Early surgical intervention and its impact on patients presenting with necrotizing soft tissue infections: A single academic center experience

Abstract

Objectives:Early diagnosis and emergent surgical debridement of necrotizing soft tissue infections (NSTIs) remains the cornerstone of care. We aimed to study the effect of early surgery on patients' outcomes and, in particular, on hospital length of stay (LOS) and Intensive Care Unit (ICU) LOS.Materials and Methods:Over a 6-year period (January 2003 through December 2008), we analyzed the records of patients with NSTIs. We divided patients into two groups based on the time of surgery (i.e., the interval from being diagnosed and surgical intervention): Early (<6 h) and late (≥6 h) intervention groups. For these two groups, we compared baseline demographic characteristics, symptoms, and outcomes. For our statistical analysis, we used the Student's t-test and Pearson Chi-square (χ2) test. To evaluate the clinical predictors of early diagnosis of NSTIs, we performed multivariate logistic regression analysis.Results:In the study population (n = 87; 62% males and 38% females), age, gender, wound locations, and comorbidities were comparable in the two groups. Except for higher proportion of crepitus, the clinical presentations showed no significant differences between the two groups. There were significantly shorter hospital LOS and ICU LOS in the early than late intervention group. The overall mortality rate in our study patients with NSTIs was 12.5%, but early intervention group had a mortality of 7.5%, but this did not reach statistical significance.Conclusions:Our findings show that early surgery, within the first 6 h after being diagnosed, improves in-hospital outcomes in patients with NSTIs.

Pattern and predictors of mortality in necrotizing fasciitis patients in a single tertiary hospital

“…In the present study, the median number of debridement procedures performed per patient was two interventions, and these were comparable for both non-survivors as well as survivors. Data suggested that early surgical intervention is crucial in reducing morbidity and mortality in NF patients [ 35 ]. However, there is still a lack of clear definition on ‘How early should we be’.…”

“…Delay of surgical treatment of >12 h was associated with an increased number of surgical debridement, septic shock and acute renal failure [ 36 ]. Hadeed et al [ 35 ] reported outcomes of earlier surgical treatment (within the first 6 h) and found that although there was no statistically significantly difference in mortality between the study groups, higher mortality among late intervention group was clinically significant. Moreover, the outcomes in terms of the duration of hospital and intensive care unit stay were in favor of early intervention [ 35 ].…”

“… Treatment delayed beyond 3 days is an independent factor indicating a poor prognosis (OR 10.75, 95 % CI 1.02-113.39, p = 0.048) Khamnuan P et al [ 50 ] 2015/Thailand Retrospective/2009 to 2012 n = 290/1504 (19.3 %) Female gender; age >60; chronic heart disease, cirrhosis, skin necrosis, pulse rate >130/min, systolic BP <90 mmHg, and serum creatinine ≥1.6 mg/dL Khamnuan P et al [ 51 ] 2015/Thailand Retrospective observational cohort study/2009 to 2012 165 (69.6) in patients with severe sepsis ( n = 237) 66 (5.5) without severe sepsis ( n = 1,215) P <0.001 Female sex, diabetes mellitus, chronic heart disease, hemorrhagic bleb, skin necrosis, and serum protein <6 g/dL Arif et al [ 52 ] 2016/USA Retrospective/2003 to 2013 9871 NF-related deaths 4 · 8 deaths/ 1000000 person-yr Diabetes mellitus, obesity, and renal failure were significantly associated with NF-related death. However, age, sex, and race were independently associated with the rate of NF-related deaths Hadeed GJ et al [ 35 ] 2016/USA Retrospective/2003 to 2008 11/87 (12.5 %) Clinically significant difference based on the timing of surgical intervention (< or > 6 h) (17.5 % in late vs. 7.5 % in early intervention group), however no statistical significance a = Deaths/total NF cases …”

The Role of Streptococcal and Staphylococcal Exotoxins and Proteases in Human Necrotizing Soft Tissue Infections

“…Recent studies suggest that early surgical intervention within 24 h post admission significantly improves the survival of patients [258,259]. Survival further increases if debridement is performed even earlier [260,261].…”

Can necrotizing soft tissue infection be reliably diagnosed in the emergency department?

“…Although the early cohort (n=40) had a lower mortality of 7.5% compared with the late cohort (n=47) of 17%, it did not achieve statistical significance. 6 The issue of timing remains poorly understood and there are many confounding factors such as time to antimicrobial therapy and fluid resuscitation; however, safe practice involves rapid access to surgery.…”