Survival and Health-Related Quality of Life after Hospitalization for Necrotizing Soft Tissue Infections of the Upper Extremity: A Long-Term Outcome Study

Quality of Life After Intensive Care Unit Admittance for Necrotizing Soft Tissue Infections Is Deemed Acceptable for Patients

Background: Because mortality and amputation rates are declining for necrotizing soft tissue infections (NSTIs), this study aimed to assesses the self-reported one-year quality of life (QoL) of severely ill patients with NSTI who survived beyond the intensive care unit (ICU). Patients and Methods: A retrospective cohort study of patients with NSTI admitted to the ICU between 2010 and 2019 was conducted. A year after ICU discharge, QoL was assessed using the three-level EuroQol five-dimensions (EQ-5D-3L) questionnaire, Impact of Event Scale-Revised (IES-R) questionnaires, and pain scales. Furthermore, willingness to undergo ICU admission again if needed was reviewed. Results: Twenty-nine (of 38) patients with NSTI survived their hospitalization (76%). During the one-year follow-up, three patients died (8%; one-year survival 68%). Nineteen patients filled out the questionnaires (73%). The median EQ-5D-3L index score was 0.775 (interquartile range [IQR], 0.687-0.843). The domains reported most to cause impairment were "usual activity" and "pain/discomfort." Patients had a median pain score of five (of 10; IQR, 1-6) and two patients (15%; of 13) scored "clinical concern for PTSD.". Eighty-five percent of the patients would undergo the ICU treatment again if needed. Conclusions: The one-year QoL of ICU-admitted patients with NSTI varies widely, however, the overall QoL and one-year survival was similar to other ICU patients who underwent acute surgery and the QoL was slightly lower than the general ICU population. Most patients experience problems with daily activity and pain, but this does not mean that patients with NSTI automatically had poor self-reported quality of life or unwillingness to undergo ICU treatment again if needed.

Impact of Comorbidities on the Cause of Death by Necrotizing Soft Tissue Infections

Background: The aim of this study was to identify the cause of death in patients with necrotizing soft tissue infections (NSTIs) stratified by patient's pre-existing comorbidities (American Society of Anesthesiologists [ASA] classification 3/4 vs. ASA 1/2). Differences in clinical presentation, mortality rate, and factors associated with mortality between those two comorbidity groups were investigated. Patients and Methods: A retrospective multicenter study of patients with NSTIs between 2010 and 2020 was conducted. The primary outcome was the cause of death within the first 30 days. Furthermore, factors associated with mortality were identified. All analysis were stratified by severity of comorbidities (ASA 1/2 or ASA 3/4). Results: Of the 187 patients, 39 patients (21%) died within 30 days. American Society of Anesthesiologists 1/2 patients (overall mortality rate, 11%) died more often as direct result of the infection compared with ASA 3/4 patients (overall mortality rate, 33%) (ASA 1/2 group: 92% vs. ASA 3/4 group: 48%; p = 0.013). American Society of Anesthesiologists 3/4 patients died more often due to withdrawal of life-sustaining therapies based on assumed poor outcome after severe critical illness (ASA 1/2 group: 52% vs. ASA 3/4 group: 8%; p = 0.013). Conclusions: Mortality rates of patients with NSTIs varied from 11% in previously healthy patients to 33% in patients with multiple or severe comorbidities. The predominant cause of mortality was overwhelming infection and associated sepsis in healthy patients whereas in patients with multiple or severe pre-existing medical disease, death most often occurred after treatment limitations based on patient's wishes and prognosis.

Incidence and mortality of necrotizing fasciitis in The Netherlands: the impact of group A Streptococcus

BACKGROUND

Little is known about the exact incidence of necrotizing soft tissue infections. The few incidences reported in international literature are not directly relatable to the Netherlands, or other European countries, due to geographic heterogeneity in causative micro-organisms involved. This resulted in the aim of this study to map the incidence, mortality rate and hospital course of necrotizing fasciitis infections in the Netherlands to gain insight in the incidence of necrotizing fasciitis in the Netherlands and the associated mortality and health care burden.

METHODS

This nationwide retrospective database study used three distinct data sources to map the incidence of necrotizing fasciitis in the Netherlands between 2014 and 2019, being data from the Dutch Hospital Data (DHD) foundation, data from Osiris-AIZ, which is a database of notifiable diseases managed by regional Public Health Services (GGD) and the National Institute for Public Health and the Environment (RIVM), and previously published studies on necrotizing fasciitis conducted in the Netherlands.

RESULTS

The incidence of necrotizing fasciitis in the Netherlands is estimated to be approximately 1.1 to 1.4 cases per 100,000 person years, which corresponds to 193-238 patients per year. Of all necrotizing fasciitis infections, 34 to 42% are caused by the group A Streptococcus. Annually, 56 patients die as a result of a necrotizing fasciitis infection (mortality of 23-29%) and 26 patients undergo an amputation for source control (11-14%). Patients stay a mean of 6 to 7 days at the intensive care unit and have a mean hospital length of stay of 24 to 30 days.

CONCLUSION

The combination of nationwide databases provides reliable insight in the epidemiology of low-incidence and heterogenic diseases. In the Netherlands, necrotizing fasciitis is a rare disease with group A Streptococcus being the most common causative micro-organism of necrotizing fasciitis. The prior Dutch cohort studies on necrotizing fasciitis report slightly higher sample mortality rates, compared to the population mortality. However, necrotizing fasciitis remain associated with substantial morbidity and mortality, risk at amputation and health care burden characterized by prolonged ICU and hospital stay.