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Optimal Timing of Initial Debridement for Necrotizing Soft Tissue Infection

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Optimal Timing of Initial Debridement for Necrotizing Soft Tissue Infection GUIDELINES 07/09/2018 on e8Uh+klvnESopBmb8BES3t75bWoVvBK6DHulSTiH+NAZV/6XdDgve329EvYnpsFG3DSBSAcgCZE3hjZfN0J5EqRuPR7sIQuIfGoP47Nb8I741A2BY1s8JlLZlOPe6+YNVutsMjWfPKmD+WbGnUX9cr2Xe3B4xHkZhYcPC5X7Ll1XiUKGvWsq9w== by https://journals.na.lww.com/jtrauma from Downloaded Optimal timing of initial debridement for necrotizing soft tissue Downloaded infection: A Practice Management Guideline from the Eastern from https://journals.na.lww.com/jtrauma Association for the Surgery of Trauma Rondi B. Gelbard, MD, Paula Ferrada, MD, D. Dante Yeh, MD, Brian H. Williams, MD, Michele Loor, MD, James Yon, MD, Caleb Mentzer, DO, Kosar Khwaja, MD, MBA, MSc, Mansoor A. Khan, MBBS, PhD, by Anirudh Kohli, MD, Eileen M. Bulger, MD, and Bryce R.H. Robinson, MD,Atlanta,Georgia e8Uh+klvnESopBmb8BES3t75bWoVvBK6DHulSTiH+NAZV/6XdDgve329EvYnpsFG3DSBSAcgCZE3hjZfN0J5EqRuPR7sIQuIfGoP47Nb8I741A2BY1s8JlLZlOPe6+YNVutsMjWfPKmD+WbGnUX9cr2Xe3B4xHkZhYcPC5X7Ll1XiUKGvWsq9w== AAST Continuing Medical Education Article Accreditation Statement This activity has been planned and implemented in accordance with the Es- sential Areas and Policies of the Accreditation Council for Continuing Medical Disclosure Information Education through the joint providership of the American College of Surgeons In accordance with the ACCME Accreditation Criteria, the American College of and the American Association for the Surgery of Trauma. The American Surgeons, as the accredited provider of this journal activity, must ensure that anyone College Surgeons is accredited by the ACCME to provide continuing medical in a position to control the content of JTraumaAcuteCareSurgarticles selected for education for physicians. CME credit has disclosed all relevant financial relationships with any commercial ™ interest. Disclosure forms are completed by the editorial staff, associate editors, AMA PRA Category 1 Credits reviewers, and all authors. The ACCME defines a `commercial interest' as “any The American College of Surgeons designates this journal-based CME activity for entity producing, marketing, re-selling, or distributing health care goods or services a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the consumed by, or used on, patients.”“Relevant” financial relationships are those (in credit commensurate with the extent of their participation in the activity. any amount) that may create a conflict of interest and occur within the 12’months Of the AMA PRA Category 1 Credit™ listed above, a maximum of 1 credit preceding and during the time that the individual is engaged in writing the article. All meets the requirements for self-assessment. reported conflicts are thoroughly managed in order to ensure any potential bias Credits can only be claimed online within the content is eliminated. However, if you’perceive a bias within the article, please report the circumstances on the evaluation form. Please note we have advised the authors that it is their responsibility to disclose within the article if they are describing the use of a device, product, or drug that is not FDA approved or the off-label use of an approved device, product, or drug or unapproved usage. Disclosures of Significant Relationships with Relevant Commercial Companies/Organizations by the Editorial Staff Ernest E. Moore, Editor: PI, research support and shared U.S. patents Haemonetics; Objectives PI, research support, Instrumentation Laboratory, Inc.; Co-founder, Thrombo Thera- After reading the featured articles published in the Journal of Trauma and Acute peutics. Associate Editors David Hoyt, Ronald V. Maier and Steven Shackford have Care Surgery, participants should be able to demonstrate increased understanding nothing to disclose. Editorial staff and Angela Sauaia have nothing to disclose. Michelle Loor, MD, discloses payment of registration for conference and travel expenses of the material specific to the article. Objectives for each article are featured at the from Lifecell and Intuitive Surgical. beginning of each article and online. Test questions are at the end of the article, Eileen Bulger, MD, discloses a PI grant from Atox Bio. with a critique and specific location in the article referencing the question topic. Claiming Credit Reviewer Disclosures To claim credit, please visit the AAST website at http://www.aast.org/ and click on The reviewers have nothing to disclose. the “e-Learning/MOC” tab. You must read the article, successfully complete the Cost post-test and evaluation. Your CME certificate will be available immediately upon For AAST members and Journal of Trauma and Acute Care Surgery subscribers receiving a passing score of 75% or higher on the post-test. Post-tests