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The Role of Computed Tomography in the Diagnosis of Necrotizing Soft Tissue Infections
*Myriam M Martinez Aguilar, *Thomas Peponis, *Aglaia Hage, *Daniel D Yeh, Haytham M Kaafarani, *Kathryn Butler, *Peter Fagenholz, *David R King, *Marc A DeMoya, George Velmahos
Massachusetts General Hospital, Boston, MA

Objective: To explore the value of IV contrast-enhanced computed tomography (CT) for the diagnosis of necrotizing soft tissue infections (NSTI).
Design: Retrospective cohort study.
Setting: Academic tertiary medical center.
Patients: Admissions between 2009 and 2015 who received a CT to rule out NSTI. CT was considered positive for NSTI if: a) gas was identified in the soft tissues, b) multiple fluid collections were found (as opposed to a single collection, which was more consistent with pyomyositis), c) tissues were not enhanced by IV contrast, indicating necrosis, d) significant inflammatory changes were noted under the fascia. NSTI was defined positive by the presence of necrotic soft tissue during surgical exploration. NSTI was considered absent if surgical exploration failed to identify necrosis or if the patient was successfully treated without surgical exploration.
Main Outcome Measures: The outcome measure was Sensitivity and specificity of CT for diagnosing NSTI.
Results: Of the 195 patients, 14 had a positive CT result and thereby underwent surgical exploration with NSTI confirmed in 10 (71%) patients. Of the 181 patients that had a negative CT result, 36 (20%) underwent surgical exploration owing to high clinical suspicion for NSTI and all were found to have non-necrotizing infections, while the remaining 145(80%) were managed non-operatively with successful resolution of their symptoms. The sensitivity of CT to identify NSTI was 100%, the specificity was 96%, the positive predictive value was 57%, and the negative predictive value was 100%.
Conclusions: IV contrast-enhanced CT can reliably rule out NSTI. In the presence of a negative CT, the patient can safely be managed non-operatively under the assumption that there are no necrotizing elements in the infected soft tissues.


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