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Immunocompromised Status in Patients With Necrotizing Soft-Tissue Infection

Emily Z. Keung, MD; Xiaoxia Liu, MS; Afrin Nuzhad, BS; Christopher Adams, PharmD, BCPS; Stanley W. Ashley, MD; Reza Askari, MD
JAMA Surg. 2013;148(5):419-426. doi:10.1001/jamasurg.2013.173.
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Importance There is a scarcity of research on immunocompromised patients with necrotizing soft-tissue infection (NSTI).

Objective To evaluate the effect of immunocompromised status in patients with NSTI.

Design and Setting Single-institution retrospective cohort study at a tertiary academic teaching hospital affiliated with a major cancer center.

Participants Patients with NSTI.

Exposure Treatment at Brigham and Women's Hospital and Dana-Farber Cancer Institute between November 25, 1995, and April 25, 2011.

Main Outcome and Measure Necrotizing soft-tissue infection–associated in-hospital mortality.

Results Two hundred one patients were diagnosed as having NSTI. Forty-six were immunocompromised (as defined by corticosteroid use, active malignancy, receipt of chemotherapy or radiation therapy, diagnosis of human immunodeficiency virus or AIDS, or prior solid organ or bone marrow transplantation with receipt of chronic immunosuppression). At presentation, immunocompromised patients had lower systolic blood pressure (105 vs 112 mm Hg, P = .02), glucose level (124 vs 134 mg/dL, P = .03), and white blood cell count (6600/μL vs 17 200/μL, P < .001) compared with immunocompetent patients. Immunocompromised patients were less likely to have been transferred from another institution (26.1% vs 52.9%, P = .001), admitted to a surgical service (45.7% vs 83.2%, P < .001), or undergone surgical debridement on admission (4.3% vs 61.3%, P = .001). Time to diagnosis and time to first surgical procedure were delayed in immunocompromised patients (P < .001 and P = .001, respectively). Immunocompromised patients had higher NSTI-associated in-hospital mortality (39.1% vs 19.4%, P = .01).

Conclusions and Relevance Immunocompromised status in patients with NSTI in this study is associated with delays in diagnosis and surgical treatment and with higher NSTI-associated in-hospital mortality. At presentation, immunocompromised patients may fail to exhibit typical clinical and laboratory signs of NSTI. Physicians caring for similar patient populations should maintain a heightened level of suspicion for NSTI and consider early surgical evaluation and treatment.

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