Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, Hirschmann JV, Kaplan SL, Montoya JG, Wade JC.
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 Jul 15;59(2):147-59. doi: 10.1093/cid/ciu296. Epub 2014 Jun 18.
Abstract/Text
A panel of national experts was convened by the Infectious Diseases Society of America (IDSA) to update the 2005 guidelines for the treatment of skin and soft tissue infections (SSTIs). The panel's recommendations were developed to be concordant with the recently published IDSA guidelines for the treatment of methicillin-resistant Staphylococcus aureus infections. The focus of this guideline is the diagnosis and appropriate treatment of diverse SSTIs ranging from minor superficial infections to life-threatening infections such as necrotizing fasciitis. In addition, because of an increasing number of immunocompromised hosts worldwide, the guideline addresses the wide array of SSTIs that occur in this population. These guidelines emphasize the importance of clinical skills in promptly diagnosing SSTIs, identifying the pathogen, and administering effective treatments in a timely fashion.
© The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.
Wong CH, Wang YS.
The diagnosis of necrotizing fasciitis.
Curr Opin Infect Dis. 2005 Apr;18(2):101-6. doi: 10.1097/01.qco.0000160896.74492.ea.
Abstract/Text
PURPOSE OF REVIEW: A delay in the diagnosis and appropriate treatment of necrotizing fasciitis has clearly been demonstrated to increase mortality. However, paucity of specific cutaneous signs makes early recognition extremely difficult. This review highlights recent developments in the approaches to the diagnosis of necrotizing fasciitis.
RECENT FINDINGS: A clinical staging of necrotizing fasciitis is proposed to better define the progression of the disease. Several clinical subtypes of necrotizing fasciitis have been described recently with hyperacute and sub-acute variants. Imaging techniques, such as magnetic resonance imaging and frozen section biopsies, have been reported to be of value in the early recognition of necrotizing fasciitis. However availability and cost limit the routine use of these tests. Several diagnostic adjuncts that have been developed recently to help in early recognition will be discussed. These include the fasciitis LRINEC (laboratory risk indicator for necrotizing fasciitis) score and transcutaneous tissue oxygen saturation monitoring. Some may have the potential for widespread application in the assessment of severe soft tissue infections.
SUMMARY: Delayed recognition, with consequent massive soft tissue loss and sepsis, remains a deadly pitfall in the management of necrotizing fasciitis. With a better understanding of the clinical manifestations and the potential use and limitations of various diagnostic adjuncts available for the assessment of equivocal cases of soft tissue infections, it is hoped that a clear and logical approach to the diagnosis of necrotizing fasciitis may be developed.
Chelsom J, Halstensen A, Haga T, Høiby EA.
Necrotising fasciitis due to group A streptococci in western Norway: incidence and clinical features.
Lancet. 1994 Oct 22;344(8930):1111-5. doi: 10.1016/s0140-6736(94)90629-7.
Abstract/Text
During November, 1992, to May, 1994, 13 patients were treated at Haukeland University Hospital, Norway, for necrotising fasciitis due to group A beta-haemolytic streptococci. 3 patients died, 1 before admission. Mucoid group A streptococci were isolated from affected tissue (12 patients) and/or blood (5). Strains from 11 patients were serotype M-1 (5 patients), M-3 (2), M-6 (2), M-28 (1), and M-untypable (T-1, opacity factor negative) (1). For the 12 patients admitted alive, the following preoperative events were recorded: 8 had clinical signs of shock with systolic blood pressure of 90 mm Hg or less, 8 had impaired renal function, and 7 had biochemical markers of disseminated intravascular coagulation. At least 6 patients fulfilled the criteria for streptococcal toxic shock syndrome. Preoperative C-reactive protein was substantially raised ( > 200 mg/L) in 10 patients. The 12 patients were given high doses of antibiotics and were operated on with aggressive debridement of necrotic skin and fascia, 7 of them within 24 h of admission. The increasing incidence of necrotising fasciitis in western Norway reflects the resurgence of invasive group A streptococcal infections documented in Scandinavia since 1987. The high case-fatality rate can be reduced by early diagnosis and aggressive surgery combined with adequate antibiotic therapy.
