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Meta-Analysis
. 2020 Jan 8:15:4.
doi: 10.1186/s13017-019-0286-6. eCollection 2020.

Time is of the essence when treating necrotizing soft tissue infections: a systematic review and meta-analysis

Femke Nawijn  1 , Diederik P J Smeeing  1 , Roderick M Houwert  1 , Luke P H Leenen  1 , Falco Hietbrink  1
Affiliations
Meta-Analysis

Time is of the essence when treating necrotizing soft tissue infections: a systematic review and meta-analysis

Femke Nawijn et al. World J Emerg Surg. .

Abstract

Background: Although the phrase "time is fascia" is well acknowledged in the case of necrotizing soft tissue infections (NSTIs), solid evidence is lacking. The aim of this study is to review the current literature concerning the timing of surgery in relation to mortality and amputation in patients with NSTIs.

Methods: A systematic search in PubMed/MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Controlled Register of Trials (CENTRAL) was performed. The primary outcomes were mortality and amputation. These outcomes were related to the following time-related variables: (1) time from onset symptoms to presentation; (2) time from onset symptoms to surgery; (3) time from presentation to surgery; (4) duration of the initial surgical procedure. For the meta-analysis, the effects were estimated using random-effects meta-analysis models.

Result: A total of 109 studies, with combined 6051 NSTI patients, were included. Of these 6051 NSTI patients, 1277 patients died (21.1%). A total of 33 studies, with combined 2123 NSTI patients, were included for quantitative analysis. Mortality was significantly lower for patients with surgery within 6 h after presentation compared to when treatment was delayed more than 6 h (OR 0.43; 95% CI 0.26-0.70; 10 studies included). Surgical treatment within 6 h resulted in a 19% mortality rate compared to 32% when surgical treatment was delayed over 6 h. Also, surgery within 12 h reduced the mortality compared to surgery after 12 h from presentation (OR 0.41; 95% CI 0.27-0.61; 16 studies included). Patient delay (time from onset of symptoms to presentation or surgery) did not significantly affect the mortality in this study. None of the time-related variables assessed significantly reduced the amputation rate. Three studies reported on the duration of the first surgery. They reported a mean operating time of 78, 81, and 102 min with associated mortality rates of 4, 11.4, and 60%, respectively.

Conclusion: Average mortality rates reported remained constant (around 20%) over the past 20 years. Early surgical debridement lowers the mortality rate for NSTI with almost 50%. Thus, a sense of urgency is essential in the treatment of NSTI.

Keywords: Amputation; Debridement; Meta-analysis; Mortality; Necrotizing fasciitis; Necrotizing soft tissue infection; Surgery; Systematic review.

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Conflict of interest statement

Competing interestsThe authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Historical cumulative mortality rates for necrotizing soft tissue infections based on included studies
Fig. 2
Fig. 2
Flowchart of study inclusion process for meta-analysis of surgical timing of necrotizing soft tissue infections
Fig. 3
Fig. 3
Mortality in a meta-analysis assessing time from presentation to surgery in necrotizing soft tissue patients. a Mortality in a meta-analysis comparing surgery within and after 6 h after presentation; b Mortality in a meta-analysis comparing surgery within and after 12 h after presentation
Fig. 4
Fig. 4
Funnel plot of meta-analysis assessing surgical timing and mortality in necrotizing soft tissue infections. a Funnel plot for meta-analysis comparing mortality in necrotizing soft tissue infection patients operated within or after 6 h after presentation; b Funnel plot for meta-analysis comparing mortality in necrotizing soft tissue infection patients operated within or after 12 h after presentation
See this image and copyright information in PMC

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