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      2018 WSES/SIS-E consensus conference: recommendations for the management of skin and soft-tissue infections

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      World Journal of Emergency Surgery : WJES
      BioMed Central
      Soft-tissue infections, Necrotizing infection, Surgical site infection

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          Abstract

          Skin and soft-tissue infections (SSTIs) encompass a variety of pathological conditions that involve the skin and underlying subcutaneous tissue, fascia, or muscle, ranging from simple superficial infections to severe necrotizing infections. SSTIs are a frequent clinical problem in surgical departments. In order to clarify key issues in the management of SSTIs, a task force of experts met in Bertinoro, Italy, on June 28, 2018, for a specialist multidisciplinary consensus conference under the auspices of the World Society of Emergency Surgery (WSES) and the Surgical Infection Society Europe (SIS-E). The multifaceted nature of these infections has led to a collaboration among general and emergency surgeons, intensivists, and infectious disease specialists, who have shared these clinical practice recommendations.

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          Most cited references144

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          Grading strength of recommendations and quality of evidence in clinical guidelines: report from an american college of chest physicians task force.

          While grading the strength of recommendations and the quality of underlying evidence enhances the usefulness of clinical guidelines, the profusion of guideline grading systems undermines the value of the grading exercise. An American College of Chest Physicians (ACCP) task force formulated the criteria for a grading system to be utilized in all ACCP guidelines that included simplicity and transparency, explicitness of methodology, and consistency with current methodological approaches to the grading process. The working group examined currently available systems, and ultimately modified an approach formulated by the international GRADE group. The grading scheme classifies recommendations as strong (grade 1) or weak (grade 2), according to the balance among benefits, risks, burdens, and possibly cost, and the degree of confidence in estimates of benefits, risks, and burdens. The system classifies quality of evidence as high (grade A), moderate (grade B), or low (grade C) according to factors that include the study design, the consistency of the results, and the directness of the evidence. For all future ACCP guidelines, The College has adopted a simple, transparent approach to grading recommendations that is consistent with current developments in the field. The trend toward uniformity of approaches to grading will enhance the usefulness of practice guidelines for clinicians.
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            Necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality.

            Necrotizing fasciitis is a life-threatening soft-tissue infection primarily involving the superficial fascia. The present report describes the clinical presentation and microbiological characteristics of this condition as well as the determinants of mortality associated with this uncommon surgical emergency. The medical records of eighty-nine consecutive patients who had been admitted to our institution for necrotizing fasciitis from January 1997 to August 2002 were reviewed retrospectively. The paucity of cutaneous findings early in the course of the disease makes the diagnosis difficult, and only thirteen of the eighty-nine patients had a diagnosis of necrotizing fasciitis at the time of admission. Preadmission treatment with antibiotics modified the initial clinical picture and often masked the severity of the underlying infection. Polymicrobial synergistic infection was the most common cause (forty-eight patients; 53.9%), with streptococci and enterobacteriaceae being the most common isolates. Group-A streptococcus was the most common cause of monomicrobial necrotizing fasciitis. The most common associated comorbidity was diabetes mellitus (sixty-three patients; 70.8%). Advanced age, two or more associated comorbidities, and a delay in surgery of more than twenty-four hours adversely affected the outcome. Multivariate analysis showed that only a delay in surgery of more than twenty-four hours was correlated with increased mortality (p < 0.05; relative risk = 9.4). Early operative débridement was demonstrated to reduce mortality among patients with this condition. A high index of suspicion is important in view of the paucity of specific cutaneous findings early in the course of the disease.
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              Necrotizing soft-tissue infection: diagnosis and management.

              Necrotizing soft-tissue infections (NSTIs) are highly lethal. They are frequent enough that general and specialty physicians will likely have to be involved with the management of at least 1 patient with NSTI during their practice, but they are infrequent enough that familiarity with the disease will seldom be achieved. Establishing the diagnosis of NSTI can be the main challenge in treating patients with NSTI, and knowledge of all available tools is key for early and accurate diagnosis. The laboratory risk indicator for necrotizing fasciitis score can be helpful for distinguishing between cases of cellulitis, which should respond to medical management alone, and NSTI, which requires operative debridement in addition to antimicrobial therapy. Imaging studies are less helpful. The mainstay of treatment is early and complete surgical debridement, combined with antimicrobial therapy, close monitoring, and physiologic support. Novel therapeutic strategies, including hyperbaric oxygen and intravenous immunoglobulin, have been described, but their effect is controversial. Identification of patients at high risk of mortality is essential for selection of patients that may benefit from future novel treatments and for development and comparison of future trials.
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                Author and article information

