Epidemiology and costs of patients with toxic epidermal necrolysis: a 27-year retrospective study

Quantifying the clinical and economic burden of desquamating dermatological conditions: Implications for a supraregional burns centre

INTRODUCTION

This study aimed to identify the spectrum of desquamating skin diseases referred for tertiary burns care and quantify the care requirements and expenses associated with caring for these patients within the burns service.

METHODS

Patient records were identified with nonburn-induced skin loss between 2016 and 2022. Data was extracted from inpatient records, operative notes, and dressing clinic records. A cost analysis was conducted using figures from the National Schedule of National Health Service Costs and our own unit-specific costs.

RESULTS

Twenty patients were identified, with a median age of 46.5 and a median total body surface area of 30%. The mean length of stay was 21.2 days, with 8/20 patients requiring intensive care. Overall mortality was 30%, rising to 50% if patients required intensive treatment unit (ITU) admission. Patients had a mean of 1.5 procedures under general anaesthesia and a mean operative time of 169 min per patient. Postoperatively, a mean of 8.3 dressing changes was required per patient (range 1-21). Of 75% of patients referred as suspected toxic epidermal necrolysis syndrome (TENS), only 32% of patients histologically had TENS (32%), with linear IgA disease, pemphigus vulgaris and bullous lupus comprising the other diagnoses. Cost analysis predicted a total cost to the unit of £1,422,106.

CONCLUSION

Desquamating dermatological diseases are life-threatening conditions with exhaustive care requirements. Our experiences highlight the importance of awareness of the range of desquamating skin conditions beyond TENS to enable optimum management and the need to ensure adequate financial provisions to accommodate the care requirements mandated by these patients.

Genotyping for HLA Risk Alleles to Prevent Drug Hypersensitivity Reactions: Impact Analysis

Human Leukocyte Antigen (HLA) variants can be a risk factor for developing potentially fatal drug hypersensitivity reactions. Our aim was to estimate the potential impact of genotyping for the HLA risk alleles incorporated in the Dutch Pharmacogenetics Working Group (DPWG) guidelines in The Netherlands. We estimated the number of hypersensitivity reactions and associated deaths that can be avoided annually by genotyping for these HLA risk alleles. Additionally, the cost-effectiveness was estimated. Nationwide implementation of genotyping HLA risk alleles before initiating drugs with an actionable drug-gene interaction can potentially save the life of seven allopurinol initiators and two flucloxacillin initiators each year in The Netherlands. Besides these deaths, 28 cases of abacavir hypersensitivity, 24 cases of allopurinol induced SCARs, 6 cases of carbamazepine induced DRESS and 22 cases of flucloxacillin induced DILI can be prevented. Genotyping HLA-B*5701 in abacavir initiators has a number needed to genotype of 31 to prevent one case of abacavir hypersensitivity and is cost-saving. Genotyping HLA-B*5801 in allopurinol initiators has a number needed to genotype of 1149 to prevent one case of SCAR but is still cost-effective. Genotyping before initiating antiepileptic drugs or flucloxacillin is not cost-effective. Our results confirm the need for mandatory testing of HLA-B*5701 in abacavir initiators, as indicated in the drug label, and show genotyping of HLA-B*5801 in allopurinol initiators should be considered.

Application of a simple point-of-care test to reduce UK healthcare costs and adverse events in outpatient acute respiratory infections

