Severe necrotizing soft-tissue infection-associated mortality: Have a look at the computed tomography!

© The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. 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]:

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]: The presence of these criteria was compared between survivors and nonsurvivors at day-90.
In this study involving 100 severe ICU NSTI patients, we found that even if CT is not a diagnostic tool, it can Open Access *Correspondence: sebastien.tanaka@aphp.fr † Sébastien Tanaka and Michael Thy have contributed equally to the work 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 Full list of author information is available at the end of the article 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.