                Contributors
                massimosartelli@gmail.com
                xguirao@gmail.com
                Hardcastle@ukzn.ac.za
                y_kluger@rambam.health.gov.il
                m.a.boermeester@amc.uva.nl
                kemrasa@gmail.com
                aiace63@gmail.com
                federico.coccolini@gmail.com
                philippe.montravers@aphp.fr
                fabuzidan@uaeu.ac.ae
                michele.bartoletti4@unibo.it
                matteo.bassetti@asuiud.sanita.fvg.it
                o_ben-ishay@rambam.health.gov.il
                walt@biffl.com
                ochiara@yahoo.com
                massimo.chiarugi@med.unipi.it
                raulcoimbra62@yahoo.com
                francescogiuseppe.derosa@unito.it
                desimone.belinda@gmail.com
                salo75@inwind.it
                maddalena.giannella@unibo.it
                georgiokas@yahoo.com
                vladimirkhokha@gmail.com
                labricciosafrancesco@gmail.com
                ari.leppaniemi@hus.fi
                aalitvin@gmail.com
                ernest.moore@dhha.org
                negoiionut@gmail.com
                lpagani.ID@gmail.com
                maddalena.peghin@gmail.com
                edoardopicetti@hotmail.com
                tadeja.pintar@kclj.si
                aslimnicagp@gmail.com
                i.rubio@aecirujanos.es
                bsakakushev@gmail.com
                hhaassll@gmail.com
                gsganga@sepsi.org
                vgshelat@rediffmail.com
                michaelesugrue@gmail.com
                atarasconi@gmail.com
                trana.cristian@gmail.com
                Jan.Ulrych@vfn.cz
                pierluigi.viale@unibo.it
                faustocatena@gmail.com
                Journal
                World J Emerg Surg
                World J Emerg Surg
                World Journal of Emergency Surgery : WJES
                BioMed Central (London )
                1749-7922
                14 December 2018
                14 December 2018
                2018
                : 13
                : 58
                Affiliations
                [1 ]Department of Surgery, Macerata Hospital, Macerata, Italy
                [2 ]ISNI 0000 0000 9238 6887, GRID grid.428313.f, Unit of Endocrine, Head, and Neck Surgery and Unit of Surgical Infections Support, Department of General Surgery, , Parc Taulí Hospital Universitari, ; Sabadell, Spain
                [3 ]Trauma Service, Inkosi Albert Luthuli Central Hospital and Department of Surgery, Nelson R Mandela School of Clinical Medicine, Durban, South Africa
                [4 ]ISNI 0000 0000 9950 8111, GRID grid.413731.3, Department of General Surgery, Division of Surgery, , Rambam Health Care Campus, ; Haifa, Israel
                [5 ]ISNI 0000000404654431, GRID grid.5650.6, Department of Surgery, , Academic Medical Centre, ; Amsterdam, Netherlands
                [6 ]Department of Surgery, Anadolu Medical Center, Kocaali, Turkey
                [7 ]ISNI 0000 0004 1758 8744, GRID grid.414682.d, General Surgery Department, , Bufalini Hospital, ; Cesena, Italy
                [8 ]ISNI 0000 0000 8588 831X, GRID grid.411119.d, Anesthesiology and Critical Care Medicine, Paris Diderot Sorbonne Cite University, Bichat-Claude Bernard University Hospital, HUPNSV, ; Paris, France
                [9 ]ISNI 0000 0001 2193 6666, GRID grid.43519.3a, Department of Surgery, College of Medicine and Health Sciences, , UAE University, ; Al-Ain, United Arab Emirates
                [10 ]ISNI 0000 0004 1757 1758, GRID grid.6292.f, Infectious Diseases Unit, Department of Medical and Surgical Sciences, , Alma Mater Studiorum University of Bologna, ; Bologna, Italy
                [11 ]ISNI 0000 0001 2113 062X, GRID grid.5390.f, Infectious Diseases Division, Department of Medicine University of Udine and Azienda Sanitaria Universitaria Intergrata di Udine, ; Udine, Italy
                [12 ]Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, CA USA
                [13 ]General Surgery-Trauma Team, State University of Milano, Niguarda Hospital Milano, Milan, Italy
