Necrotizing skin and soft-tissue infections in the intensive care unit

Abstract

Background: Necrotizing skin and soft-tissue infections (NSTI) are rare but potentially life-threatening and disabling infections that often require intensive care unit admission. Objectives: To review all aspects of care for a critically ill individual with NSTI. Sources: Literature search using Medline and Cochrane library, multidisciplinary panel of experts. Content: The initial presentation of a patient with NSTI can be misleading, as features of severe systemic toxicity can obscure sometimes less impressive skin findings. The infection can spread rapidly, and delayed surgery worsens prognosis, hence there is a limited role for additional imaging in the critically ill patient. Also, the utility of clinical scores is contested. Prompt surgery with aggressive debridement of necrotic tissue is required for source control and allows for microbiological sampling. Also, prompt administration of broad-spectrum antimicrobial therapy is warranted, with the addition of clindamycin for its effect on toxin production, both in empirical therapy, and in targeted therapy for monomicrobial group A streptococcal and clostridial NSTI. The role of immunoglobulins and hyperbaric oxygen therapy remains controversial. Implications: Close collaboration between intensive care, surgery, microbiology and infectious diseases, and centralization of care is fundamental in the approach to the severely ill patient with NSTI. As many aspects of management of these rare infections are supported by low-quality data only, multicentre trials are urgently needed.

<p>Fournier Gangrene in the Emergency Department: Diagnostic Dilemmas, Treatments and Current Perspectives</p>

“…Delays in surgical consultation due to laboratory or imaging investigations negatively impact morbidity and mortality. 10 An additional modifiable risk factor includes surgical familiarity with the disease; early consultation with the appropriate surgical team including urology, general surgery, acute care surgery, and/or obstetrics and gynecology can greatly benefit ultimate patient outcomes. 10 Hyperbaric Oxygen Therapy (HBOT)…”

“…Prompt surgical consultation and intervention with early surgical intensive care involvement allow for more timely management and handoff of the patients with NSTI's and are associated with decreased mortality. 10,54 Typically patients with NSTI will require intensive care management. Transfer of NSTI patients is reasonable for resourcelimited facilities and should occur in consultation with surgical teams at the transferring and receiving facilities.…”

“…[7][8][9] The most significant modifiable risk factor for NSTI mortality is time to surgical intervention. 10 Early intervention has the potential to decrease mortality by half. 11…”

Improving care for the ICU patient with suspected infection: a multidisciplinary perspective

“…However, more uncommon infections may also be encountered in ICU patients, either as a reason for admission or as a complication during the ICU stay. In this issue of Clinical Microbiology and Infection, we focus on three uncommon yet severe infections: necrotizing skin and tissue infection [8], pancreatic infection [9] and mediastinitis [10]. By definition uncommon infections have a low prevalence, which often means that experience in treating these infections is diluted.…”

“…Another feature shared by the patients with such infections is the lack of consensus about the best duration of antimicrobial treatment. Five to 7 days, 7e14 days and 14e21 days are suggested for pancreatic infections [9], necrotizing skin and tissue infections [8], and mediastinitis [10], respectively. However, these durations are only based on expert opinion e no adequate randomized clinical trials were conducted to test different durations in the ICU patients.…”