NecrotizingSoftTissueInfections:

Updateindiagnosisandmanagement
NathanI.Shapiro,MD,MPH
DepartmentofEmergencyMedicine
BethIsraelDeaconessMedicalCenter
Boston,MA

IsitaNecrotizingSoftTissueInfection?
CASE1:36yomwithnomedicalproblemsc/o0.5cm
lacerationtotheleftindexfingerduetoscrapingitona
photocopieryesterday.Alsohasanatraumaticsoreleft
shoulder.
CASE2:42yofc/oastiffrightarmandasmallcut
ontherightdorsalringfingerafterskiingforoneday.
CASE3:86yomwithdiabetes,PVD,c/ofever,
alteredmentalstatusandblackpurulentvessiclesonhis
scrotumandperineum.

Terminology
BestterminologyisNecrotizingSoftTissue
Infection(NSTI)
Includes:
NecrotizingFasciitis
Fourniersgangrene
Clostridialgasgangreneormyonecrosis

necroticfasciaand/ormusclenotedonsurgeryor
pathologicexamofdebridedtissue

BasicsofNSTIs
Incidence:estimated1000cases/yearinUS
Mortalityhasnotchangedsignificantly
since1924
approximatemeanmortalityof22%
rangeof680%

ClassificationofNSTIs
TypeIarepolymicrobial(7892%)
2.14.4organismsperwoundculture

TypeIIaremonomicrobial(812%)
GroupAstreptococcus
Staphylococcus
Clostridium

TypeIvsIINecrotizingFasciitis
infectiveagents
TypeI

Bacteroides
Candida
Clostridium
Corynebacterium
Cryptococcus
Eikenella
Enterobacter
Escherichia
Fusobacterium
Histoplasma

TypeII

GroupAStreptococcus
Klebsiella
Neisseria
+/Staph
Pasturella
Proteus
Salmonella
Serratia
Shigella
Staphylococcus
Streptococcus
(nonGroupA)
Vibrio

Diagnosticchallange
Innocentbeginnings
Rapidprogressionofdisease
Lackofstudiesonearlydiseasepresentation
oronprogressionofearlydisease
Ultimatediagnosisismadeatsurgical
exploration

DiagnosticModalities:ClinicalExam
Historyadvanceddiseaseeasy,earlydiseaseutility
requiresHIGHDEGREEOFSUSPICION.
Heightensuspicionwiththefollowing:

Painoutofproportiontoclinicallesion
Tenseedema
Edemaextendsbeyonderythema
Purplishskindiscoloration
Numbness/weaknessintheaffectedarea(possibleedema
inducedcompartmentlikesyndromeordirectlydamaged
cutaneousnerves)

Walletal.JAmCollSurg2000;191:227

ClinicalExam
CommonHardClinicalFindings??

Bullae1624%
Necroticskin63%
Crepitance036%
Hypotension711%
Gasonplainxray3257%
Tenseedema2338%
Eveninlatepresentingcases,2061%lackanyhard
clinicalsign!
Elliottetal.AnnSurg1996;224:672
Walletal.JAmCollSurg2000;191:227

DiagnosticLabTestingforNSTI
Walletal.JAmCollSurg2000;191:227231
WalletalAmJsurg179:2000:1720
Retrospectivecasecontrolstudyof31
consecutiveNSTIvs328nonNSTIpatients
Modelselectedbydecisiontreeanalysisonvital
signsandlaboratorytesting
PositivemodeldemonstratedWBC>15.4or
serumNa<135

DiagnosticLabTestingforNSTI
Validation:
WBC>15.4orNa<135inpredictingNSTI
90%sensitivity(7490%)
76%specific(7180%)
PositivePredictiveValue(1835%)
NegativePredictiveValue(97100%)

DiagnosticLabTestingforNSTI
Pitfalls

Retrospective,casecontrolstudy
Retrospectivevalidation

Walletal.JAmCollSurg2000;191:227

RadiographicDiagnosticAdjuncts
Plainfilmxray

Maydemonstrategasintissues(3975%ofcases)
Negativepredictivevalue62%inWalletal.

