Community-acquired necrotizing soft tissue infections: a review of 122 cases presenting to a single emergency department over 12 years

Abstract

Purpose: To characterize the Emergency Department (ED) presentation of necrotizing soft tissue infections (NSTI) and identify severity markers.

Procedures: Retrospective chart review of pathologically diagnosed NSTIs presenting to an urban ED from 1990-2001. Cases were identified from a surgical database, ICD-9 search and prospectively. Five Emergency Physicians (EPs) abstracted data using a standardized form. Severe NSTI was defined by any of the following: death, amputation, intensive care unit (ICU) stay >24 h, >300 cm(2) debrided. Severe and non-severe cases were compared using chi-square, Fisher's exact, and multivariate logistic regression testing.

Findings: The 122 cases were characterized by: injection drug use, 80%; fever, 44%; systolic blood pressure (BP) <100 mm Hg, 21%; white blood cell count (WBC) >20 x 10(9)/L, 43%; median time to operation, 8.4 h; mortality, 16%. The managing EP suspected NSTI in 59%. A systolic BP <100 mm Hg, BUN >18 mg/dL, radiographic soft tissue gas, admission to a non-surgical service and clostridial species were independently associated with severe NSTI.

Conclusions: Pathologically defined NSTIs have a wide spectrum of ED presentations and early diagnosis remains difficult.