk stratification 5.

Organ Dysfunction Assessment: Modified Sequential Organ Failure Assessment (mSOFA) score helps in monitoring systemic impact 1 6.

Management

Surgical Debridement: Extensive and repeated surgical debridement is crucial to remove necrotic tissue and prevent disease progression 2 3.

Antibiotics: Broad-spectrum antibiotics targeting aerobic and anaerobic pathogens, including Bacteroides species, streptococci, staphylococci, and gram-negative rods 9.

Wound Care: Open-to-air wound management can facilitate early detection of recurrence without increasing pain or necessitating frequent dressing changes 3.

Supportive Care: Intensive care support including mechanical ventilation, fluid resuscitation, and management of organ dysfunction 1 6.

Monitoring: Regular assessment of mSOFA scores to evaluate resolution of organ dysfunction and predict long-term outcomes 1 6.

Special Populations

Elderly and Comorbidities: Higher age and comorbidity burden correlate with worse outcomes; close monitoring and early intervention are critical 1 5.

Diabetes: Diabetic patients are at increased risk; meticulous glycemic control may improve outcomes 5.

Key Recommendations

Early and Aggressive Surgical Debridement: Essential for survival and limb preservation; prioritize surgical intervention over transfer 2 3.

Monitor and Address Organ Dysfunction: Use mSOFA scores to assess and predict long-term survival; resolution of organ dysfunction by Day 14 is associated with better outcomes 1 6.

Optimal Antibiotic Coverage: Empiric therapy should cover aerobic and anaerobic pathogens, including Bacteroides species and streptococci 9(Evidence: Moderate).

Prompt Recognition and Management: High index of suspicion and early diagnosis are crucial, especially in atypical presentations like those from neglected peritonsillar abscess 8(Evidence: Expert opinion).

Facilitate Early Detection with Appropriate Wound Care: Consider open-to-air wound management to monitor for recurrence effectively 3(Evidence: Moderate).

References

1 Brakenridge SC, Wilfret DA, Maislin G, Andrade KE, Walker V, May AK et al.. Resolution of organ dysfunction as a predictor of long-term survival in necrotizing soft tissue infections: Analysis of the AB103 Clinical Composite Endpoint Study in Necrotizing Soft Tissue Infections trial and a retrospective claims database-linked chart study. The journal of trauma and acute care surgery 2021. link 2 Lee A, May A, Obremskey WT. Necrotizing Soft-tissue Infections: An Orthopaedic Emergency. The Journal of the American Academy of Orthopaedic Surgeons 2019. link 3 Yang D, Davies A, Burge B, Watkins P, Dissanaike S. Open-to-Air Is a Viable Option for Initial Wound Care in Necrotizing Soft Tissue Infection that Allows Early Detection of Recurrence without Need for Painful Dressing Changes or Return to Operating Room. Surgical infections 2018. link 4 Bulger EM, May A, Dankner W, Maislin G, Robinson B, Shirvan A. Validation of a clinical trial composite endpoint for patients with necrotizing soft tissue infections. The journal of trauma and acute care surgery 2017. link 5 Marinis A, Voultsos M, Foteinos A, Tselioti P, Avraamidou A, Paschalidis N et al.. Necrotizing soft tissue infection of the right anterolateral abdominal wall caused by a ruptured gangrenous appendix in an elderly diabetic patient. Le infezioni in medicina 2015. link 6 Bulger EM, May A, Bernard A, Cohn S, Evans DC, Henry S et al.. Impact and Progression of Organ Dysfunction in Patients with Necrotizing Soft Tissue Infections: A Multicenter Study. Surgical infections 2015. link 7 Gunter OL, Guillamondegui OD, May AK, Diaz JJ. Outcome of necrotizing skin and soft tissue infections. Surgical infections 2008. link 8 Losanoff JE, Missavage AE. Neglected peritonsillar abscess resulting in necrotizing soft tissue infection of the neck and chest wall. International journal of clinical practice 2005. link 9 Elliott D, Kufera JA, Myers RA. The microbiology of necrotizing soft tissue infections. American journal of surgery 2000. link00360-3)

Necrotizing soft tissue infection