Abstract
Background
Skin and soft tissue infections are common emergency department (ED) presentations.
These infections cover a wide spectrum of disease, from simple cellulitis to necrotizing
fasciitis. Despite the commonality, a subset of skin and soft tissue infections known
as necrotizing soft tissue infections (NSTIs) can cause significant morbidity and
mortality.
Objective
This review evaluates the current evidence regarding the presentation, evaluation,
and management of NSTI from the ED perspective.
Discussion
NSTIs are commonly missed diagnoses. History and physical examination findings are
inconsistent, and the risk factors for this high mortality disease are common amongst
ED populations. Laboratory evaluation and the Laboratory Risk in Necrotizing Fasciitis
(LRINEC) score is helpful but is insufficient to rule out the disease. Imaging modalities
including ultrasound, computed tomography, and magnetic resonance imaging are highly
sensitive and specific, but may delay definitive management. The gold standard for
diagnosis includes surgical exploration. Surgical intervention and empiric broad-spectrum
antibiotic coverage are the foundations of treatment. Adjuvant therapies including
hyperbaric oxygen and intravenous immunoglobulin have not yet been proven to be beneficial
or to improve outcome.
Conclusion
NSTIs are associated with significant morbidity and mortality. Knowledge of the history,
examination, evaluation, and management is vital for emergency clinicians.
Keywords
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References
- Decreasing incidence of skin and soft-tissue infections in 86 US emergency departments, 2009-2014.Clin Infect Dis. 2019; 68: 453-459
- Incidence of skin and soft tissue infections in ambulatory and inpatient settings, 2005–2010.BMC Infect Dis. 2015; 15: 362
- Diagnosis and management of skin and soft-tissue infections (SSTI). A literature review and consensus statement: an update.J Chemother. 2017; 29: 197-214
- Trends in the incidence and treatment of necrotizing soft tissue infections: an analysis of the National Hospital Discharge Survey.J Burn Care Res. 2014; 35: 449-454
- Current concepts in the management of necrotizing fasciitis.Front Surg. 2014; 1: 36
- Necrotizing skin and soft-tissue infections in the intensive care unit.Clin Microbiol Infect. 2020; 26: 8-17
- Early diagnosis of necrotizing fasciitis.Br J Surg. 2014; 101: e119-e125
- Necrotizing soft tissue infection: diagnostic accuracy of physical examination, imaging, and LRINEC score: a systematic review and meta-analysis.Ann Surg. 2019; 269: 58-65
- Current guidelines and recommendations for the management of skin and soft tissue infections.Curr Opin Infect Dis. 2016; 29: 131-138
- Population-based surveillance for group A streptococcal necrotizing fasciitis: clinical features, prognostic indicators, and microbiologic analysis of seventy-seven cases. Ontario Group A Streptococcal Study.Am J Med. 1997; 103: 18-24
- Necrotizing soft-tissue infections.N Engl J Med. 2018; 378: 971
- A necrotizing fasciitis fake out on point-of-care ultrasound–watch the shadow.J Emerg Med. 2017; 52: 523-526
- Necrotizing soft tissue infections.J Intensive Care Med. 2014; 29: 138-144
- Aggressive soft tissue infections.Surg Clin North Am. 2018; 98: 1097-1108
- Evaluation and management of necrotizing soft tissue infections.Infect Dis Clin North Am. 2017; 31: 497-511
- Predisposing factors of necrotizing fasciitis with comparison to cellulitis in Taiwan: a nationwide population-based case-control study.J Formos Med Assoc. 2020; 119: 18-25
- Validation and simplification of Fournier's gangrene severity index: simplified index for Fournier's gangrene.Int J Urol. 2014; 21: 696-701
- Presentation and outcomes of necrotizing soft tissue infections.Int J Gen Med. 2017; 10: 215-220
- Techniques for early diagnosis and management of cervicofacial necrotising fasciitis.J Laryngol Otol. 2010; 124: 759-764
