Mechanisms and management of necrotizing soft tissue shock

Necrotizing Soft Tissue Infection (NSTI)  is a rapidly progressive infection of – in most cases – the deep fascial layer, in a sequence of inflammation, thrombosis and necrosis, thus spreading through the soft tissue surrounding the fascia. The most frequent identified pathogen is Streptococcus pyogenes, bud mixed infections have been reported. Often, parallel to the local manifestations, the patient presents with signs of shock and urgent intensive care is needed.

It seems that the incidence of NSTI is increasing. A cause for this evolution is not yet found. A higher degree of suspicion and quicker referral to specialized centers could constitute a simple explanation. Another possibility could be that the pathogen or pathogens has become more aggressive over the past years or maybe, that man – or part of the population – has become more sensitive to a profuse progress of the infection.

Key stone to the treatment of NSTI is the recognition of the first symptoms. Our experience seems to indicate the importance of toxic shock as a key stone to the diagnosis. Next to the rapid spread of the local infection, the hemodynamic and respiratory parameters will constitute an important part of our decision tree. By performing a review of the literature, the pathologic processes, that explain the local infection spread and the generalized shock, will be identified. This will enable to identify relevant parameters with which the files of all the patients that were admitted with at least a suspicion of NSTI can be analyzed. Parallel to this, a prospective study can be performed in order to identify genetic vulnerability and possible causal factors.

In conclusion, this study should demonstrate the involvement of multiple organ systems and that the generalized inflammation and shock are essential constituents of  the disease, justifying a change of the name “Necrotizing Soft Tissue Infection” to Necrotizing Soft Tissue Shock”.