Severe group A streptococcal infections associated with a toxic shock-like syndrome and scarlet fever toxin A. - PubMed - NCBI [Internet]. [cited 2019 Nov 14]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/?term=2659990
Wong CH, Chang HC, Pasupathy S, Khin LW, Tan JL, Low CO.
Necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality.
J Bone Joint Surg Am. 2003 Aug;85(8):1454-60.
Abstract/Text
BACKGROUND: Necrotizing fasciitis is a life-threatening soft-tissue infection primarily involving the superficial fascia. The present report describes the clinical presentation and microbiological characteristics of this condition as well as the determinants of mortality associated with this uncommon surgical emergency.
METHODS: The medical records of eighty-nine consecutive patients who had been admitted to our institution for necrotizing fasciitis from January 1997 to August 2002 were reviewed retrospectively.
RESULTS: The paucity of cutaneous findings early in the course of the disease makes the diagnosis difficult, and only thirteen of the eighty-nine patients had a diagnosis of necrotizing fasciitis at the time of admission. Preadmission treatment with antibiotics modified the initial clinical picture and often masked the severity of the underlying infection. Polymicrobial synergistic infection was the most common cause (forty-eight patients; 53.9%), with streptococci and enterobacteriaceae being the most common isolates. Group-A streptococcus was the most common cause of monomicrobial necrotizing fasciitis. The most common associated comorbidity was diabetes mellitus (sixty-three patients; 70.8%). Advanced age, two or more associated comorbidities, and a delay in surgery of more than twenty-four hours adversely affected the outcome. Multivariate analysis showed that only a delay in surgery of more than twenty-four hours was correlated with increased mortality (p < 0.05; relative risk = 9.4).
CONCLUSIONS: Early operative débridement was demonstrated to reduce mortality among patients with this condition. A high index of suspicion is important in view of the paucity of specific cutaneous findings early in the course of the disease.
Early recognition of potentially fatal necrotizing fasciitis. The use of frozen-section biopsy. - PubMed - NCBI [Internet]. [cited 2019 Nov 14]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/?term=6727947
The diagnosis of necrotizing fasciitis. - PubMed - NCBI [Internet]. [cited 2019 Nov 14]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/?term=15735411
Stevens DL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ, Gorbach SL, Hirschmann JV, Kaplan EL, Montoya JG, Wade JC; Infectious Diseases Society of America.
Practice guidelines for the diagnosis and management of skin and soft-tissue infections.
Clin Infect Dis. 2005 Nov 15;41(10):1373-406. doi: 10.1086/497143. Epub 2005 Oct 14.
Abstract/Text
Wong CH, Khin LW, Heng KS, Tan KC, Low CO.
The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections.
Crit Care Med. 2004 Jul;32(7):1535-41. doi: 10.1097/01.ccm.0000129486.35458.7d.
Abstract/Text
OBJECTIVE: Early operative debridement is a major determinant of outcome in necrotizing fasciitis. However, early recognition is difficult clinically. We aimed to develop a novel diagnostic scoring system for distinguishing necrotizing fasciitis from other soft tissue infections based on laboratory tests routinely performed for the evaluation of severe soft tissue infections: the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score.
DESIGN: Retrospective observational study of patients divided into a developmental cohort (n = 314) and validation cohort (n = 140)
SETTING: Two teaching tertiary care hospitals.
PATIENTS: One hundred forty-five patients with necrotizing fasciitis and 309 patients with severe cellulitis or abscesses admitted to the participating hospitals.
INTERVENTIONS: None.
