Pediatric NSTI: Rare Complication from IV Catheter Insertion

Imagine a routine medical procedure, something as commonplace as inserting a simple IV line in a child's arm, suddenly spiraling into a life-threatening crisis. This is the shocking reality we uncover in a groundbreaking case study of pediatric necrotizing soft tissue infection—a rare and devastating complication that could stem from everyday hospital practices. But here's where it gets controversial: Could the way we handle these basic interventions be putting kids at unnecessary risk? And this is the part most people miss: Early detection might hinge on subtle clues that even seasoned doctors overlook. Let's dive into this eye-opening report, breaking it down step by step to ensure everyone, from medical novices to experts, can follow along and understand the stakes.

Discovering a Hidden Danger: Pediatric Necrotizing Soft Tissue Infection as a Rare Outcome of Standard Peripheral Venous Catheter Placement

Case Study

Freely Accessible (via https://www.springernature.com/gp/open-science/about/the-fundamentals-of-open-access-and-open-research)

Released: October 22, 2025

Contributors: Shih-Hsuan Mao¹, Chun-Yee Ho², Chun-Wei Li², Chih-Hao Chen¹²

BMC Pediatrics (found at https://bmcpediatr.biomedcentral.com/) volume 25, Article 847 (2025). Reference this piece as: Mao SH, Ho CY, Li CW, Chen CH. Pediatric necrotizing soft tissue infection: unveiling a rare complication of routine procedures - peripheral venous catheter insertion. BMC Pediatr. 2025;25:847.

Synopsis

Necrotizing soft tissue infection, or NSTI for short, is an uncommon but extraordinarily dangerous condition that attacks the body's soft tissues, often progressing at a frightening speed. In kids, it's especially alarming, with a prevalence of roughly 1.12 cases per 10,000 hospital stays [1]. Mortality rates hover between 6% and 18% overall, but for newborns, that figure jumps to about two-thirds [2, 3]. Survivors might need reconstructive surgery in 20-30% of cases due to tissue loss or amputation, and long-term effects like prominent scars, deformities, or limited joint movement affect up to 91% of them [4, 5]. For beginners, think of NSTI as a 'flesh-eating' infection where bacteria rapidly destroy skin, fat, and muscle layers, turning a minor wound into a medical emergency that demands swift action.

We're sharing the very first recorded instance of a healthy toddler—a 1-year-and-7-month-old boy—developing MRSA-induced NSTI after a peripheral venous catheter (PVC) insertion. This child showed initial signs of redness and swelling at the IV site, prompting a contrast-enhanced CT scan that revealed widespread inflammation along the fascia, a clear marker of NSTI. Immediate treatment kicked in, including powerful antibiotics like vancomycin, meropenem, and clindamycin, paired with careful, tissue-preserving surgery. The boy made a full recovery after 11 days, leaving only faint scars and full arm mobility three months later. This example shines a light on the critical need to differentiate between harmless PVC-related issues and serious infections in children, while tackling ongoing debates about catheter upkeep, skin prep methods, and constant oversight. Crucially, it demonstrates how quick imaging can guide precise diagnosis and treatment plans. The tissue-sparing surgical approach we used marks a shift from old-school aggressive removals, focusing instead on saving healthy tissues while battling the infection. We also stress the value of vigilant checks, balanced nurse staffing, and tailored pediatric guidelines to catch problems early and cut down on harm. Plus, input from infectious disease specialists helped fine-tune antibiotic use, balancing strong initial coverage with smart stewardship to avoid overuse.

Background

Necrotizing soft tissue infection stands out as a rare but intense soft tissue ailment, known for its swift and aggressive spread that can lead to severe health declines or death. Among children, its rarity doesn't diminish its threat, with stats showing significant impacts on survival and quality of life. Peripheral venous catheters, or PVCs, are standard tools for delivering fluids, meds, or nutrients directly into the bloodstream, used in the vast majority of hospitalized folks [8]. While most complications are mild—think irritation, bruising, or minor leaks—infections make up just 0.4% of issues, and severe ones like deep skin infections or clot-based problems are even rarer [6, 7]. To our knowledge, NSTI tied specifically to PVC insertion in a child has never been documented before.