CTScan/Ultrasound

Identifyairbubblesintissuerelativetofascialplanes

MRI

WithGdcontrastdistinguishesperfusedvsnecrotic
tissue
Definesextentofdisease,mayhelpguidesurgical
approach

MinimumStandardofCare
Antibiotics

SurgicalDebridement

AntibioticChoices
Empiric!CoveralltheBases
TetanusStatus?
Tripletherapyshouldbestandard
PenicillinG
Aminoglycoside
Clindamycin/Metronidazole

ChoicesforSurgeon
Youreonyourown.

PossibleAdjunctiveTherapies
Hyperbaricoxygen(HBO)
Directlytoxictocertainanerobes(clostridium)
Improvedinfectionsitetissueoxygentension
improvesneutrophilbacteriocidalactivity
Caseseriessuggestpossibleimprovementsin
mortality,numberofsurgeriesrequired,wound
closurerates

EvidenceforHBOandNSTIs

Riseman,etal.Surgery1990;108:847
Group1:12stdofcarevsGroup2:17+HBO
(beforeandafterstudy)
MortalityreducedwithHBO,23vs66%
Reducedoperativedebridements,1.2vs3.3
Pitfalls
Smallpatientnumbers
Noillnessseverityscoringsystem
IncludesmoreperinealinfectionsinGroup2

EvidenceforHBOandNSTIs
Hollabaugh, et al. Plast Reconstr Surg. 1998;101:94.

Group1:12standardofcarevsGroup2:
14+HBOMortalityreducedwithHBO7vs
42%
Nodifferenceinnumberofoperations
required
Pitfalls
Smallpatientnumbers
Noseverityofillnessscoringsystem

EvidencenotsupportingHBOinNSTI
Brownetal.AmJSurg1994;167:485

TruncalNSTI:Stdcaren=24vs+HBOn=30
APACHEIIstdused,NSdifferenceingroups
HBOgrouphadmoreoperations/patient:3.2vs1.6
MortalitynotsignificantlyimprovedwithHBO
HBOvscontrol:30vs42%

Pitfalls

Smallnumberofpatients
16HBOgrouppatientstransferredforcare
HBOgrouppatientsyounger(51vs63P<0.05)
Multiplecentersandpossiblestandardcarevariation

EvidencenotsupportingHBOinNSTI

Elliotetal.AnnSurg1996;224:672
198patientconsecutiveretrospectivereview
Groups:survivors148vsnonsurvivorsn=50
NoimprovementinmortalitywithHBO:25%
ImprovedrateofwoundclosurewithHBO
28vs48days

Pitfalls
Retrospectiveuncontrolledstudy

PossibleAdjunctiveTherapies
Polyspecifici.v.IgG

Rationaleofusage:
Strep/staphinfectionscommoninNSTI(58%)
Superantigentoxinscommonlysecrteted during
infectionandcausetoxicshock
Polyspecifici.v.IgGcontainsantibodies
neutralizingsuperantigens
IndividualswithseriousstrepNSTIslack
neutralizingantibodiestosuperantigens

Tcell

TcellAntigen
receptor

Cytokine
production

Superantigen

Antigen

MHCII
Antigenpresentingcell

AlgorithmicApproachtoR/ONSTI
Suspicion
Low
Nohardsigns

Intermediate

Antibioticsforstaph/strep
WBC>15
Admitandobserve
Na+<135
Or
Antibioticsforstaph/strep
D/Cwithf/uwoundcheck

High
AnyHardSign
Tripleantibiotics
Surgicalconsultation

Surgicalexploration
MRI
?IVIgGforpossibleSTTS

MypatienthasaNecrotizing
SoftTissueInfection!
ShouldItransfertoafacilitythathas
Hyperbaricoxygen(HBO)?

EvidencebasedsurveyofHBO
intreatingNSTIs
Therearenoprospectiverandomized
controlledstudiesonthissubject
AllinformationonNSTItreatmentisbased
onretrospectivecasereviews
Becauseoftherarity,variedeitiologiesand
presentationsofthisdisease,therewill
likelyneverbeagoldstandardstudy

RoleofHBOinNSTI
Currentlynotsufficientdatatomandate
transferofpatienttoHBOcontaining
facilitydonotdelaysurgical
intervention!
IfavailableHBOshouldbeconsidered
forpossiblebenefitsonmortalityand
improvedwoundclosure

Themorethingschange