MEASUREMENTS AND MAIN RESULTS: The developmental cohort consisted of 89 consecutive patients admitted for necrotizing fasciitis. Control patients (n = 225) were randomly selected from patients admitted with severe cellulitis or abscesses during the same period. Hematologic and biochemical results done on admission were converted into categorical variables for analysis. Univariate and multivariate logistic regression was used to select significant predictors. Total white cell count, hemoglobin, sodium, glucose, serum creatinine, and C-reactive protein were selected. The LRINEC score was constructed by converting into integer the regression coefficients of independently predictive factors in the multiple logistic regression model for diagnosing necrotizing fasciitis. The cutoff value for the LRINEC score was 6 points with a positive predictive value of 92.0% and negative predictive value of 96.0%. Model performance was very good (Hosmer-Lemeshow statistic, p =.910); area under the receiver operating characteristic curve was 0.980 and 0.976 in the developmental and validation cohorts, respectively.
CONCLUSIONS: The LRINEC score is a robust score capable of detecting even clinically early cases of necrotizing fasciitis. The variables used are routinely measured to assess severe soft tissue infections. Patients with a LRINEC score of > or = 6 should be carefully evaluated for the presence of necrotizing fasciitis.
Fernando SM, Tran A, Cheng W, Rochwerg B, Kyeremanteng K, Seely AJE, Inaba K, Perry JJ.
Necrotizing Soft Tissue Infection: Diagnostic Accuracy of Physical Examination, Imaging, and LRINEC Score: A Systematic Review and Meta-Analysis.
Ann Surg. 2019 Jan;269(1):58-65. doi: 10.1097/SLA.0000000000002774.
Abstract/Text
OBJECTIVE: We sought to summarize accuracy of physical examination, imaging, and Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score in diagnosis of necrotizing soft tissue infection (NSTI) in adults with a soft tissue infection clinically concerning for NSTI.
SUMMARY OF BACKGROUND DATA: NSTI is a life-threatening diagnosis. Delay to diagnosis and surgical management is associated with increased mortality.
METHODS: We searched 6 databases from inception through November 2017. We included English-language studies reporting diagnostic accuracy of testing or LRINEC Score. Outcome was NSTI confirmed by surgery or histopathology. Two reviewers screened all citations and extracted data independently. Summary measures were obtained from the Hierarchical Summary Receiver Operating Characteristic model.
RESULTS: From 2,290 citations, we included 23 studies (n = 5982). Of physical examination signs, pooled sensitivity and specificity for fever was 46.0% and 77.0% respectively, for hemorrhagic bullae 25.2% and 95.8%, and for hypotension 21.0% and 97.7%. Computed tomography (CT) had sensitivity of 88.5% and specificity of 93.3%, while plain radiography had sensitivity of 48.9% and specificity of 94.0%. Finally, LRINEC ≥ 6 had sensitivity of 68.2% and specificity of 84.8%, while LRINEC ≥ 8 had sensitivity of 40.8% and specificity of 94.9%.
CONCLUSIONS: Absence of any 1 physical examination feature (eg, fever or hypotension) is not sufficient to rule-out NSTI. CT is superior to plain radiography. LRINEC had poor sensitivity, and should not be used to rule-out NSTI. Given the poor sensitivity of these tests, a high clinical suspicion warrants early surgical consultation for definitive diagnosis and management.
Tarricone A, Mata K, Gee A, Axman W, Buricea C, Mandato MG, Trepal M, Krishnan P.
A Systematic Review and Meta-Analysis of the Effectiveness of LRINEC Score for Predicting Upper and Lower Extremity Necrotizing Fasciitis.
J Foot Ankle Surg. 2022 Mar-Apr;61(2):384-389. doi: 10.1053/j.jfas.2021.09.015. Epub 2021 Sep 20.