This report fills that knowledge gap by detailing the inaugural case of pediatric NSTI linked to PVC use. It calls attention to the urgency of spotting early signs in kids, who might not communicate well and show subtler symptoms, complicating monitoring. By exploring this, we aim to boost awareness and push for better practices, such as specialized protocols for children.

In our narrative, a young boy without any usual risk factors—like injuries or immune issues—ended up with MRSA-driven NSTI post-PVC. Thanks to rapid and robust care, involving surgery and tailored antibiotics, he healed without issues. This marks the first known pediatric NSTI from a simple catheter in a healthy child, underscoring how even basic procedures can lead to grave outcomes. It also prompts a closer look at hospital routines, from catheter checks to staffing levels.

Patient Account

Our patient was a robust 1-year-and-7-month-old boy, free of chronic illnesses and up-to-date on all vaccinations. He arrived at the hospital with intermittent fevers lasting two days. At first, doctors suspected a common throat infection or viral illness, ruling out tests for strep or flu. Bloodwork showed slight increases in monocytes and platelets, with normal white blood cells, CRP, and electrolytes despite his stable condition and poor appetite. To combat potential dehydration, we started IV fluids, and as a precaution for possible hidden bacterial issues, added broad antibiotics. No harsh chemicals were given through the line, and viral causes were still under consideration as we monitored.

By day three in the hospital, redness and puffiness emerged around the PVC site on his left hand. Mistaking it for a common leak or vein irritation, we removed the catheter right away and switched to oxacillin, following our hospital's guidelines for MSSA, the typical bug in such cases. But within 12 hours, the symptoms exploded, spreading up the left arm (as seen in Fig. 1). This triggered an urgent CT scan, which spotted diffuse tissue changes confirming NSTI. The boy hit pediatric sepsis markers with a racing heart (160 bpm), high fever (up to 39.5°C), and mild low blood pressure. Kidneys and liver stayed fine, no acid buildup or heart issues. Labs showed elevated CK at 280 U/L and AST at 64 U/L, hinting at muscle stress, plus a corrected calcium of 8.2 mg/dL with no signs of imbalance. CRP climbed to 152 mg/L by day 4, dropping later, while PCT hit 12.3 ng/mL on day 5, pointing to a bad bacterial infection.

Guided by the CT, we performed emergency surgery with minimal 'skipped' cuts to spare tissue (Fig. 2), removing dead fascia and fluid, which grew MRSA. Post-op, he went to the PICU, and further debridement followed. Antibiotics ran: vancomycin for 14 days, meropenem for 7, and clindamycin for 5, adjusted by ID experts. He was discharged after 25 days, with light scarring and perfect arm function at three months (Fig. 3).

Pre-op Image of the Left Arm Showing Rapid Redness and Swelling from the PVC Spot

Surgical View with Gentle, Spaced-Out Incisions for Tissue-Sparing Removal

Three-Month Check-Up Image Revealing Minimal Scars and Restored Arm Movement

Ethics Statement: This study got approval from Chang Gung Memorial Hospital's Ethics Committee, following Helsinki guidelines. Parents gave written consent for the report and images.

Analysis

Putting in a peripheral venous catheter is a go-to procedure for over 80% of inpatients [8], but it's not risk-free. Problems like clots, blockages, leaks, spills, irritation, or bugs can complicate care [9]. In pediatrics, troubles occur in about a quarter of cases, but they're usually not severe [10].

Though most PVC issues are minor, our case warns about recognizing big ones, like extravasation—when fluids escape into nearby tissues. It's rare but urgent, needing quick catheter pull and treatment to avoid worse harm. Our initial hunch of extravasation led to fast action, showing how vital early spotting is.

Extravasation shows as swelling and redness at the site. In kids, telling apart early leaks from brewing infections is tough due to their limited ability to express pain and vague signs. This screams for extra watchfulness. At our hospital, PVC care includes daily site checks, shift-by-shift notes on condition, and swaps every 72-96 hours. Nurses use a checklist for signs of irritation, leaks, or infections, logging details like insertion time, needle size, and prep method.

