Advertisement

Management of Necrotizing Soft Tissue Infection

  • Heather Leigh EvansEmail author
  • Lena M. Napolitano
  • Eileen M. Bulger
Chapter
  • 6 Downloads

Abstract

Necrotizing soft tissue infection is a relatively rare, but highly morbid condition requiring immediate surgical evaluation and initiation of multimodal treatment. The key to effective treatment for NSTI is early recognition of the problem, facilitated by history and physical examination, as well as laboratory data. Imaging is rarely helpful and often only serves to delay definitive surgical evaluation and debridement. Severe systemic disease can manifest as septic shock and multisystem organ failure, and surgical source control is the mainstay of successful treatment, when combined with broad spectrum antibiotic administration and hemodynamic support to minimize progression of organ failure. It may be necessary to perform radical debridement, even amputation, to arrest progression of the disease, and interval reoperations should continue until no further debridement of necrotic tissue is needed. Adjunctive therapies may be helpful, but should be considered secondary and should not delay definitive surgical debridement or transfer to a facility if surgical intervention is not available.

Keywords

Necrotizing fasciitis Necrotizing soft tissue infection Source control Septic shock Debridement Toxic shock syndrome Streptococcal sepsis 

References

  1. 1.
    Stevens DL, Bryant AE. Necrotizing soft-tissue infections. N Engl J Med. 2017;377:2253–65.  https://doi.org/10.1056/NEJMra1600673.CrossRefPubMedGoogle Scholar
  2. 2.
    McHenry CR, Piotrowski JJ, Petrinic D, Malangoni MA. Determinants of mortality for necrotizing soft-tissue infections. Ann Surg. 1995;221(5):558–63. discussion 563–5CrossRefGoogle Scholar
  3. 3.
    Wall DB, de Virgilio C, Black S, Klein SR. Objective criteria may assist in distinguishing necrotizing fasciitis from nonnecrotizing soft tissue infection. Am J Surg. 2000;179(1):17–21.CrossRefGoogle Scholar
  4. 4.
    Wong C-H, Chang H-C, Pasupathy S, Khin L-W, Tan J-L, Low C-O. Necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality. J Bone Joint Surg Am. 2003;85-A(8):1454–60.CrossRefGoogle Scholar
  5. 5.
    Bilton BD, Zibari GB, McMillan RW, Aultman DF, Dunn G, McDonald JC. Aggressive surgical management of necrotizing fasciitis serves to decrease mortality: a retrospective study. Am Surg. 1998;64(5):397–400. discussion 400–1PubMedGoogle Scholar
  6. 6.
    Kobayashi L, Konstantinidis A, Shackelford S, Chan LS, Talving P, Inaba K, et al. Necrotizing soft tissue infections: delayed surgical treatment is associated with increased number of surgical debridements and morbidity. J Trauma. 2011;71(5):1400–5.CrossRefGoogle Scholar
  7. 7.
    Wong C, Khin L. Clinical relevance of the LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score for assessment of early necrotizing fasciitis. Crit Care Med. 2005;33(7):1677.CrossRefGoogle Scholar
  8. 8.
    Arslan A, Pierre-Jerome C, Borthne A. Necrotizing fasciitis: unreliable MRI findings in the preoperative diagnosis. Eur J Radiol. 2000;36(3):139–43.CrossRefGoogle Scholar
  9. 9.
    Loyer EM, DuBrow RA, David CL, Coan JD, Eftekhari F. Imaging of superficial soft-tissue infections: sonographic findings in cases of cellulitis and abscess. Am J Roentgenol. 1996;166(1):149–52.CrossRefGoogle Scholar
  10. 10.
    Anaya DA, Bulger EM, Kwon YS, Kao LS, Evans H, Nathens AB. Predicting death in necrotizing soft tissue infections: a clinical score. Surg Infect. 2009;10(6):517–22.CrossRefGoogle Scholar
  11. 11.
    Busse JW, Jacobs CL, Swiontkowski MF, Bosse MJ, Bhandari M, Evidence-Based Orthopaedic Trauma Working Group. Complex limb salvage or early amputation for severe lower-limb injury: a meta-analysis of observational studies. J Orthop Trauma. 2007;21(1):70–6.CrossRefGoogle Scholar
  12. 12.
    Babbar A, Bruun T, Hyldegaard O, Nekludov M, Arnell P, INECT Study Group, Pieper DH, Itzek A. Pivotal role of preexisting pathogen-specific antibodies in the development of necrotizing soft-tissue infections. J Infect Dis. 2018;218(1):44–52.  https://doi.org/10.1093/infdis/jiy110. CrossRefPubMedGoogle Scholar
  13. 13.
