探讨坏死性软组织感染(NSTI)病例的临床特征，及对其采取综合序贯诊疗策略后的临床治疗效果。

回顾性分析解放军总医院第四医学中心烧伤整形医学部烧伤科三病区2016年1月至2021年5月采用综合序贯诊疗策略[包括早期及时诊断、全身治疗、尽快清创、反复清创结合持续负压创面治疗联合灌洗(NPWTi)、序贯性封闭创面]治疗的NSTI患者病例资料。收集并分析患者的临床特征，包括一般资料(性别、年龄、糖尿病史、病因、创面部位等)、创面感染病原菌和NSTI分型；统计患者的治疗资料，包括患者出院时创面愈合情况(治愈、好转、未愈)，截肢/趾情况，结肠造瘘情况，治愈患者的手术次数、NPWTi治疗时间、住院时间。

本研究共纳入分析NSTI患者45例，其中男34例，女11例；年龄1.0～82.0岁，平均年龄(52.4±16.2)岁；23例(51.11%)患者既往有2型糖尿病病史；按照病因分类，其中疖、带状疱疹等导致的皮肤感染13例，压力性损伤8例，外伤7例，糖尿病足4例，蚊虫叮咬伤4例，针灸后感染2例，药物注射后感染1例，术后感染1例，肠道吻合口瘘1例，肛周脓肿1例，病因不明3例；按照创面始发部位分类，其中四肢21例，躯干部13例，会阴部6例，颈部5例。45例患者中，34例患者创面病原菌培养阳性，共培养菌株58株，其中金黄色葡萄球菌和粪肠球菌各8株，大肠杆菌和鲍曼不动杆菌各7株，铜绿假单胞菌和肺炎克雷伯杆菌各4株，白色念珠菌1株，其他细菌共19株。NSTI 1型患者23例(67.65%)，2型患者10例(29.41%)，4型患者1例(2.94%)。NSTI 2型患者中，6例为金黄色葡萄球菌感染，4例为A群溶血性链球菌感染，包括2例化脓性链球菌感染和2例星座链球菌感染。1例4型患者感染真菌为白色念珠菌。45例患者中，37例患者治愈，5例患者经综合序贯治疗后病情好转提前离院，3例患者院内死亡(其中1例为转入ICU后死亡)，院内病死率6.67%。2例患者行小腿中下段截肢治疗，1例患者行截趾治疗。5例患者行结肠造瘘手术。治愈患者平均手术次数为(4.2±2.0)次；平均NPWTi治疗时间为(45.5±31.7) d；平均住院时间为(63.6±39.5) d。

本研究中，NSTI患者以中老年群体为主，且男性患者多于女性患者，糖尿病可能是NSTI发生的危险因素，常见发病部位依次是四肢、躯干、会阴部和颈部，最常见的病原菌主要包括金黄色葡萄球菌、粪肠球菌、大肠杆菌、鲍曼不动杆菌、铜绿假单胞菌、肺炎克雷伯杆菌等，创面病原菌阳性NSTI患者以1型和2型为主，应用综合序贯诊疗策略，能够对NSTI治疗起到较好的临床治疗效果。

To investigate the clinical characteristics of necrotizing soft tissue infection (NSTI) and the clinical therapeutic effect of comprehensive sequential diagnosis and treatment strategy.

The clinical medical records of NSTI patients treated with comprehensive sequential diagnosis and treatment strategies in the Third Ward of Senior Department of Burns and Plastic Surgery, Fourth Medical Center of PLA General Hospital from January 2016 to May 2021 were retrospectively analyzed. The comprehensive sequential diagnosis and treatment strategies included prompt diagnosis, systemic therapy, early and repeated debridement combined with negative pressure wound therapy with instillation( NPWTi) and sequential wound closing. The clinical characteristics including general data (gender, age, history of diabetes, etiology, wound site, etc.), pathogenic bacteria of wound infection and type of NSTI were collected. The treatment data of patients including the wound healing situation (cured, improved or unhealed), amputation situation, colostomy or not, and the number of operations, the NPWTi treatment time and the hospitalization time of cured patients were counted.

Totally 45 patients were included, with 34 males and 11 females, aged 1.0- 82.0 years with an average age of (52.4 ± 16.2) years; 23 patients (51.11%) had a history of type 2 diabetes. According to the etiological classification, there were 13 cases of skin infection caused by furuncle and herpes zoster, 8 cases of pressure injury, 7 cases of trauma, 4 cases of diabetic foot, 4 cases of insect bite, 2 cases of infection after acupuncture, 1 case of infection after drug injection, 1 case of postoperative infection, 1 case of intestinal anastomotic fistula, 1 case of perianal abscess, and 3 cases of unknown etiology. According to the initial site of the wound, there were 21 cases of limbs, 13 cases of trunk, 6 cases of perineum and 5 cases of neck. Thirty-four patients had positive wound pathogen culture in 45 patients, in which 58 bacterial strain were cultivated, including 8 strains of Staphylococcus aureus, 8 strains of Enterococcus faecalis, 7 strains of Escherichia coli, 7 strains of Acinetobacter baumannii, 4 strains of Pseudomonas aeruginosa, 4 strains of Klebsiella pneumoniae, 1 strain of Candida albicans, and 19 strains of other bacteria. There were 23 cases (67.65%) of type-1 NSTI patients, 10 cases (29.41%) of type-2 NSTI in which 6 cases were Staphylococcus aureus infections and 4 cases were group A hemolytic streptococcal infections including 2 cases of Streptococcus pyogenes infection and 2 cases of Streptococcus constellations infection, and 1 case (2.94%) of type-4 NSTI which is Candida albicans infection. Among the 45 patients, 37 patients were cured, 5 patients left the hospital in advance after comprehensive sequential treatment, and 3 patients died (one of them died after being transferred to ICU), the hospital mortality was 6.67%. Two patients received amputation of the middle and lower leg, and 1 patient received toe amputation. Five patients received colostomy. The average operation times of cured patients was (4.2±2.0) times, the average NPWTi treatment time was (45.5 ± 31.7) d, and the average length of stay in hospital was (63.6 ± 39.5) d.

In this study, NSTI patients were mainly middle-aged and elderly people, and more men than women. Diabetes may be a risk factor for NSTI. The original wound sites were extremity, trunk, perinaeum and neck in turn. The most common pathogens mainly included Staphylococcus aureus, Enterococcus faecalis, Escherichia coli, Acinetobacter baumannii, Pseudomonas aeruginosa, Klebsiella pneumoniae, etc. NSTI patients with positive wound pathogens were mainly type 1 and type 2. The application of comprehensive sequential diagnosis and treatment strategy can play a good clinical effect on the treatment of NSTI.