Necrotizing Soft Tissue Infections, the Challenge Remains

Abstract

Background: Necrotizing Soft Tissue Infections (NSTIs) are uncommon rapidly spreading infection of the soft tissues for which prompt surgical treatment is vital for survival. Currently, even with sufficient awareness and facilities available, ambiguous symptoms frequently result in treatment delay.Objectives: To illustrate the heterogeneity in presentation of NSTIs and the pitfalls entailing from this heterogeneity.Discussion: NSTI symptoms appear on a spectrum with on one side the typical critically ill patient with fast onset and progression of symptoms combined with severe systemic toxicity resulting in severe physical derangement and sepsis. In these cases, the suspicion of a NSTI rises quickly. On the other far side of the spectrum is the less evident type of presentation of the patient with gradual but slow progression of non-specific symptoms over the past couple of days without clear signs of sepsis initially. This side of the spectrum is under represented in current literature and some physicians involved in the care for NSTI patients are still unaware of this heterogeneity in presentation.Conclusion: The presentation of a critically ill patient with evident pain out of proportion, erythema, necrotic skin and bullae is the classical presentation of NSTIs. On the other hand, non-specific symptoms without systemic toxicity at presentation frequently result in a battery of diagnostics tests and imaging before the treatment strategy is determined. This may result in a delay in presentation, delay in diagnosis and delay in definitive treatment. This failure to perform an adequate exploration expeditiously can result in a preventable mortality.

Identifying patients with difficult-to-treat acute bacterial skin infections

“…Many comorbidities have been associated with the onset of ABSIs, and their highly variable proportions limit the capacity for identifying patients at risk (Table 1 and Fig. 1) [3,4 ▪ ,5 ▪▪ ]. In patients with cellulitis, underlying diseases, including prior episodes of cellulitis, venous insufficiency, lymphedema, and immunosuppression, play a pivotal role in the poor prognosis, which results in clinical failure or relapse [6].…”

“…The variability of clinical symptoms in NSTIs illustrates the threat of misleading management (Table 1) [3,4 ▪ ,5 ▪▪ ]. The diagnosis is specifically challenging in immunocompromised patients, as they may not develop the same symptoms as immunocompetent patients [10].…”

“…Polymicrobial infections represent up to 84% of the cases of NSTIs [3,4 ▪ ]. Differentiation between polymicrobial and monomicrobial infections is impossible based on clinical grounds.…”

“…or Vibrio spp. [3,4 ▪ ,31,32]. A recent comparison suggests a worse prognosis of monomicrobial infections versus polymicrobial infection, mostly due to Streptococcus pyogenes [33 ▪ ].…”

A Case of Fatal Non-Clostridial Gas Gangrene Following Intramuscular Injection: A Diagnostic Challenge and Dilemma at Autopsy

“…followed by Klebsiella pneumonia and the rest are mixed infections of gram-positive cocci, Corynebacterium, and E. coli (2). Monomicrobial infections result in systemic toxicity much more common than polymicrobial infections because of the need for microbial synergy (3). The classical findings of necrotizing skin infections are observed when the causative organisms are Group A Streptococcus and Clostridium (4).…”