- Interventions for necrotizing soft tissue infections in adults.Cochrane Database Syst Rev. 2018; 5CD011680
- A retrospective review of patients with necrotizing fasciitis presenting to an emergency department in Hong Kong.Hong Kong J Emerg Med. 2002; 9: 10-17
- Necrotising fasciitis: an 8.5-year retrospective case review in a New Zealand intensive care unit.Crit Care Resusc. 2011; 13: 232-237
- The potential prognostic significance of the Laboratory Risk Indicator for the Necrotizing Fasciitis (LRINEC) score in necrotizing fasciitis.Chirurgia (Bucur). 2019; 114: 376-383
- The roles of early surgery and comorbid conditions on outcomes of severe necrotizing soft-tissue infections.Eur J Trauma Emerg Surg. 2019; 45: 919-926
- A case of necrotizing fasciitis with a LRINEC score of zero: clinical suspicion should trump scoring systems.J Emerg Med. 2013; 44: 928-931
- Ultrasonographic screening of clinically-suspected necrotizing fasciitis.Acad Emerg Med. 2002; 9: 1448-1451
- Necrotizing fasciitis: CT characteristics.Radiology. 1997; 203: 859-863
- The role of computed tomography in the diagnosis of necrotizing soft tissue infections.World J Surg. 2018; 42: 82-87
- Differentiation of necrotizing fasciitis and cellulitis using MR imaging.AJR Am J Roentgenol. 1998; 170: 615-620
- Gadolinium-DTPA-enhanced magnetic resonance imaging of musculoskeletal infectious processes.Skeletal Radiol. 1995; 24: 325-330
- Necrotizing soft tissue infections: review and current concepts in treatment, systems of care, and outcomes.Curr Probl Surg. 2014; 51: 344-362
- Point-of-care ultrasound diagnosis of necrotizing fasciitis missed by computed tomography and magnetic resonance imaging.J Emerg Med. 2014; 47: 172-175
- Sonographic findings in necrotizing fasciitis: two ends of the spectrum.J Ultrasound Med. 2016; 35: 2273-2277
- Case report: role of bedside ultrasonography in early diagnosis of myonecrosis rapidly developed in deep soft tissue infections.J Ultrasound. 2016; 19: 217-221
- The relationship between fluid accumulation in ultrasonography and the diagnosis and prognosis of patients with necrotizing fasciitis.Ultrasound Med Biol. 2019; 45: 1545-1550
- Early surgical intervention and its impact on patients presenting with necrotizing soft tissue infections: a single academic center experience.J Emerg Trauma Shock. 2016; 9: 22-27
- Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America.Clin Infect Dis. 2014; 59: e10-e52
- Lexicomp.2021 (Available at:)http://online.lexi.com/?cesid=6BqX1UzCJn6&searchUrl=%2Flco%2Faction%2Fsearch%3Fq%3DamphotericinDate accessed: June 21, 2021
- Adjunctive hyperbaric oxygen for necrotizing fasciitis. Cochrane Emergency and Critical Care Group.ed. Cochrane Database Syst Rev. 2015; 1CD007937
- 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: 877-885
- Role of tissue oxygen saturation monitoring in diagnosing necrotizing fasciitis of the lower limbs.Ann Emerg Med. 2004; 44: 222-228
- The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).JAMA. 2016; 315: 801-810
- Impact of source control in patients with severe sepsis and septic shock.Crit Care Med. 2017; 45: 11-19
- Determinants of mortality for necrotizing soft-tissue infections.Ann Surg. 1995; 221: 558-565
- Treatment of necrotizing soft tissue infections. The need for a new approach.Am J Surg. 1985; 149: 751-755
- Early diagnosis and treatment of necrotizing fasciitis can improve survival: an observational intensive care unit cohort study: early diagnosis and treatment of NF.ANZ J Surg. 2013; 83: 365-370
Article info
Publication history
Published online: January 31, 2022
Accepted:
December 23,
2021
Received in revised form:
October 18,
2021
Received:
August 25,
2021
Footnotes
Special thanks to Dr. Jonathan Nogueira, DO, for the use of his ultrasound images. This review does not reflect the views or opinions of the U.S. government, Department of Defense, U.S. Army, U.S. Air Force, or SAUSHEC Emergency Medicine Residency Program.
Identification
Copyright
© 2021 Published by Elsevier Inc.