Abstract/Text
This review and meta-analysis aims to assess the prognostic value of the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score for detecting necrotizing fasciitis in the extremities. The LRINEC score has been validated in multiple studies as a clinical tool for differentiating necrotizing fasciitis from non-necrotizing infections however many studies do not specify the location of infection. As the prevalence of diabetes and diabetic foot infections continues to rise, the utility of LRINEC scores in these populations becomes of increased importance. Four databases were reviewed for citations between January 2010 and December 2020. English, full text articles reporting the diagnostic effects of LRINEC were utilized in the systematic review portion of this paper. Further inclusion of 2 × 2 tables and discussion specific to the extremities were applied for citations implemented in the meta-analysis. Of the 111 results, 12 citations (n = 932) were included in this review. The diagnostic sensitivity of the LRINEC score ranged from 36% to 77% while specificity ranged from 72% to 93%. Cumulative odds ratio for LRINEC ≥6 among the 4 studies assessing extremity necrotizing fasciitis was 4.3 with p value of <.05. Sensitivity, specificity, positive predictive value, and negative predictive value was 49.39%, 83.17%, 34.91%, and 89.99%, respectively. Accuracy, the classification by whether a patient was correctly classified, was 77.95%. LRINEC score is effective at distinguishing necrotizing fasciitis from other soft tissue infections however the LRINEC's score greatest clinical application may be its ability to rule out necrotizing fasciitis while its ability to accurately identify the presence of infection remains suboptimal.
Copyright © 2021 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Necrotizing soft-tissue infection: diagnosis and management. - PubMed - NCBI [Internet]. [cited 2019 Nov 14]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/?term=17278065
Zacharias N, Velmahos GC, Salama A, Alam HB, de Moya M, King DR, Novelline RA.
Diagnosis of necrotizing soft tissue infections by computed tomography.
Arch Surg. 2010 May;145(5):452-5. doi: 10.1001/archsurg.2010.50.
Abstract/Text
HYPOTHESIS: In contrast to previous beliefs, we hypothesize that computed tomography (CT) scanning is sensitive and specific for the diagnosis of necrotizing soft tissue infections (NSTIs).
DESIGN: Retrospective and prospective case series.
SETTING: Academic medical center.
PATIENTS: Patients who were clinically suspected of having NSTIs from January 1, 2003, through April 30, 2009, and who underwent imaging with a 16- or 64-section helical CT scanner were studied. The CT result was considered positive if inflamed and necrotic tissue with or without gas or fluid collections across tissue planes was found. The disease (NSTI) was considered present if surgical exploration revealed elements of infection and necrosis of the soft tissues and pathological analysis confirmed the findings. The disease was considered absent if surgical exploration and pathological analysis failed to identify any of these findings or the patient was successfully treated without surgical exploration.
MAIN OUTCOME MEASURES: Sensitivity and specificity of CT for diagnosing NSTI.
RESULTS: Of 67 patients with study inclusion criteria, 58 underwent surgical exploration, and NSTI was confirmed in 25 (43%). The remaining 42 patients had either nonnecrotizing infections during surgical exploration (n = 33) or were treated nonoperatively with successful resolution of the symptoms (n = 9). The sensitivity of CT to identify NSTI was 100%, specificity was 81%, positive predictive value was 76%, and negative predictive value was 100%. No differences were found in demographics, white blood cell count on admission, symptoms, or site of infection between those with a false- or true-positive CT result.
CONCLUSIONS: A negative CT result reliably excludes the diagnosis of NSTI. A positive CT result correctly identifies the disease with a high likelihood.
Differentiation of necrotizing fasciitis and cellulitis using MR imaging. - PubMed - NCBI [Internet]. [cited 2019 Nov 14]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/?term=9490940
Stevens DL, Bryant AE, Goldstein EJ.
Necrotizing Soft Tissue Infections.
Infect Dis Clin North Am. 2021 Mar;35(1):135-155. doi: 10.1016/j.idc.2020.10.004. Epub 2020 Dec 7.
Abstract/Text
Necrotizing soft tissue infections occur after traumatic injuries, minor skin lesions, nonpenetrating injuries, natural childbirth, and in postsurgical and immunocompromised patients. Infections can be severe, rapidly progressive, and life threatening. Survivors often endure multiple surgeries and prolonged hospitalization and rehabilitation. Despite subtle nuances that may distinguish one entity from another, clinical approaches to diagnosis and treatment are highly similar. This review describes the clinical and laboratory features of necrotizing soft tissue infections and addresses recommended diagnostic and treatment modalities. It discusses the impact of delays in surgical debridement, antibiotic use, and resuscitation on mortality, and summarizes key pathogenic mechanisms.