    Kaul R, McGeer A, Norrby-Teglund A, Kotb M, Schwartz B, O'Rourke K, et al. Intravenous immunoglobulin therapy for streptococcal toxic shock syndrome--a comparative observational study. The Canadian Streptococcal Study Group. Clin Infect Dis. 1999;28(4):800–7.CrossRefGoogle Scholar
  14. 14.
    Davies HD, McGeer A, Schwartz B, Green K, Cann D, Simor AE, et al. Invasive group A streptococcal infections in Ontario, Canada. Ontario Group A Streptococcal Study Group. N Engl J Med. 1996;335(8):547–54.CrossRefGoogle Scholar
  15. 15.
    Linnér A, Darenberg J, Sjölin J, Henriques-Normark B, Norrby-Teglund A. Clinical efficacy of polyspecific intravenous immunoglobulin therapy in patients with streptococcal toxic shock syndrome: a comparative observational study. Clin Infect Dis. 2014;59(6):851–7.CrossRefGoogle Scholar
  16. 16.
    Darenberg J, Ihendyane N, Sjolin J, et al. Intravenous immunoglobulin G therapy in streptococcal toxic shock syndrome: a European randomized, double-blind, placebo-controlled trial. Clin Infect Dis. 2003;37:333–40.CrossRefGoogle Scholar
  17. 17.
    Matsushima A, Kuroki Y, Nakajima S, et al. Low level of TSST-1 antibody in burn patients with toxic shock syndrome caused by methicillin-resistant Staphylococcus aureus. J Burn Care Res. 2015;36:e120–4.CrossRefGoogle Scholar
  18. 18.
    Madsen MB, Hjortrup PB, Hansen MB, et al. Immunoglobulin G for patients with necrotising soft tissue infection (INSTINCT): a randomised, blinded, placebo-controlled trial. Intensive Care Med. 2017;43:1585–93.CrossRefGoogle Scholar
  19. 19.
    Kadri SS, Swihart BJ, Bonne SL, et al. Impact of intravenous immunoglobulin on survival in necrotizing fasciitis with vasopressor-dependent shock: a propensity score-matched analysis from 130 US hospitals. Clin Infect Dis. 2017;64:877–85.PubMedGoogle Scholar
  20. 20.
    Riseman JA, Zamboni WA, Curtis A, Graham DR, Konrad HR, Ross DS. Hyperbaric oxygen therapy for necrotizing fasciitis reduces mortality and the need for debridements. Surgery. 1990;108(5):847–50.PubMedGoogle Scholar
  21. 21.
    Pizzorno R, Bonini F, Donelli A, Stubinski R, Medica M, Carmignani G. Hyperbaric oxygen therapy in the treatment of Fournier's disease in 11 male patients. J Urol. 1997;158(3 Pt 1):837–40.CrossRefGoogle Scholar
  22. 22.
    George ME, Rueth NM, Skarda DE, Chipman JG, Quickel RR, Beilman GJ. Hyperbaric oxygen does not improve outcome in patients with necrotizing soft tissue infection. Surg Infect. 2009;10(1):21–8.CrossRefGoogle Scholar
  23. 23.
    Massey PR, Sakran JV, Mills AM, Sarani B, Aufhauser DD, Sims CA, et al. Hyperbaric oxygen therapy in necrotizing soft tissue infections. J Surg Res. 2012;177(1):146–51.CrossRefGoogle Scholar
  24. 24.
    Brown DR, Davis NL, Lepawsky M, Cunningham J, Kortbeek J. A multicenter review of the treatment of major truncal necrotizing infections with and without hyperbaric oxygen therapy. Am J Surg. 1994;167(5):485–9.CrossRefGoogle Scholar
  25. 25.
    Levett D, Bennett MH, Millar I. Adjunctive hyperbaric oxygen for necrotizing fasciitis. Cochrane Database Syst Rev. 2015;1:CD007937.PubMedGoogle Scholar
  26. 26.
    Arad G, Levy R, Nasie I, Hillman D, Rotfogel Z, Barash U, et al. Binding of superantigen toxins into the CD28 homodimer interface is essential for induction of cytokine genes that mediate lethal shock. PLoS Biol. 2011;9:e1001149.CrossRefGoogle Scholar
  27. 27.
    Bulger EM, Maier RV, Sperry J, Joshi M, Henry S, Moore FA, et al. A novel drug for treatment of necrotizing soft-tissue infections: a randomized clinical trial. JAMA Surg. 2014;149(6):528–36.CrossRefGoogle Scholar
  28. 28.
    Stevens DL, et al. (Clin Infect Dis 2014; 59:147–59). Clinical Infectious Diseases. 2015;60(9):1448–9.Google Scholar
  29. 29.
    Phase III Efficacy and Safety Study of AB103 in the Treatment of Patients With Necrotizing Soft Tissue Infections - Full Text View - ClinicalTrials.gov [Internet]. [cited 2019 Sep 11]. Available from: https://clinicaltrials.gov/ct2/show/NCT02469857.

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Heather Leigh Evans
    • 1
    Email author
  • Lena M. Napolitano
    • 2
  • Eileen M. Bulger
    • 3
  1. 1.Department of SurgeryMedical University of South CarolinaCharlestonUSA
  2. 2.Department of SurgeryUniversity of MichiganAnn ArborUSA
  3. 3.Department of SurgeryUniversity of WashingtonSeattleUSA

Personalised recommendations