Histologically confirmed necrotizing fasciitis: risk factors, microbiology, and mortality in Hawaii
2012; Elsevier BV; Volume: 16; Issue: 12 Linguagem: Inglês
10.1016/j.ijid.2012.05.1021
ISSN1878-3511
AutoresNuntra Suwantarat, Dominic C. Chow, Wega Koss, Dagmar Lin, Alan D. Tice,
Tópico(s)Antimicrobial Resistance in Staphylococcus
ResumoTsai et al.1Tsai Y.H. Huang K.C. Shen S.H. Hsu W.H. Peng K.T. Huang T.J. Microbiology and surgical indicators of necrotizing fasciitis in a tertiary hospital of southwest Taiwan.Int J Infect Dis. 2012; 16: e159-e165Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar recently reported a retrospective study of 143 patients with surgically confirmed necrotizing fasciitis (NF) in southwest Taiwan. Although the authors concluded that hypotensive shock, hypoalbuminemia, and increased banded leukocytes were predictors of mortality, these risk factors necessitate immediate surgical intervention. These indicators may reflect the high severity of disease in these NF patients. Once NF is suspected, prompt surgical intervention should be performed. We conducted a retrospective study at a major tertiary care hospital in Hawaii between 1998 and 2005 to specifically examine the risk factors and microbiology associated with mortality in histologically confirmed NF. One hundred and twenty NF cases were identified by ICD-9 code (rate of 75 cases/100 000 hospital admissions). Among 58 cases confirmed by histopathology, the median age was 58 years; 69% were male and 36% Hawaiian/Pacific Islanders. Demographic information, bacteriology, co-morbidities, ethnicity, intensive care unit (ICU) admission, and APACHE II scores were determined, along with the time from admission to surgery and the length of hospital stay. These factors were compared between those who survived and those who died (Table 1). An APACHE II score >17 was a significant independent predictor of mortality. The majority of NF wound infections in our study were polymicrobial (58.6%), which is different to the study of Tsai et al. and others.1Tsai Y.H. Huang K.C. Shen S.H. Hsu W.H. Peng K.T. Huang T.J. Microbiology and surgical indicators of necrotizing fasciitis in a tertiary hospital of southwest Taiwan.Int J Infect Dis. 2012; 16: e159-e165Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 2Bair M. Chi H. Wang W. Hsiao Y. Chiang R. Chang K. et al.Necrotizing fasciitis in southeast Taiwan: clinical features, microbiology, and prognosis.Int J Infect Dis. 2009; 13: 255-260Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar, 3Oncul O. Erenoglu C. Top C. Küçükardali Y. Karabudak O. Kurt Y. et al.Necrotizing fasciitis: a life-threatening clinical disorder in uncontrolled type 2 diabetic patients.Diabetes Res Clin Pract. 2008; 8: 218-223Abstract Full Text Full Text PDF Scopus (20) Google ScholarTable 1Comparison of characteristics and mortality of necrotizing fasciitis survivors versus non-survivorsCharacteristicsDied (n = 13)Survived (n = 45)p-ValueMale gender, n (%)10 (76.9%)30 (66.7%)0.48Age, years, median (IQR)64 (10.5)55 (19.0)0.02Age >60 years, n (%)9 (69.2%)15 (33.3%)0.02Weight, kg, median (IQR)100 (34.1)84 (30.8)0.61Height, cm, median (IQR)168 (4.5)170 (15.2)0.53Body mass index, kg/m2, median (IQR)32.8 (12.6)30.5 (8.5)0.39Ethnicity, n (%) Hawaiian and Pacific Islander (Micronesia, Tonga, Samoa)3 (23.1%)14 (31.1%)0.40 Caucasian3 (23.1%)13 (28.9%)0.57 Asian6 (46.2%)15 (33.3%)0.68 Other (African-American, Hispanic)1 (7.6%)3 (6.7%)0.89ICU admission, n (%)13 (100%)28 (55.6%)<0.01 Medical ICU9 (69.2%)8 (17.8%)<0.01 Surgical ICU4 (30.8%)20 (44.4%)0.55Amputation, n (%)2 (15.4%)5 (11.1%)0.68APACHE II scores, median (IQR)23.5 (10)13 (9)0.01Time from admission to surgery, days, median (IQR)1 (3)2 (1)0.73Length of hospitalization, days, median (IQR)5 (8.5)55 (40.0)<0.01Pathogen, positive culture, n (%)Bacteremia, n (%)6 (46.2%)15 (33.3%)0.41 Polymicrobial1 (7.7%)3 (6.7%)0.90 Group A Streptococcus6 (46.2%)7 (15.6%)0.02 MRSA0 (0%)1 (2.2%)0.59 MSSA1 (7.7%)2 (4.4%)0.59 Gram-negative bacteria0 (0%)5 (11.1%)0.23 Anaerobes03 (6.7%)0.33Positive wound culture, n (%)11 (84.7%)42 (93.3%)0.32 Polymicrobial7 (53.8%)27 (60.0%)0.69 Group A Streptococcus7 (53.8%)18 (40.0%)0.38 MRSA1 (7.7%)11 (24.4%)0.19 MSSA2 (15.4%)13 (28.9%)0.33 Gram-negative bacteria6 (46.2%)17 (37.8%)0.59 Anaerobes2 (15.4%)5 (11.1%)0.68Risk factors, n (%) Diabetes mellitus5 (38.5%)13 (28.9%)0.51 Peripheral vascular disease3 (23.1%)6 (13.3%)0.39 Cancer2 (15.4%)5 (11.1%)0.68 Congestive heart failure5 (38.5%)7 (15.6%)0.07 NSAIDs3 (23.1%)10 (22.2%)0.95 Injection drug user1 (7.7%)3 (6.7%)0.89 History of immunosuppressant use 17. Overall, the mortality of patients with NF was related to patients with severe clinical diseases. Rapid detection and regional differences in pathogens can provide additional insight into severity and mortality risks. The prompt institution of broad-spectrum antibiotics, surgical intervention, and intensive support are essential for the effective management of NF patients. The authors greatly appreciate Queen's Medical Center Research Planning and Development for funding support, Sonia Howman, MD, Critical Care Medicine, for research initiation, and Kirk Hirata, MD, Pathologist, University of Hawaii for his review of the final pathology reports. D.C. was supported in part by grants through the National Institutes of Health, Department of Health and Human Services, USA, K23 HL088981, NCRRR25 RR019321, U54RR026136 and U54MD007584. Conflict of interest: Alan Tice has served as a consultant, speaker, or investigator for Astellas, Cubist, Merck, Novartis, and Pfizer. He has no conflict of interest with this study.
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