                [14 ]GRID grid.414498.4, Emergency Surgery Unit, State University of Pisa, Cisanello Hospital, ; Pisa, Italy
                [15 ]ISNI 0000 0000 9852 649X, GRID grid.43582.38, Riverside University Health System Medical Center and Loma Linda University School of Medicine, ; Moreno Valley, CA USA
                [16 ]ISNI 0000 0001 2336 6580, GRID grid.7605.4, Department of Medical Sciences, Infectious Diseases, , University of Turin, ; Turin, Italy
                [17 ]Unit of General, Emergency and Trauma Surgery, Regional Hospital of Perpignan, Perpignan, France
                [18 ]ISNI 0000 0004 0383 8386, GRID grid.24029.3d, Department of Surgery, Addenbrooke’s Hospital, , Cambridge University Hospitals NHS Foundation Trust, ; Cambridge, UK
                [19 ]ISNI 0000 0001 2155 0800, GRID grid.5216.0, Second Department of Surgery, Aretaieion University Hospital, National and Kapodistrian University of Athens, ; Athens, Greece
                [20 ]Department of Emergency Surgery, City Hospital, Mozyr, Belarus
                [21 ]Global Alliance for Infections in Surgery, Porto, Portugal
                [22 ]Abdominal Center, University Hospital Meilahti, Helsinki, Finland
                [23 ]ISNI 0000 0001 1018 9204, GRID grid.410686.d, Department of Surgical Disciplines, , Immanuel Kant Baltic Federal University, Regional Clinical Hospital, ; Kaliningrad, Russian Federation
                [24 ]Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, CO USA
                [25 ]Department of Surgery, Emergency Hospital of Bucharest, Bucharest, Romania
                [26 ]Infectious Diseases Unit, Bolzano Central Hospital, Bolzano, Italy
                [27 ]GRID grid.411482.a, Department of Anesthesia and Intensive Care, , Azienda Ospedaliero-Universitaria Parma, ; Parma, Italy
                [28 ]ISNI 0000 0004 0571 7705, GRID grid.29524.38, Department of Surgery, , UMC Ljubljana, ; Ljubljana, Slovenia
                [29 ]ISNI 0000 0004 0375 2558, GRID grid.488518.8, Department of General and Emergency Surgery, , Riga East University Hospital ‘Gailezers’, ; Riga, Latvia
                [30 ]ISNI 0000 0000 8970 9163, GRID grid.81821.32, General Surgery Department, Colorectal Surgery Unit, , La Paz University Hospital, ; Madrid, Spain
                [31 ]ISNI 0000 0001 0726 0380, GRID grid.35371.33, General Surgery Department, , Medical University, University Hospital St George, ; Plovdiv, Bulgaria
                [32 ]ISNI 0000 0001 2289 5077, GRID grid.412213.7, Second Department of Surgery, Hospital de Clínicas, , Universidad Nacional de Asuncion, ; San Lorenzo, Paraguay
                [33 ]ISNI 0000 0001 0941 3192, GRID grid.8142.f, Emergency Surgery (or Division of Emergency Surgery), , Fondazione Policlinico Universitario A. Gemelli IRCCS – Università Cattolica del Sacro Cuore, ; Rome, Italy
                [34 ]GRID grid.240988.f, General Surgery, , Tan Tock Seng Hospital, ; Singapore, Singapore
                [35 ]ISNI 0000 0004 0617 6488, GRID grid.415900.9, Department of Surgery, , Letterkenny University Hospital and Donegal Clinical Research Academy, ; Letterkenny, Ireland
                [36 ]Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
                [37 ]ISNI 0000 0000 9100 9940, GRID grid.411798.2, First Department of Surgery, Department of Abdominal, Thoracic Surgery and Traumatology, First Faculty of Medicine, , Charles University and General University Hospital, ; Prague, Czech Republic
                Article
                219
                10.1186/s13017-018-0219-9
                6295010
                30564282
                a977e52e-a131-4971-b1af-b710be5dd478
                © The Author(s). 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 18 October 2018
                : 22 November 2018
                Categories
                Review
                Custom metadata
                © The Author(s) 2018

                Surgery
                soft-tissue infections,necrotizing infection,surgical site infection
                Surgery
                soft-tissue infections, necrotizing infection, surgical site infection

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