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Severe necrotizing soft-tissue infection-associated mortality: Have a look at the computed tomography!
Critical Care ( IF 15.1 ) Pub Date : 2022-01-25 , DOI: 10.1186/s13054-022-03898-1
Sébastien Tanaka 1, 2 , Michael Thy 1, 3, 4 , Ralph Khoury 5 , Alexy Tran-Dinh 1, 3, 6 , Antoine Khalil 3, 5, 7 , Philippe Montravers 1, 3, 7
Affiliation  

Necrotizing soft-tissue infection (NSTI) is a life-threatening pathology, and the cornerstone treatment is based on early diagnosis, surgical source control and antimicrobial therapy [1]. Even if the diagnosis remains essentially clinical, computed tomography (CT) could be helpful in the diagnosis but remains controversial [2]. To date, there are no data screening the criteria for the place of initial CT-scan and patient outcomes. We aimed to evaluate the relationship between CT signs and the outcome of severe NSTI patients.

We retrospectively collected data for 100 patients with severe NSTI hospitalized in our intensive care unit (ICU) between 2009 and 2019 and whose diagnoses were surgically confirmed. Methods of this cohort have been previously published [3]. Patients who were clinically suspected of having NSTI benefited from urgent surgical exploration. CT was performed prior to surgery at the discretion of the clinician if the diagnosis of NSTI was uncertain or to assess the extent of the damage.

Four criteria for CT were evaluated according to previous guidelines [4, 5]:

  • Gas in the soft tissues,

  • Multiple fluid collections,

  • Absence or heterogeneity of tissue enhancement by IV contrast,

  • Significant inflammatory changes of the fascia and under.

The presence of these criteria was compared between survivors and nonsurvivors at day-90.

Of the 100 patients, 54 underwent CT before surgical exploration. Table 1 shows the comparison of general characteristics between the patients with and without CT. The median (IQR) delay between CT and the surgical procedure was 5 [2–20] hours. Table 2 shows the clinical and CT characteristics according to the survival or death status at day-90. In the multivariate analysis, in addition to the surface parameter (OR 1.15, 95% CI 1.34, p = 0.01), the criterion for inflammatory changes of the fascia was associated with mortality at day-90 (OR 8.09, 95% CI 63.5, p = 0.015). Inflammatory changes of the fascia parameter had a sensitivity of 60% (32-84), specificity of 92% (79-98), positive predictive value of 75% (43–95) and negative predictive value of 86% (71–95).

Table 1 Overall baseline and outcome features of the study patients according to CT evaluation
Full size table
Table 2 Relationship between the clinical and CT criteria and mortality at day-90
Full size table

In this study involving 100 severe ICU NSTI patients, we found that even if CT is not a diagnostic tool, it can nevertheless provide some information on the patient's outcome. It is well established that the contribution of CT for an NSTI diagnosis is not only unreliable but can also delay the management of the patient, which is why in most cases, the diagnosis is made on the basis of clinical examinations and operative findings [4]. Our work partly confirms these elements since, when comparing patients who had a CT-scan versus those who did not, no difference according to the initial severity was found.

There are many diagnostic studies in which changes in the fascia (thickness, presence of edema, nonenhancement) can help in the diagnosis, but to our knowledge, our study is the first to evidence a link between fascia imaging and prognosis [6]. Nevertheless, as the fascia is a key structure in the spread of infection, our findings seem quite consistent.

Our study has limitations, including its monocentric design with only 100 NSTI patients and a long cohort period. Of course, almost half of the patients in the cohort did not have a CT-scan, which is an undeniable source of bias. A multicenter prospective larger cohort study has to be performed to confirm these results.

The datasets analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request.

CT:

Computed tomography

ICU:

Intensive care unit

NSTI:

Necrotizing soft-tissue infection

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The authors would like to thank the medical and paramedical team of the Bichat Claude Bernard Surgical ICU, Paris, France.

None.

Author notes

  1. Sébastien Tanaka and Michael Thy have contributed equally to the work

Affiliations

  1. Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anesthesiology and Critical Care Medicine, DMU PARABOL, Bichat-Claude Bernard Hospital, 46 Rue Henri Huchard, 75018, Paris, France

    Sébastien Tanaka, Michael Thy, Alexy Tran-Dinh & Philippe Montravers

  2. French Institute of Health and Medical Research (INSERM), U1188 Diabetes Atherothrombosis Réunion Indian Ocean (DéTROI), CYROI Plateform, Réunion Island University, Saint-Denis de La Réunion, France

    Sébastien Tanaka

  3. Université de Paris, Paris, France

    Michael Thy, Alexy Tran-Dinh, Antoine Khalil & Philippe Montravers

  4. EA 7323 - Pharmacology and Therapeutic Evaluation in Children and Pregnant Women, Paris Descartes University, Sorbonne Paris Cité University, Paris, France

