Epidemiology and Outcomes of Hospitalized Children With Necrotizing Soft-Tissue Infections

A Cross-Sectional Analysis of Pediatric Necrotizing Soft Tissue Infection Cases and Racial Disparities From the 2016 to 2020 National Inpatient Sample

INTRODUCTION

The incidence, treatment, and outcomes of necrotizing soft tissue infections (NSTIs) and associated racial disparities have been described in adults, but research in the pediatric population is limited. The purpose of this study is to provide a nationally representative characterization of pediatric NSTI and determine the presence of any racial disparities.

METHODS

The National Inpatient Sample was analyzed from 2016 through 2020. Patients aged less than 20 y with a diagnosis of necrotizing fasciitis, Fournier's gangrene, or gas gangrene (based on International Classification of Diseases, Tenth Revision, Clinical Modification codes) were included for analysis.

RESULTS

A total of 355 patients were identified. Black and Hispanic patients accounted for the most admissions in 2016 and 2018, respectively (P = 0.024). Compared to White patients, more Black patients were insured by Medicaid (P = 0.037) and were in the first zip code-based income quartile (P = 0.005). The leading infection overall was necrotizing fasciitis and most patients (81.7%) underwent a surgical procedure by the first calendar day after admission. Although the proportion of Black patients undergoing subcutaneous tissue and fascia excisions was more than that of White patients (P = 0.005), there were no significant differences by race in the time to first procedure, the total number of procedures, or number of postoperative complications. Our amputation and mortality rates were low and unreportable, but there were no differences by race.

CONCLUSIONS

NSTI is rare in the pediatric population and mortality is low. Black patients are disproportionately diagnosed, but these disparities do not extend to disease treatment or outcomes.

The clinical characteristics and risk factors for necrotizing soft tissue infection in children

Importance

Necrotizing soft tissue infection (NSTI) is a serious infectious disease. However, the early clinical manifestations and indicators of NSTI in children are still unclear.

Objective

The purpose of this study was to analyze the clinical characteristics and risk factors of NSTI in pediatric patients.

Methods

A total of 127 children with skin and soft tissue infection (SSTI) were treated at our hospital and divided into two groups: the NSTI group and the non-NSTI group, based on their discharge diagnosis from January 2011 to December 2022. Then, we collected and analyzed the clinical characteristics and risk factors of all patients, including sex and age, disease inducement, admission temperature, local skin manifestations, infection site, the presence of sepsis, bacterial culture, and laboratory indicators.

Results

In our study, there was a statistical difference in the age distribution and disease inducement between NSTI and non-NSTI groups. The occurrence of local skin manifestations (blisters/bullae and ecchymosis) and the presence of sepsis significantly increased in the NSTI group compared to the non-NSTI group. Additionally, only the platelet count on laboratory tests was statistically different between the NSTI and non-NSTI groups. Finally, the logistic regression analysis suggested that local skin manifestations such as blisters/bullae, and ecchymosis, as well as the presence of sepsis, were identified as risk factors for NSTI.

Interpretation

Children with SSTI and skin manifestations such as blisters/bullae, ecchymosis, and the presence of sepsis are at a higher risk of developing NSTI. These symptoms serve as useful indicators for early detection of NSTI.

Racial and Socioeconomic Disparities in Necrotizing Soft-Tissue Infection

Necrotizing soft-tissue infection (NSTI) is a medical emergency. We investigated the impact of racial, socioeconomic disparities, and comorbidities on mortality, complications, length of stay, and charges in patients with NSTI.

Data were acquired from the National Inpatient Sample from Q4 2015 to 2017. ICD-10, Clinical Modification codes were utilized to identify relevant cases. Logistic regression was used to assess socioeconomic, racial, and health risk factors for adverse outcomes in NSTI patients.

Of 16,071,053 cases identified during the study period, 15,078 (0.094%) NSTI cases were recognized. Black patients had increased odds of amputation (OR 1.40 95% CI 1.24-1.58, p < 0.001), prolonged hospital stay (OR 1.40 95% CI 1.24-1.58, p < 0.001), excessive charges (OR 1.22 95% CI 1.03-1.43, p = 0.019), and adverse discharge disposition (OR 1.32 95% CI 1.19-1.46, p < 0.001) compared to white patients. Hispanic patients had increased odds of mortality (OR 1.30 95% CI 1.05-1.60, p = 0.014) and amputation (OR 1.21 95% CI 1.04-1.42, p = 0.016) compared to white patients. Medicare patients had increased odds of mortality (OR 1.35 95% CI 1.09-1.67, p = 0.006), Medicaid patients had increased odd of amputation (OR 1.33 95% CI 1.17-1.51, p < 0.001) and prolonged LOS (OR 1.33 95% CI 1.17-1.51, p < 0.001). Patients in the lower income quartiles had decreased odds of amputation compared to the highest income quartile, including the 26^th to 50^th income quartile (OR 0.84 95% CI 0.73-0.98, p = 0.022) and 51^st to 75^th income quartile (OR 0.84 95% CI 0.73-0.98, p = 0.022).

Racial and socioeconomic disparities exist for patients being treated for NSTIs.

Necrotizing fasciitis after scrotum skin injury in an infant: A case report

RATIONALE

Necrotizing fasciitis (NF) is a life-threatening situation that is rare in children, especially infants, and early diagnosis is challenging. Timely identification and broad-spectrum antibiotic and supportive treatment before surgical debridement are very important for survival and may reduce scar formation.

PATIENT CONCERNS

A previously healthy 4-month-old infant was admitted to our pediatric intensive care unit (PICU) with a history of fever and cough for 5 days and extreme swelling of the scrotum for one day. Necrotic-like tissue without margins appeared on his scrotum and perineum in 24 hours.

DIAGNOSIS

NF was suspected, and the patient soon developed shock. The patient underwent surgical debridement after his condition stabilized. Pathological analysis confirmed the diagnosis of NF.

INTERVENTION

Broad-spectrum antibiotic, immediate fluid resuscitation, assistant ventilation, and vasoactive drugs were administered. Surgical debridement and autologous split-thickness skin grafting were performed.

OUTCOMES

The wound recovered well after 2 months. Ultrasound revealed normal testicles, and no anorectal injury was found.

LESSONS

Close clinical monitoring and timely treatment of skin injuries in sick children are very important. Sufficient antibiotic administration and supportive treatment before surgical debridement are crucial for survival from NF.