Orthopaedic Knowledge Update®: Musculoskeletal Infection 2 Print + Ebook (AAOS - American Academy of Orthopaedic Surgeons)

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Chapter 27: Necrotizing Fasciitis and Other Complicated Skin and Soft-Tissue Infections

of stay, readmission rates, ability to ambulate, and short term and long-term mortality, worsen by the hour in some cases without surgical intervention.

Europe/the American Association for the Surgery of Trauma) drafted global clinical pathways for patients with SSTIs. 5. Gupta Y, Chhetry M, Pathak KR, et al: Risk factors for necrotizing fasciitis and its outcome at a tertiary care centre. J Ayub Med Coll Abbottabad 2016;28(4):680-682. 6. Liu TJ, Tai HC, Chien KL, Cheng NC: Predisposing factors of necrotizing fasciitis with comparison to cellulitis in Taiwan: A nationwide population-based case–control study. J Formos Med Assoc 2020;119(1 pt 1):18-25. Age and the presence of chronic diseases were major risk fac tors and prognostic factors of necrotizing fasciitis in Taiwan from 2002 to 2011. Level of evidence: III. 7. Pelletier J, Gottlieb M, Long B, Perkins JC: Necrotizing soft tissue infections (NSTI): Pearls and pitfalls for the emergency clinician. J Emerg Med 2022;62(4):480-491. This review assessed the current evidence regarding the pre sentation, evaluation, and management of NSTI from the emergency department perspective. 8. Peetermans M, de Prost N, Eckmann C, Norrby-Teglund A, Skrede S, De Waele JJ: Necrotizing skin and soft-tissue infections in the intensive care unit. Clin Microbiol Infect 2020;26(1):8-17. This review emphasizes the importance of multidisciplinary teams in the care of critically ill patients with NSTI. 9. Bruun T, Rath E, Madsen MB, et al: Risk factors and pre dictors of mortality in streptococcal necrotizing soft-tissue infections: A multicenter prospective study. Clin Infect Dis 2021;72(2):293-300. This prospective cohort identified risk factors associated with mortality in patients with group A Streptococcus NSTI, such as older age, septic shock, and lack of intravenous immuno globulin administration. Level of evidence: II. 10. Eason TB, Cosgrove CT, Mihalko WM: Necrotizing soft-tis sue infections after hip arthroplasty. Orthop Clin North Am 2022;53(1):33-41. This publication reviews two case reports of prosthetic joint infection presenting as NSTI in patients with hip implants. Level of evidence: IV. 11. Duane TM, Huston JM, Collom M, et al: Surgical Infection Society 2020 updated guidelines on the management of com plicated skin and soft tissue infections. Surg Infect (Larchmt) 2021;22(4):383-399. The 2020 guidelines from the Surgical Infection Society on the management of complicated SSTI remain unchanged except for increased support for adjuvant antimicrobial ther apy after drainage of complex abscess and updated findings regarding the use of alternative antimicrobial agents. 12. Lim SH, Tunku Ahmad TS, Devarajooh C, Gunasagaran J: Upper limb infections: A comparison between diabetic and non-diabetic patients. J Orthop Surg (Hong Kong) 2022;30(1): 23094990221075376. Patients with diabetes were more likely to present with emer gent scenarios, especially necrotizing fasciitis and infectious tenosynovitis, compared with patients without diabetes. Level of evidence: II.

ACKNOWLEDGMENTS The authors are extremely grateful for the philanthropic support provided by a gift from Eva and Gene Lane (L.M.B.), which was paramount in the work to advance the science of cardiovascular infections, an ongoing focus of investigation at Mayo Clinic for more than 60 years. 1. Morgan E, Hohmann S, Ridgway JP, Daum RS, David MZ: Decreasing incidence of skin and soft-tissue infections in 86 US emergency departments, 2009-2014. Clin Infect Dis 2019;68(3):453-459. The rate of SSTIs decreased by 8% among all patients and by 14.6% among patients with HIV infection in the United States between 2009 and 2014. Level of evidence: II. 2. Lipsky BA, Silverman MH, Joseph WS: A proposed new classification of skin and soft tissue infections modeled on the subset of diabetic foot infection. Open Forum Infect Dis 2016;4(1):ofw255. 3. Saldana CS, Vyas DA, Wurcel AG: Soft tissue, bone, and joint infections in people who inject drugs. Infect Dis Clin North Am 2020;34(3):495-509. SSTIs have a wide variety of manifestations in people who inject drugs ranging from cellulitis to necrotizing fasciitis and are polymicrobial in up to 40%. 4. Sartelli M, Coccolini F, Kluger Y, et al: WSES/GAIS/WSIS/ SIS-E/AAST global clinical pathways for patients with skin and soft tissue infections. World J Emerg Surg 2022;17(1):3. This extensive nonsystematic review conducted by several societies (including the World Society of Emergency Surgery/ the Global Alliance for Infections in Surgery/the World Surgical Infection Society/the Surgical Infection Society KEY STUDY POINTS • NSTIs are limb and life threatening and are charac terized by extensive and acute destruction of tissue associated with systemic signs of toxicity. • Because NSTIs often result in increased morbidity (including limb loss) and mortality, they represent a surgical emergency where aggressive and prompt débridement, hemodynamic support, and antimi crobial therapy are required. • Other types of complicated SSTIs also require surgi cal intervention as source control. Delays in diagno sis and surgical management have been associated with increased mortality rates. ANNOTATED REFERENCES

Section 6: Bone, Joint, and Soft-Tissue Infections

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Orthopaedic Knowledge Update ® : Musculoskeletal Infection 2

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