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Published on: April 10, 2019
Children Are Not Small Adults: An Epidemiologic Review of Necrotizing Soft Tissue Infections in Pediatric Patients
Stephanie N Moore-Lotridge1,2, Samuel R Johnson3, Naadir H Jamal3
1Departments of Orthopaedic Surgery.
Insights
Pediatric necrotizing soft tissue infections (NSTI) present differently than adult cases, with children experiencing more extremity infections and lower mortality rates. These findings suggest a need for tailored treatment approaches for pediatric NSTI.
Area of Science:
- Infectious Diseases
- Pediatric Critical Care
- Surgical Infections
Background:
- Necrotizing soft tissue infections (NSTI) are rare, life-threatening infections with limited pediatric research.
- Current NSTI management guidelines primarily rely on adult data.
- This study addresses the knowledge gap by comparing pediatric and adult NSTI cases.
Purpose of the Study:
- To compare and contrast adult and pediatric necrotizing soft tissue infections (NSTI).
- To identify differences in demographics, infection characteristics, and patient outcomes.
- To inform potential modifications in pediatric NSTI management strategies.
Main Methods:
- Retrospective review of 446 patients (27 children, 419 adults) with confirmed NSTI at a single tertiary center.
- Analysis of deidentified electronic medical records for demographics, infection origin, comorbidities, symptoms, and mortality.
- Comparison of clinical presentation, culture results, and treatment outcomes between pediatric and adult cohorts.
Main Results:
- Children had a higher rate of extremity infections (76.9% vs. 34.1%) and culture-negative NSTI (20.0% vs. 4.6%) compared to adults.
- Pediatric patients exhibited significantly lower mortality rates (3.7% vs. 20.3%) and rates of amputation and organ dysfunction.
- Despite similar ICU admission rates and C-reactive protein levels, adult outcomes were more severe.
Conclusions:
- Pediatric NSTI cases exhibit distinct characteristics and patient outcomes compared to adults.
- The findings question the universal applicability of aggressive adult-based operative management for pediatric NSTI.
- Further research is needed to differentiate pediatric NSTI and optimize treatment, alongside enhanced education for adult care providers.
Background:
Necrotizing soft tissue infections (NSTI) are rare but potentially life-threatening infections that can occur in both pediatric and adult patients. To date, few studies have examined NSTI in pediatric populations. Thus, the majority of guidelines for diagnosis and managing NSTI are based on adult data. The goal of this study was to utilize a large retrospective database to compare and contrast adult and pediatric cases of NSTI from a single center.
Methods:
A retrospective review from a single tertiary center identified 446 patients with confirmed NSTI, 27 children (below 18 years of age) and 419 adults. Records were verified for the presence of disease based on retrospective review of a deidentified EMR (notes, reports, etc.). Demographics including age, sex, infection origin, comorbidities, patient presenting symptoms, and mortality rate were compared.
Results:
Between children and adults with confirmed NF, similar rates of sex and ethnic distribution were observed. Upon admission, pain, erythema, and swelling were present at similar rates between cohorts. The origin and mechanism of infection were markedly different between cohorts with children experiencing extremity infections at double the rate of adults (76.9% vs. 34.1%). In patients with available culture data, tissue culture results were significantly different between cohorts with children developing culture-negative NSTI at more than 5× the rate of adults (20.0% vs. 4.6%). Finally, children had significantly lower mortality rates than adults (3.7% vs. 20.3%). Given this variability, a focused analysis of extremity cases of NSTI was conducted. Similar rates of ICU admission and peak C-reactive protein levels were identified, but adults experienced a significantly greater rate of amputation (5.5% vs. 27.8%) and organ dysfunction (38.9% vs. 76.7%) compared with children. As such, adults still maintained a significantly higher mortality rate compared with children (5.5% vs. 27.8).
Conclusion:
Cases of pediatric NSTI differ from those of adults, including variable patient outcomes. These unique features raise the question of whether equally aggressive operative management of NSTI, traditionally applied in adults, is necessary for pediatric cases. As such, future studies differentiating NSTI from other severe forms of infection, efforts to optimize treatment, and continued education for adult community providers remain warranted to support physicians treating pediatric cases of NSTI.
Level Of Evidence:
Level III.
