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Intensive multidisciplinary management in critical care patients affected by severe necrotizing soft tissue infections: a cooperative method to improve the efficacy of treatment

  • Milo Gatti
  • Laura Elisa Gasparini
  • Matteo Laratta
  • Anna Sigurtà
  • Anna Rossi
  • Paolo Brioschi
  • Osvaldo Chiara
  • Chiara Vismara
  • Francesco Scaglione
  • Sergio ArlatiEmail author
Original Article
  • 298 Downloads

Abstract

To illustrate the effectiveness of our intensive multidisciplinary management (IMM) in the treatment of severely ill patients with necrotizing soft tissue infections (NSTIs). A retrospective observational study was conducted in a general ICU. Thirty-two consecutive patients undergoing IMM were carefully compared with 30 consecutive patients receiving a standard management (SM). IMM combined intensive care management, early surgical debridement followed by daily inspection of surgical wounds, close microbiological surveillance, and targeted high-dose antibiotics. IMM was associated with the better decrease of daily SOFA score (p = 0.04). Also, IMM caused + 12% increase in the overall number of surgical procedures (p = 0.022) and a higher number of tissue biopsies/per day (median 0.63 versus 0.32; p = 0.025), leading to a more targeted antimicrobial changes (89.6% vs 51.6%; p < 0.00001). High-dose daptomycin (75% vs 36.7%; p = 0.002) and extended/continuous infusion of beta-lactams (75% vs 43.3%; p = 0.011) were more frequently utilized. A specific efficiency score correlated with the decrease of SOFA score (efficacy) in IMM patients only (p = 0.027). Finally, IMM was associated with a significant lower ICU mortality rate (15.6% vs 40%; p = 0.032). IMM was more effective than SM as it allowed the earlier control of infection and the faster reduction of multiple organ-dysfunction.

Keywords

Severe necrotizing soft tissue infections Intensive care unit Intensive multidisciplinary management Targeted antimicrobial therapy Antibiotic de-escalation 

Notes

Acknowledgements

In memory of Giovanni Pietro Gesu, for his essential contribution in the implementation of a multidisciplinary task force between microbiologists, infectious disease specialists and intensive care physicians in Niguarda-Ca′ Granda Hospital. Special thanks are due to medical and nursing ICU staff for treating and caring the patient.

Funding source

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Compliance with ethical standards

Conflict of interest

Professor Scaglione declares Personal Fees from Pfizer, Novartis, Bayer, and GSK. Other authors have no conflict of interest to declare.

Ethical standard statement

The study was performed in accordance with ethical standards laid down in the 1964 Declarations of Helsinki and its later amendments and with guidelines laid down by the hospital ethics committee.

Supplementary material

10096_2019_3521_MOESM1_ESM.xlsx (16 kb)
ESM 1 (XLSX 16 kb)

