Understanding necrotizing soft tissue infections in the intensive care unit
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UNDERSTANDING THE DISEASE
Understanding necrotizing soft tissue infections in the intensive care unit Tomas Urbina1,2, Martin Bruun Madsen3 and Nicolas de Prost4,5,6* © 2020 Springer-Verlag GmbH Germany, part of Springer Nature
Necrotizing soft tissue infections (NSTIs) are a rare group of severe and heterogenous infections. Distinguishing NSTIs from much more frequent non-necrotizing infections is a crucial step of initial management, as the former require not only medical treatment but also urgent surgical debridement of infected tissues [1]. Additional categorizations based on the microbiology or the anatomical extent of the disease have been proposed but are of little help to the clinician [2]. Only the topography (i.e., limb, abdomino-perineal, thoracic or head/neck localization) is immediately available and can modify early management. Approximately half of NSTI patients will develop organ failures and require intensive care unit (ICU) admission. Thus, intensivists must maintain high awareness for this rare condition, particularly in patients having a locally benign cutaneous presentation but with signs of systemic toxicity (i.e., sepsis/septic shock) and no other obvious source of infection. Initial misdiagnosis has been reported in about 50% of cases as presentation can be insidious, with no reliable biological or radiological diagnostic tool. Mortality ranges from 10 to 30% according to initial patient severity, and long-term health-related quality of life is deeply impacted in survivors, 15% of whom require limb amputations. A recent survey across European ICUs revealed great heterogeneity regarding both the expertise of practitioners (be it intensivists, surgeons or dermatologists) and the local management of patients [3]. For surveyed intensivists, the main factors contributing to surgical delay, one of the main modifiable prognostic factors, were misdiagnosis, a
*Correspondence: nicolas.de‑[email protected] 4 Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor, Assistance Publique – Hôpitaux de Paris (AP-HP), Créteil, France Full author information is available at the end of the article
delayed surgical decision and logistical issues regarding operating room access. Suspecting the diagnosis must trigger the initiation of multiple urgent interventions and involve a multidisciplinary team coordinated by the managing physician (Fig. 1).
When to suspect a NSTI? Any cutaneous infection showing any local or systemic sign of severity must be managed with a high index of suspicion for a necrotizing infection. Clinicians must be aware that the most frequent clinical features of NSTIs are also those of non-necrotizing infections (i.e., erythema, edema and pain), with prospective data showing that more specific signs of NSTIs, including bruising, bullae and crepitus, are present in only 51%, 27% and 14% of cases [4]. Thus, the diagnosis of NSTI must never be ruled out if these signs are lacking, particularly in patients presenting with sepsis/septic shock, failure to improve under an
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