receiving a there is no charge to participate in this activity. For those who are not a member score of below 75% will require a retake of the test to receive credit. orsubscriber, the cost for each credit is $25. System Requirements on The system requirements are as follows: Adobe® Reader 7.0 or above installed; Internet Explorer® 7 and above; Firefox® 3.0 and above, Chrome® 8.0 and above, or 07/09/2018 Safari™ 4.0 and above. Questions If you have any questions, please contact AAST at 800-789-4006. Paper test and evaluations will not be accepted. J Trauma Acute Care Surg 208 Volume 85, Number 1 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. J Trauma Acute Care Surg Volume 85, Number 1 Gelbard et al. BACKGROUND: Necrotizing soft tissue infections (NSTI) are rare, life-threatening, soft-tissue infections characterized by rapidly spreading inflam- mation and necrosis of the skin, subcutaneous fat, and fascia. While it is widely accepted that delay in surgical debridement con- tributes to increased mortality, there are currently no practice management guidelines regarding the optimal timing of surgical management of this condition. Although debridement within 24 hours of diagnosis is generally recommended, the time ranges from 3 hours to 36 hours in the existing literature. Therefore, the objective of this article is to provide evidence-based recommen- dations for the optimal timing of surgical management of NSTI. METHODS: The MEDLINE database using PubMed was searched to identify English language articles published from January 1990 to September 2015 regarding adult and pediatric patients with NSTIs. A systematic review of the literature was performed, and the Grading of Recommendations Assessment, Development and Evaluation framework were used. A single population [P], intervention [I], comparator [C], and outcome [O] (PICO) question was applied: In patients with NSTI (P), should early (<12 hours) initial debridement (I) versus late (≥12 hours) initial debridement (C) be performed to decrease mortality (O)? RESULTS: Two hundred eighty-seven articles were identified. Of these, 42 papers underwent full text review and 6 were selected for guideline construction. A total of 341 patients underwent debridement for NSTI. Of these, 143 patients were managed with early versus 198 with late operative debridement. Across all studies, there was an overall mortality rate of 14% in the early group versus 25.8% in the late group. CONCLUSION: For NSTIs, we recommend early operative debridement within 12 hours of suspected diagnosis. Institutional and regional systems should be optimized to facilitate prompt surgical evaluation and debridement. (J Trauma Acute Care Surg. 2018;85: 208–214. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.) LEVEL OF EVIDENCE: Systematic review/meta-analysis, level IV. KEY WORDS: Necrotizing soft tissue infection; debridement; acute care surgery; Fournier gangrene; emergency general surgery; practice man- agement guideline. ecrotizing soft tissue infections (NSTI) are severe and rap- characteristics, and share the same diagnostic and treatment N idly progressing infections with extremely high morbidity strategies. Early diagnosis and treatment are essential, because and mortality rates. The term “necrotizing soft tissue infection” the mortality ranges from 10% to 17% with some sources cit- encompasses all types of infection involving any layers of the ing mortality rates up to 73%.2,3 soft tissue including superficial fascia, deep fascia or muscle. Necrotizing soft tissue infections can be caused by poly- The clinical manifestations range from pyoderma to necrotizing microbial (Type I) or monomicrobial organisms (Type II). Mono- cellulitis, myositis, progressive bacterial synergistic gangrene, microbial infections account for 10% of NSTI and are most 1 and life-threatening necrotizing fasciitis. commonly caused by Group A β-hemolytic streptococci, espe- Necrotizing soft tissue infections are commonly seen in cially the toxin producing strains of S. pyogenes. Other less com- the extremities and abdominal walls, although any part of the mon organisms include Vibrio vulnificus (Type III NSTI), which body can be affected. Fournier gangrene, for example, is a ful- is found in marine environments; Aeromonas hydrophila,found minant form of NSTI that involves the perineal, genital, or in fresh or brackish water; and Clostridium perfringens.4 Poly- perianal regions in men. Even though there are several defini- microbial infections account for the majority of infections and tions and classification systems that have been used to describe involve a combination of bacteria, including Staphylococcal, these infections, they all have similar pathophysiologic, clinical Streptococcal species, Escherichia coli, Bacteroides fragilis, or Clostridium species.5 There are no specific diagnostic
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