References

  1. 1.
    Ellis Simonsen SM, van Orman ER, Hatch BE, Jones SS, Gren LH, Hegmann KT, Lyon JL (2006) Cellulitis incidence in a defined population. Epidemiol Infect 134(2):293–299CrossRefPubMedGoogle Scholar
  2. 2.
    Anaya DA, Dellinger EP (2007) Necrotizing soft-tissue infection: diagnosis and management. Clin Infect Dis 44(5):705–710CrossRefPubMedGoogle Scholar
  3. 3.
    McHenry CR, Piotrowski JJ, Petrinic D, Malangoni MA (1995) Determinants of mortality for necrotizing soft-tissue infections. Ann Surg 221(5):558–565CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Anaya DA, McMahon K, Nathens A, Sullivan SR, Foy H, Bulger E (2005) Predictors of mortality and limb loss in necrotizing soft tissue infections. Arch Surg 140:151–158CrossRefPubMedGoogle Scholar
  5. 5.
    Boyer A, Vargas F, Coste F, Saubusse E, Castaing Y, Gbikpi-Benissan G, Hilbert G, Gruson D (2009) Influence of surgical treatment timing on mortality from necrotizing soft tissue infections requiring intensive care management. Intensive Care Med 35(5):847–853CrossRefPubMedGoogle Scholar
  6. 6.
    Voros D, Pissitois C, Georgantas D, Katsaragakis S, Antoniou S, Papadimitriou J (1993) Role of early and extensive surgery in the treatment of severe necrotizing soft tissue infection. Br J Surg 80(9):1190–1191CrossRefPubMedGoogle Scholar
  7. 7.
    Bilton BD, Zibari GB, McMillan RW, Aultman DF, Dunn G, McDonald JC (1998) Aggressive surgical management of necrotizing fasciitis serves to decrease mortality: a retrospective study. Am Surg 64(5):397–400PubMedGoogle Scholar
  8. 8.
    Hadeed GJ, Smith J, O’Keeffe, Kulvatunyou N, Wynne JL, Joseph B, Friese RS, Wachtel TL, Rhee PM, El-Menyar A et al (2016) Early surgical intervention and its impact on patients presenting with necrotizing soft tissue infections: a single academic center experience. J Emerg Trauma Shock 9(1):22–27CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Wong CH, Haw-Chong C, Shanker P, Khin LW, Tan JL, Low CO (2003) Necrotizing fasciitis: clinical presentation, microbiology and determinants of mortality. J Bone Joint Surg Am 85(8):1454–1460CrossRefPubMedGoogle Scholar
  10. 10.
    Elliot DC, Kufera JA, Myers RAM, Necrotizing soft tissue infections (1996) Risk factors for mortality and strategies for management. Ann Surg 224(5):672–683CrossRefGoogle Scholar
  11. 11.
    Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, Hirschmann JV, Kaplan SL, Montoya JG, Wade JC (2014) 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 59(2):e10–e52CrossRefGoogle Scholar
  12. 12.
    Okoye O, Talving P, Lam L, Smith J, Teixeira PG, Inaba K, Koronakis N, Demetriades D (2013) Timing of redébridement after initial source control impacts survival in necrotizing soft tissue infection. Am Surg 79(10):1081–1085PubMedGoogle Scholar
  13. 13.
    Stevens DL, Bryant AE (2017) Necrotizing soft-tissue infections. N Engl J Med 377(23):2253–2265CrossRefPubMedGoogle Scholar
  14. 14.
    de Prost N, Sbidian E, Chosidow O, Brun-Buisson C, Amathieu R (2015) Management of necrotizing soft tissue infections in the intensive care unit: results of an international survey. Intensive Care Med 41(8):1506–1508CrossRefPubMedGoogle Scholar
  15. 15.
    Vincent JL, de Mendonça A, Cantraine F, Moreno R, Takala J, Suter PM, Sprung CL, Colardyn F, Blecher S (1998) Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Working group on "sepsis-related problems" of the European Society of Intensive Care Medicine. Crit Care Med 26(11):1793–1800CrossRefPubMedGoogle Scholar
  16. 16.
    Le Gall JR, Lemeshow S, Saulnier F (1993) A new simplified acute physiology score (SAPS II) based on a European/north American multicenter study. JAMA 270(24):2957–2963CrossRefGoogle Scholar
  17. 17.