PVC complications range from leaks and irritation to skin infections or clot issues, up all the way to NSTI, as here. Each needs a different fix, and mix-ups can delay help. Without typical NSTI triggers like wounds or burns, this case shows how routine procedures can hide dangers, even in low-risk kids. It pushes for including NSTI in quick-progressing redness near IV sites, no matter the setup.

But here's where it gets controversial: Routine vs. As-Needed PVC Changes

Standard practice often means swapping PVCs regularly to dodge irritation or infections. A 2022 review by Chen backs changes every 72-96 hours to lower risks like phlebitis or blockages [11]. Yet, a 2021 trial by Lin found that in kids, changing only when needed (clinically indicated) extends catheter life without boosting complications [12]. This matches CDC advice [13], and in our case, the issue popped on day 3, fitting our symptom-based approach. Some might argue routine swaps are safer, preventing buildup, while others say they're wasteful and stressful for children. What do you think—should we stick to schedules or go by signs? Share your views in the comments!

Skin prep before insertion is key. We use iodine-alcohol, per CDC, but chlorhexidine with alcohol might cut bugs better [14]. For kids, especially newborns, a study showed chlorhexidine in isopropyl alcohol tops povidone-iodine for germ reduction without skin damage [15]. Pediatric skin needs custom care, not just adult recipes.

Our case hints that late extravasation catching might have fueled the NSTI [16], perhaps from spotty monitoring. Staffing plays a role too; our night ratios of 1:13 to 1:20 might delay notices. Research links better ratios (like 1:6) to fewer errors [17]. We urge optimal staffing in pediatric units with high-risk tools like PVCs.

These challenges call for better routines: evidence-based swaps, top skin preps, and good ratios. But is pushing for 'perfect' staffing realistic in busy hospitals? This is the part most people miss: Balancing resources with safety could spark big debates—could technology, like AI monitoring, fill gaps?

Evolving Surgical Tactics

Old NSTI care meant wide skin cuts to match infection spread [18]. Wong's method added steps: confirm diagnosis, find bugs, map fascia, excise to healthy tissue [19]. Now, we use gentler methods, cutting only dead skin, along natural lines, extending to confirmed healthy areas via frozen checks. Add-ons like wound vacs or oxygen therapy help. Re-checks in 24 hours handle leftovers.

Compared to old aggressive cuts, this saves tissue, cuts hospital time, speeds recovery—huge for kids. It's cost-effective too, reducing fixes. But it needs prompt surgery, good imaging, and skilled judgment, not always available everywhere.

'Adequate' debridement is subjective—remove all dead bits, surgeon's call. 'Aggressive' lacks definition; re-visits ensure no misses [20].

At our place, we used to cut broadly but now focus on infected/non-viable tissues to stop spread and toxin release [21]. Imaging like ultrasounds or MRIs confirm depth, but surgery with frozen analysis is gold. Our tissue-sparing shift aims for control with less loss, key for pediatrics. 'Aggressive' needs clearer guidelines; more studies on preservation vs. control could refine this. Pediatric rules for NSTI could improve results, with surgeons and plastics teaming up.

Antibiotic Approaches

Options include single drugs like meropenem or combos like triple therapy. Add vancomycin or similar for MRSA until ruled out. Clindamycin blocks toxins, vital for certain bugs [22]. But overuse risks resistance or side effects. ID consults guide de-escalation, using local data—like our high MRSA rates justifying vancomycin, low CRE/ESBL. Treat until no more surgery, patient stable—avoid long runs to prevent resistant bugs.

Source control via debridement is core; antibiotics support, broad at first (cover MRSA, gram-negatives, anaerobes), tailored by cultures [23]. Consider tigecycline for resistant cases [24]. IDSA guidelines detail this [23].

Wrap-Up

Pediatric NSTI: Rare Complication from IV Catheter Insertion - Case Study Explained (2025)