Copyright © 2020 Elsevier Inc. All rights reserved.
Majeski J, Majeski E.
Necrotizing fasciitis: improved survival with early recognition by tissue biopsy and aggressive surgical treatment.
South Med J. 1997 Nov;90(11):1065-8. doi: 10.1097/00007611-199711000-00001.
Abstract/Text
BACKGROUND: Necrotizing fasciitis is a soft tissue gangrenous infection that is optimally treated by early diagnosis, radical surgical debridement of all involved necrotic tissue, broad spectrum antibiotics, and aggressive nutritional support. The early clinical diagnosis of an area of necrotizing fasciitis is difficult and frequently unreliable. We are reporting a series of cases in which an early, accurate diagnosis of necrotizing fasciitis was established by a frozen section tissue biopsy obtained at the bedside.
METHODS: Over a 15-year period, a consecutive series of 43 patients had a bedside biopsy under local anesthesia with immediate frozen section evaluation. All patients were seen in the hospital or emergency room for treatment of an inflammatory process.
RESULTS: These 43 patients had bedside biopsy and frozen section evaluation of an inflammatory process. Twelve patients were found to have necrotizing fasciitis. These patients were treated with immediate surgical debridement of all gross necrotic tissue, broad spectrum antibiotics, and adequate nutritional support. All of them survived. No cases of infectious gangrene occurred in the group of patients whose biopsy did not reveal necrotizing fasciitis.
CONCLUSION: Frozen section tissue biopsy is a useful adjunct in establishing an early, accurate diagnosis of infectious gangrene.
Sudarsky LA, Laschinger JC, Coppa GF, Spencer FC.
Improved results from a standardized approach in treating patients with necrotizing fasciitis.
Ann Surg. 1987 Nov;206(5):661-5. doi: 10.1097/00000658-198711000-00018.
Abstract/Text
Necrotizing fasciitis has been associated with significant morbidity and mortality. Thirty-three patients were studied over a 3-year period. Predisposing factors included intravenous drug abuse (30%), diabetes (21%), and obesity (18%). Severe pain (94%) and abnormal temperature (88%) were present, whereas laboratory data and x-ray were nonspecific. Gram-positive organisms were most frequently recovered (B-hemolytic streptococcus 45%). Treatment consisted of antibiotics, surgical debridement, re-exploration 24 hours before surgery, nutritional support, and early soft tissue coverage as needed. Mean duration from admission to operation was 43 hours. The average number of operative debridements was three and the average length of hospitalization was 47 days. Patients operated on less than 12 hours from admission or greater than 48 hours had shorter hospital stays (36 and 38 days). The critical time period was 12-48 hours after admission; all deaths and amputations were in this group and the average hospital stay was 62 days (p less than 0.05). The number of operations did not correlate to hospital stay. Despite antibiotics and aggressive debridement, significant morbidity exists if operation is delayed more than 12 hours. Methods of early detection such as local bedside diagnostic incision and fascial inspection may be needed in high risk patients to further reduce the morbidity and mortality.
Anaya DA, Dellinger EP.
Necrotizing soft-tissue infection: diagnosis and management.
Clin Infect Dis. 2007 Mar 1;44(5):705-10. doi: 10.1086/511638. Epub 2007 Jan 22.
Abstract/Text
Necrotizing soft-tissue infections (NSTIs) are highly lethal. They are frequent enough that general and specialty physicians will likely have to be involved with the management of at least 1 patient with NSTI during their practice, but they are infrequent enough that familiarity with the disease will seldom be achieved. Establishing the diagnosis of NSTI can be the main challenge in treating patients with NSTI, and knowledge of all available tools is key for early and accurate diagnosis. The laboratory risk indicator for necrotizing fasciitis score can be helpful for distinguishing between cases of cellulitis, which should respond to medical management alone, and NSTI, which requires operative debridement in addition to antimicrobial therapy. Imaging studies are less helpful. The mainstay of treatment is early and complete surgical debridement, combined with antimicrobial therapy, close monitoring, and physiologic support. Novel therapeutic strategies, including hyperbaric oxygen and intravenous immunoglobulin, have been described, but their effect is controversial. Identification of patients at high risk of mortality is essential for selection of patients that may benefit from future novel treatments and for development and comparison of future trials.
Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, Hirschmann JV, Kaplan SL, Montoya JG, Wade JC; Infectious Diseases Society of America.
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 Jul 15;59(2):e10-52. doi: 10.1093/cid/ciu444.
Abstract/Text
A panel of national experts was convened by the Infectious Diseases Society of America (IDSA) to update the 2005 guidelines for the treatment of skin and soft tissue infections (SSTIs). The panel's recommendations were developed to be concordant with the recently published IDSA guidelines for the treatment of methicillin-resistant Staphylococcus aureus infections. The focus of this guideline is the diagnosis and appropriate treatment of diverse SSTIs ranging from minor superficial infections to life-threatening infections such as necrotizing fasciitis. In addition, because of an increasing number of immunocompromised hosts worldwide, the guideline addresses the wide array of SSTIs that occur in this population. These guidelines emphasize the importance of clinical skills in promptly diagnosing SSTIs, identifying the pathogen, and administering effective treatments in a timely fashion.
© The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.
The Eagle effect revisited: efficacy of clindamycin, erythromycin, and penicillin in the treatment of streptococcal myositis. - PubMed - NCBI [Internet]. [cited 2019 Nov 14]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/?term=3292661
Stevens DL.
Streptococcal toxic-shock syndrome: spectrum of disease, pathogenesis, and new concepts in treatment.
Emerg Infect Dis. 1995 Jul-Sep;1(3):69-78. doi: 10.3201/eid0103.950301.
Abstract/Text
Since the 1980s there has been a marked increase in the recognition and reporting of highly invasive group A streptococcal infections with or without necrotizing fasciitis associated with shock and organ failure. Such dramatic cases have been defined as streptococcal toxic-shock syndrome. Strains of group A streptococci isolated from patients with invasive disease have been predominantly M types 1 and 3 that produce pyrogenic exotoxin A or B or both. In this paper, the clinical and demographic features of streptococcal bacteremia, myositis, and necrotizing fasciitis are presented and compared to those of streptococcal toxic-shock syndrome. Current concepts in the pathogenesis of invasive streptococcal infection are also presented, with emphasis on the interaction between group A Streptococcus virulence factors and host defense mechanisms. Finally, new concepts in the treatment of streptococcal toxic-shock syndrome are discussed.
Babiker A, Li X, Lai YL, Strich JR, Warner S, Sarzynski S, Dekker JP, Danner RL, Kadri SS.
Effectiveness of adjunctive clindamycin in β-lactam antibiotic-treated patients with invasive β-haemolytic streptococcal infections in US hospitals: a retrospective multicentre cohort study.
Lancet Infect Dis. 2021 May;21(5):697-710. doi: 10.1016/S1473-3099(20)30523-5. Epub 2020 Dec 14.
Abstract/Text
BACKGROUND: Clindamycin is strongly recommended as an adjunctive treatment to β-lactam antibiotics in patients with severe invasive group A β-haemolytic streptococcal (iGAS) infections. However, there is little evidence of a benefit in the use of clindamycin in humans, and its role, if any, in treating patients with invasive non-group A/B β-haemolytic streptococcal (iNABS) infections is unclear.
METHODS: For this retrospective multicentre cohort study, we used a dataset from patients in the Cerner Health Facts database, which contains electronic health-based data from 233 US hospitals. We queried the Cerner Health Facts database for inpatients (no age restriction) admitted to hospital in 2000-15, with any clinical cultures positive for β-haemolytic streptococcal taxa of interest, and who had received β-lactam antibiotics within 3 days either side of culture sampling. This group of patients was then queried for those who had also received intravenous or oral clindamycin within 3 days either side of culture sampling. Patients were excluded if they had polymicrobial growth or clindamycin non-susceptible isolates, received linezolid, or had missing variable data needed for analysis. Patients were categorised by Lancefield group (iGAS or iNABS); β-lactam antibiotic-treated patients who had received clindamycin were propensity-matched (1:2) to those who did not receive clindamycin separately for iGAS and iNABS cohorts, and logistic regression was then used to account for residual confounding factors. The primary outcome was the adjusted odds ratio (aOR) of in-hospital mortality in propensity-matched patients treated with adjunctive clindamycin versus those not treated with clindamycin in the iGAS and iNABS infection cohorts.
