Dear Editor,

Necrotizing soft tissue infections (NSTIs) are rare and life-threatening bacterial infections characterized by subcutaneous tissue, fascia, or muscle necrosis. The mortality of NSTIs is high, ranging from 20 % in non-selected patients to up to 50 % in the most severe forms requiring intensive care unit (ICU) admission [1, 2]. Early recognition of NSTI is crucial; however, its management is challenging and requires a coordinated and multidisciplinary approach. Treatment of NSTIs consists of early broad-spectrum antimicrobial therapy together with emergency and aggressive surgical debridement with excision of all necrotic and infected tissues [3]. We aimed to assess the burden of NSTIs and the organization of their early management in ICUs worldwide.

An online self-administered questionnaire was made available on the website of the European Society for Intensive Care Medicine (ESICM, http://www.esicm.org/research/survey-of-the-month/completed), after approval from members of the Research Committee and endorsement by the Infection Section of the ESICM. The questionnaire (see the online supplement) comprised 31 questions pertaining to the following domains related to the management of NSTIs: characteristics of institutions taking care of patients with NSTIs, organization of care, diagnosis, and therapeutic aspects. There were 135 respondents representing 100 ICUs in 23 countries, predominantly in Europe (15 countries, 85 ICUs). Forty-three percent of the respondents declared having managed two or less NSTIs in the previous year and 57 % three or more. Most of the institutions which participated in the survey were equipped with facilities allowing for the management of patients with NSTIs (i.e., imaging facilities, surgeon, and consultant dermatologist available) (Table 1). The ICUs where three or more patients were declared to be managed each year tended to be more frequently located in institutions hosting hyperbaric oxygen therapy units and were more likely to have an on-site expert consultant for the surgical management of NSTIs. In terms of organization of care, more than one-third of respondents reported that the availability of the operating room was a limiting step for prompt surgical management. Yet, the factor which was deemed to have the highest impact on the time to first surgical debridement was a delay in NSTI diagnosis, with no significant difference between institutions reporting to manage at most two vs three or more patients with NSTIs per year. In all, respondents from 40 % of the ICUs declared that they had already referred patients to another center, mostly for hyperbaric oxygen therapy (34 %). Regarding therapeutic aspects, there were no striking differences between ICUs managing at most two vs three or more patients with NSTIs per year, with 90 % of respondents who reported using clindamycin and 25 % intravenous immunoglobulins (IVIGs) when a group A streptococcal (GAS) infection was suspected. Although strong evidence is still lacking on these aspects, observational studies suggest that clindamycin could reduce mortality in patients with invasive GAS infection, and that further reduction in mortality could be obtained when IVIGs are added [4]. Of note, although recommended by recent guidelines [3], less than half of the respondents declared performing a “second look” surgery after the first debridement. In contrast, two-thirds of the respondents considered hyperbaric oxygen therapy to be potentially useful while recent guidelines clearly position against its use [3]. A systematic review on interventions in NSTIs is on the way and will evaluate the evidence for medical and surgical aspects of NSTI management [5].

Table 1 Characteristics of 100 ICUs managing patients with necrotizing soft tissue infections
Full size table

In conclusion, our survey depicts the management of patients having NSTIs in 100 ICUs and highlights significant heterogeneity in terms of organization of care, treatment strategies, and adherence to the most recent guidelines. Importantly, two major and modifiable prognostic factors, i.e., delayed diagnosis of NSTI and lack of priority access to the operating room, appear responsible for increasing the time to first surgical debridement. Continued medical education programs and optimized organization of care are warranted to improve the management pathways of patients admitted to the ICU for NSTIs.