    Michael Thy

  5. Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Radiology, DMU DREAM, Bichat-Claude Bernard Hospital, Paris, France

    Ralph Khoury & Antoine Khalil

  6. Laboratory for Vascular Translational Science, French Institute of Health and Medical Research (INSERM) U1148, Paris, France

    Alexy Tran-Dinh

  7. PHERE, Physiopathology and Epidemiology of Respiratory Diseases, French Institute of Health and Medical Research (INSERM) U1152, Paris, France

    Antoine Khalil & Philippe Montravers

Authors
  1. Sébastien TanakaView author publications

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  2. Michael ThyView author publications

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  3. Ralph KhouryView author publications

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  4. Alexy Tran-DinhView author publications

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  5. Antoine KhalilView author publications

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  6. Philippe MontraversView author publications

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Contributions

ST, MT, AK and PM contributed to study concept and design. ST and MT performed statistical analysis. ST, MT, AK, RK, ATD and PM were involved in data analysis and interpretation. ST, ATD, AK and PM performed critical revision of the manuscript. All the authors read and approved the final manuscript.

Corresponding authors

Correspondence to Sébastien Tanaka or Michael Thy.

Ethics approval and consent to participate

This study was declared to the French Data Protection Authority (CNIL: 2096382) and was approved by the French Institutional Review Board (Comité d’Éthique de la Recherche en Anesthésie-Réanimation, IRB Number 00010254-2020-153). Due to the retrospective nature of this study, the need for signed informed consent was waived.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Tanaka, S., Thy, M., Khoury, R. et al. Severe necrotizing soft-tissue infection-associated mortality: Have a look at the computed tomography!. Crit Care 26, 27 (2022). https://doi.org/10.1186/s13054-022-03898-1

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Keywords

  • Necrotizing soft-tissue infection
  • Sepsis
  • Outcome
  • Intensive care unit
  • Computed tomography

中文翻译：
严重坏死性软组织感染相关死亡率：看看计算机断层扫描！

坏死性软组织感染（NSTI）是一种危及生命的病理，治疗的基石是早期诊断、手术源控制和抗菌治疗[1]。即使诊断基本上仍然是临床的，计算机断层扫描 (CT) 可能有助于诊断，但仍存在争议 [2]。迄今为止，没有数据筛选初始 CT 扫描位置和患者结果的标准。我们旨在评估 CT 征象与严重 NSTI 患者预后之间的关系。

我们回顾性收集了 2009 年至 2019 年期间在我们的重症监护病房 (ICU) 住院的 100 名严重 NSTI 患者的数据，这些患者的诊断已通过手术确认。该队列的方法先前已发表[3]。临床怀疑患有 NSTI 的患者受益于紧急手术探查。如果 NSTI 的诊断不确定或评估损伤程度，临床医生可在手术前进行 CT 检查。

根据之前的指南 [4, 5] 评估了 CT 的四个标准：

  • 软组织中的气体，

  • 多种流体收集，

  • IV对比剂组织增强不存在或不均匀，

  • 筋膜及下明显炎症变化。

在第 90 天比较幸存者和非幸存者是否存在这些标准。

100 例患者中，54 例在手术探查前接受了 CT 检查。表 1 显示了有和没有 CT 患者的一般特征的比较。CT 和外科手术之间的中位 (IQR) 延迟为 5 [2-20] 小时。表 2 显示了第 90 天时根据生存或死亡状态的临床和 CT 特征。在多变量分析中，除了表面参数（OR 1.15，95% CI 1.34，p = 0.01）外，筋膜炎症变化的标准与第 90 天的死亡率相关（OR 8.09，95% CI 63.5，p = 0.015)。筋膜参数炎症变化的敏感性为 60% (32-84)，特异性为 92% (79-98)，阳性预测值为 75% (43-95)，阴性预测值为 86% (71-95) ）。

表 1 根据 CT 评估的研究患者的总体基线和结果特征
全尺寸表
表 2 临床和 CT 标准与 90 天死亡率的关系
全尺寸表

在这项涉及 100 名重症 ICU NSTI 患者的研究中，我们发现即使 CT 不是诊断工具，它仍然可以提供有关患者预后的一些信息。众所周知，CT 对 NSTI 诊断的贡献不仅不可靠，而且还会延迟患者的治疗，这就是为什么在大多数情况下，诊断是基于临床检查和手术结果 [4] . 我们的工作部分证实了这些因素，因为在比较接受 CT 扫描的患者与未接受 CT 扫描的患者时，根据初始严重程度没有发现差异。

有许多诊断研究表明筋膜的变化（厚度、水肿存在、无增强）有助于诊断，但据我们所知，我们的研究首次证明筋膜成像与预后之间存在联系 [6]。然而，由于筋膜是感染传播的关键结构，我们的研究结果似乎相当一致。

我们的研究存在局限性，包括其单中心设计只有 100 名 NSTI 患者和较长的队列期。当然，队列中几乎一半的患者没有进行 CT 扫描，这是不可否认的偏见来源。必须进行一项多中心前瞻性更大的队列研究来确认这些结果。

当前研究期间分析的数据集不公开，但可根据合理要求从相应作者处获得。

计算机断层扫描：

CT检查

重症监护室：

重症监护室

NSTI：

坏死性软组织感染

  1. 1.