FINDINGS: We identified 1956 inpatients with invasive β-haemolytic streptococcal infection who had been treated with β-lactam antibiotics across 118 hospitals (1079 with iGAS infections and 877 with iNABS infections). 459 (23·4%) of these patients had received adjunctive clindamycin treatment (343 [31·7%] patients with iGAS infections and 116 [13·2%] patients with iNABS infections). The effect of adjunctive clindamycin therapy on in-hospital mortality differed significantly and showed the opposite trend in iGAS and iNABS infection cohorts (p=0·013 for an interaction). In the iGAS cohort, in-hospital mortality in propensity-matched patients who received adjunctive clindamycin (18 [6·5%] of 277 patients) was significantly lower than in those who did not (55 [11·0%] of 500 patients; aOR 0·44 [95% CI 0·23-0·81]). This survival benefit was maintained even in patients without shock or necrotising fasciitis (six [2·6%] of 239 patients treated with adjunctive clindamycin vs 27 [6·1%] of 422 patients not treated with adjunctive clindamycin; aOR 0·40 [0·15-0·91]). By contrast, in the iNABS infection cohort, in-hospital mortality in propensity-matched patients who received adjunctive clindamycin (ten [9·8%] of 102) was higher than in those who did not (nine [4·6%] of 193), but this difference was not significant (aOR 2·60 [0·94-7·52]). Several subset analyses found qualitatively similar results.
INTERPRETATION: Real-world data suggest that increased use of adjunctive clindamycin for invasive iGAS infections, but not iNABS infections, could improve outcomes, even in patients without shock or necrotising fasciitis.
FUNDING: Intramural Research Program of the National Institutes of Health Clinical Center and the National Institute of Allergy and Infectious Disease.
Copyright © 2021 Elsevier Ltd. All rights reserved.
Stevens DL, Bryant AE.
Necrotizing Soft-Tissue Infections.
N Engl J Med. 2017 Dec 7;377(23):2253-2265. doi: 10.1056/NEJMra1600673.
Abstract/Text
Siegel JD, Rhinehart E, Jackson M, Chiarello L; Health Care Infection Control Practices Advisory Committee.
2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings.
Am J Infect Control. 2007 Dec;35(10 Suppl 2):S65-164. doi: 10.1016/j.ajic.2007.10.007.
Abstract/Text
Prevention of Invasive Group A Streptococcal Infections Workshop Participants.
Prevention of invasive group A streptococcal disease among household contacts of case patients and among postpartum and postsurgical patients: recommendations from the Centers for Disease Control and Prevention.
Clin Infect Dis. 2002 Oct 15;35(8):950-9. doi: 10.1086/342692. Epub 2002 Sep 26.
Abstract/Text
The Centers for Disease Control and Prevention hosted a workshop to formulate recommendations for the control of invasive group A streptococcal (GAS) disease among household contacts of persons with invasive GAS infections and for responding to postpartum and postsurgical invasive GAS infections. Experts reviewed data on the risk of subsequent invasive GAS infection among household contacts of case patients, the effectiveness of chemoprophylactic regimens for eradicating GAS carriage, and the epidemiology of postpartum and postsurgical GAS infection clusters. For household contacts of index patients, routine screening for and chemoprophylaxis against GAS are not recommended. Providers and public health officials may choose to offer chemoprophylaxis to household contacts who are at an increased risk of sporadic disease or mortality due to GAS. One nosocomial postpartum or postsurgical invasive GAS infection should prompt enhanced surveillance and isolate storage, whereas > or =2 cases caused by the same strain should prompt an epidemiological investigation that includes the culture of specimens from epidemiologically linked health care workers.
