Necrotizing Soft Tissue Infection: Predicting Mortality and Limb Loss
While historical rates of mortality have approached 50%, a new study of necrotizing soft tissue infections at a single Level I trauma center between 2013 and 2018 found an overall mortality of 14%. The prospective analysis also identified several distinct patient and disease characteristics associated with mortality and limb loss.
“With earlier recognition, rapid debridement and good critical care, we’ve definitely made improvements in mortality over time,” said Dara Horn, MD, a general surgery resident at the University of Washington Medical Center, in Seattle. “For patients who do survive, however, there is still a high risk of amputation and discharge to a skilled nursing facility.”
For this prospective study, researchers analyzed demographic variables, disease characteristics and microbiology, and outcomes of 430 infections identified at a single institution. As Dr. Horn reported, risk factors for mortality included older age, a high white blood cell count, high creatinine levels and involvement of Clostridioides, while limb loss was associated with old age, male sex, a history of diabetes and chronic wounds. Conversely, patients with Fournier’s gangrene, a necrotizing soft tissue infection of the perineum, had significantly better outcomes.
“I think this literature could be informative in helping guide goals of care discussion with patients and families,” Dr. Horn said. “Patients can use this information to make truly informed decisions about how they want to proceed with what is often a prolonged hospital course with many debridements, wound care and lots of pain.”
According to Dr. Horn, the most interesting finding was that patients who were transferred from an outside facility (89%) had seven times greater odds of requiring an amputation.
“Only 40% of patients transferred to our facility had debridement prior to being transferred, which may be contributing to increased odds of amputation,” Dr. Horn said. “That delay between initial presentation at another facility and receipt of adequate source control may be associated with worse outcomes.”
Elliott R. Haut, MD, PhD, at the Johns Hopkins School of Medicine and Bloomberg School of Public Health, in Baltimore, noted that these data raise an important question of whether emergency general surgery should be regionalized into specialized centers or whether all facilities should be equipped to handle the basics.
“It is really important to get these operations done quickly, but it’s also important to get them done well in a place that takes care of the patient, even for those few hours,” Dr. Haut said. “I think it’s a tough balance, and there is no cut-and-dry answer. There are a lot of hospitals that are not ready to handle critically ill patients with a necrotizing soft tissue infection.”