    史蒂文斯 DL，科比 AE。坏死性软组织感染。N Engl J Med。2017;377(23):2253–65。

    文章谷歌学术

  2. 2.

    Zacharias N. 通过计算机断层扫描诊断坏死性软组织感染。拱外科。2010；145(5):452。

    文章谷歌学术

  3. 3.

    Tanaka S、Thy M、Tashk P、Ribeiro L、Lortat-Jacob B、Hermieu JF 等。先前抗生素治疗对 ICU 患者严重坏死性软组织感染的影响：来自法国回顾性和观察性研究的结果。Eur J Clin Microbiol Infect Dis Off Publ Eur Soc Clin Microbiol。2021；41：109-17。

    文章谷歌学术

  4. 4.

    Sartelli M、Guirao X、Hardcastle TC、Kluger Y、Boermeester MA、Raşa K 等。2018 WSES/SIS-E 共识会议：皮肤和软组织感染管理建议。World J Emerg Surg WJES。2018；13:58。

    文章谷歌学术

  5. 5.

    Martinez M、Peponis T、Hage A、Yeh DD、Kaafarani HMA、Fagenholz PJ 等。计算机断层扫描在坏死性软组织感染诊断中的作用。世界 J 外科杂志 2018;42(1):82-7。

    文章谷歌学术

  6. 6.

    布鲁斯 RJM，奎 RM。坏死性软组织感染的 CT：诊断标准及与 LRINEC 评分的比较。欧洲电台。2021；31（11）：8536-41。

    文章谷歌学术

下载参考资料

作者要感谢法国巴黎 Bichat Claude Bernard Surgical ICU 的医疗和辅助医疗团队。

没有。

作者笔记

  1. Sébastien Tanaka 和 Michael Thy 对这项工作做出了同等贡献

隶属关系

  1. Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anesthesiology and Critical Care Medicine, DMU PARABOL, Bichat-Claude Bernard Hospital, 46 Rue Henri Huchard, 75018, Paris, France

    Sébastien Tanaka、Michael Thy、Alexy Tran-Dinh 和 Philippe Montravers

  2. 法国健康与医学研究所 (INSERM)，U1188 糖尿病动脉血栓形成留尼汪岛印度洋 (DéTROI)，CYROI 平台，留尼汪岛大学，留尼汪岛，法国

    塞巴斯蒂安·田中

  3. 巴黎大学，巴黎，法国

    Michael Thy、Alexy Tran-Dinh、Antoine Khalil 和 Philippe Montravers

  4. EA 7323 - 儿童和孕妇的药理学和治疗评估，巴黎笛卡尔大学，巴黎索邦大学，巴黎，法国

    迈克尔·蒂

  5. 巴黎医院 (AP-HP) 援助公共医院 (AP-HP)，放射科，DMU DREAM，Bichat-Claude Bernard 医院，法国巴黎

    拉尔夫·库里和安托万·哈利勒

  6. 血管转化科学实验室，法国健康与医学研究所 (INSERM) U1148，巴黎，法国

    亚历克西·陈定

  7. PHERE，呼吸系统疾病的生理病理学和流行病学，法国健康与医学研究所 (INSERM) U1152，法国巴黎

    安托万·哈利勒和菲利普·蒙特拉弗斯

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贡献

ST、MT、AK 和 PM 为研究概念和设计做出了贡献。ST和MT进行了统计分析。ST、MT、AK、RK、ATD 和 PM 参与了数据分析和解释。ST、ATD、AK 和 PM 对手稿进行了严格的修改。所有作者都阅读并批准了最终手稿。

通讯作者

与 Sébastien Tanaka 或 Michael Thy 的通信。

伦理批准和同意参与

本研究已向法国数据保护局 (CNIL: 2096382) 申报，并获得法国机构审查委员会 (Comité d'Éthique de la Recherche en Anesthésie-Réanimation, IRB 编号 00010254-2020-153) 的批准。由于本研究的回顾性，无需签署知情同意书。

同意发表

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利益争夺

作者声明他们没有相互竞争的利益。

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Tanaka, S., Thy, M., Khoury, R.等人。严重坏死性软组织感染相关死亡率：看看计算机断层扫描！重症监护 26、27（2022 年）。https://doi.org/10.1186/s13054-022-03898-1

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关键词

  • 坏死性软组织感染
  • 败血症
  • 结果
  • 重症监护室
  • CT检查
更新日期：2022-01-25
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