    Wong CH, Khin LW, Heng KS, Tan KC, Low CO (2004) The LRINEC (Labroatory risk indicator for necrotizing fasciitis) score: a tool for distinguishing necrotizing fasciitis form other soft tissue infections. Crit Care Med 32(7):1535–1541CrossRefPubMedGoogle Scholar
  18. 18.
    Wallace AB (1951) The exposure treatment of burns. Lancet 1(6653):501–504CrossRefPubMedGoogle Scholar
  19. 19.
    Roberts JA, Lipman J (2009) Pharmacokinetic issues for antibiotics in the critically ill patient. Crit Care Med 37(3):840–851CrossRefGoogle Scholar
  20. 20.
    Abdul-Aziz MH, Lipman J, Roberts JA (2017) Identifying “at-risk” patients for sub-optimal beta-lactam exposure in critically ill patients with severe infections. Crit Care 21(1):283–285CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Ulldemolins M, Roberts JA, Lipman J, Rello J (2011) Antibiotic dosing in multiple organ dysfunction syndrome. Chest 139(5):1210–1220CrossRefPubMedGoogle Scholar
  22. 22.
    Blot S, Lipman J, Roberts DM, Roberts JA (2014) The influence of acute kidney injury on antimicrobial dosing in critically ill patients: are dose reductions always necessary? Diagn Microbiol Infect Dis 79(1):77–84CrossRefPubMedGoogle Scholar
  23. 23.
    De Prost N, Lipman J, Mimoz O (2017) Therapeutic targets in necrotizing soft tissue infections. Intensive Care Med 43(11):1717–1719CrossRefPubMedGoogle Scholar
  24. 24.
    D’Avolio A, Pensi D, Baietto L, Pacini G, Di Perri G, De Rosa FG (2016) Daptomycin pharmacokinetics and pharmacodynamics in septic and critically ill patients. Drugs 76(12):1161–1174CrossRefPubMedGoogle Scholar
  25. 25.
    Kiang TKL, Häfeli UO, Ensom MHH (2014) A comprehensive review on the pharmacokinetics of antibiotics in interstitial fluid spaces in humans: implications on dosing and clinical pharmacokinetic monitoring. Clin Pharmacokinet 53(8):695–730CrossRefPubMedGoogle Scholar
  26. 26.
    Hancock RE (2005) Mechanisms of action of newer antibiotics for Gram-positive pathogens. Lancet Infect Dis 5(4):209–218CrossRefPubMedGoogle Scholar
  27. 27.
    Roberts J, Gavin MJ, Gordon Y, Choi S, Gomersall CD, Lipman J (2012) How to optimise antimicrobial prescriptions in the intensive care unit: principles of individualised dosing using pharmacokinetics and pharmacodynamics. Int J Antimicrob Agents 39(3):187–192CrossRefPubMedGoogle Scholar
  28. 28.
    Blot SI, Pea F, Lipman J (2014) The effect of pathophysiology on pharmacokinetics in the critically ill patient--concepts appraised by the example of antimicrobial agents. Adv Drug Deliv Rev 77:3–11CrossRefPubMedGoogle Scholar
  29. 29.
    Scaglione F (2015) Can we transfer pharmacokinetics/pharmacodynamics of antimicrobials into clinical practice? Int J Antimicrob Agents 46(1):S40–S42CrossRefPubMedGoogle Scholar
  30. 30.
    Pea F (2016) Practical concept of pharmacokinetics/pharmacodynamics in the management of skin and soft tissue infections. Curr Opin Infect Dis 29(2):153–159CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Milo Gatti
    • 1
  • Laura Elisa Gasparini
    • 2
  • Matteo Laratta
    • 3
  • Anna Sigurtà
    • 2
  • Anna Rossi
    • 2
  • Paolo Brioschi
    • 2
  • Osvaldo Chiara
    • 4
  • Chiara Vismara
    • 5
  • Francesco Scaglione
    • 6
  • Sergio Arlati
    • 2
    Email author
  1. 1.Department of Oncology and Hemato-oncology, Postgraduate School of Clinical Pharmacology and ToxicologyUniversity of MilanMilanItaly
  2. 2.Intensive Care Unit 1ASST Grande Ospedale Metropolitano NiguardaMilanItaly
  3. 3.Intensive Care Unit 3ASST Grande Ospedale Metropolitano NiguardaMilanItaly
  4. 4.Department of General Surgery and Trauma TeamASST Grande Ospedale Metropolitano NiguardaMilanItaly
  5. 5.Department of Clinical MicrobiologyASST Grande Ospedale Metropolitano NiguardaMilanItaly
  6. 6.Department of Oncology and Hemato-oncologyUniversity of MilanMilanItaly

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