Background: Acute respiratory infection (ARI) accounts for over two-thirds of total antibiotic prescriptions although most are caused by viruses that do not benefit from antibiotics. Most antibiotics are prescribed in the outpatients setting. Antibiotic overuse leads to antibiotic-related adverse events (AEs), inclusive of secondary infections, resistance, and increased costs. Point-of-care tests (POCT) may reduce unnecessary antibiotics. A cost analysis was performed to assess diagnostic POCT options to identify patients with an ARI that may benefit from antibiotics in a United Kingdom (UK) outpatient setting.Methods: Healthcare savings were estimated using a budget impact analysis based on UK National Institute for Health and Care Excellence (NICE) data and direct costs (antibiotics, AEs, POCTs) derived from published literature. Otitis media, sinusitis, pharyngitis and bronchitis were considered the most common ARIs. Antibiotic-related AE costs were calculated using re-consultation costs for anaphylaxis, Stevens-Johnson syndrome, allergies/diarrhea/nausea, C. difficile infection (CDI). Potential cost-savings from POCTs was assessed by evaluating NICE guideline-referenced POCTs (CRP, FebriDx, Sarasota, FL) as well as a target product profile (TPP).Results: Fifty-percent (7,718,283) of ARI consultations resulted in antibiotics while guideline-based prescribing suggest appropriate antibiotic prescriptions are warranted 9% (1,444,877) of ARI consultations. Direct antibiotic costs for actual ARI consultations associated with antibiotics was £24,003,866 vs. £4,493,568 for guideline-based, "appropriate" antibiotic prescriptions. Antibiotic-related AEs and re-consultations for actual vs. appropriate prescribing totaled £302,496,486 vs. £63,854,269. ARI prescribing plus AE costs totaled £326,729,943 annually without the use of delayed prescribing practices or POCT while the addition of delayed prescribing plus POCT totaled £60,114,564-£78,148,933 depending on the POCT.Conclusions: Adding POCT to outpatient triage of ARI can reduce unnecessary antibiotics and antibiotic-related AEs, resulting in substantial cost savings. Further, near patient diagnostic testing can benefit health systems and patients by avoiding exposure to unnecessary drugs, side effects and antibiotic resistant pathogens.Key points for decision makersMany patients are unnecessarily treated with antibiotics for respiratory infections.Antibiotic misuse leads to unnecessary adverse events, secondary infections, re-consultations, antimicrobial resistance and increased costs.Point-of-care diagnostic tests used to guide antibiotic prescriptions will avoid unnecessary adverse health effects and expenses.

Epidemiology and Risk Factors for Severe Delayed Drug Hypersensitivity Reactions

Severe delayed drug hypersensitivity reactions comprise different clinical entities and can involve different immune-mediated mechanisms. Common examples are severe cutaneous adverse reactions and druginduced internal organ injuries. The incidence of such reactions is overall low but seems to be on the rise reaching numbers as high as 9 per million individuals-years in the case of SJS/TEN and DRESS. Such conditions carry an important associated morbidity, and mortality can attain 40% in SJS/TEN patients, making these hypersensitivity reactions important targets when implementing preventive measures. Several risk factors have been identified for reaction severity; some are transverse, such as older age and underlying chronic diseases. The recent advances in pharmacogenetics allowed the identification of specific populations with higher risk and permitted strategic avoidance of certain drugs being HLA-B*57:01 screening in patients initiating abacavir the best successful example. In this work, we reviewed the epidemiology of SCARs and liver/kidney/lung drug-induced immune-mediated reactions. We focus on particular aspects such as prevalence and incidence, drugs involved, mortality and risk factors.

Erythema multiforme, Stevens-Johnson syndrome/toxic epidermal necrolysis - diagnosis and treatment

Prior to the first international consensus classification published in 1993, the clinical distinction between erythema multiforme (EM), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) had been subject to uncertainty and controversy for more than a century. Based on this classification, the three conditions are defined by the morphology of the individual lesions and their pattern of distribution. Etiopathogenetically, the majority of EM cases is caused by infections (primarily herpes simplex virus and Mycoplasma pneumoniae), whereas SJS/TEN are predominantly triggered by drugs. The SCORTEN (score of toxic epidermal necrolysis) can and should be used to assess disease prognosis in patients with SJS/TEN. While supportive treatment is generally considered sufficient for EM, there is still uncertainty as to the type of systemic therapy required for SJS/TEN. Given the lack of high-quality therapeutic trials and (in some cases) conflicting results, it is currently impossible to issue definitive recommendations for any given immunomodulatory therapy. While there is always a trade-off between rapid onset of treatment-induced immunosuppression and an uptick in infection risk, there has been increasing evidence that cyclosporine in particular may be able to halt disease progression (i.e. skin detachment) and lower mortality rates. Assistance in diagnosis and management of the aforementioned conditions may be obtained from the Center for the Documentation of Severe Skin Reactions (dZh) at the Department of Dermatology, University Medical Center, Freiburg, Germany.

Nursing problems in patients with toxic epidermal necrolysis and Stevens-Johnson syndrome in a Dutch burn centre: A 30-year retrospective study

OBJECTIVE

Multiple studies have been published on toxic epidermal necrolysis (TEN) and Stevens-Johnsen syndrome (SJS). Nursing care is an important part of the treatment of TEN patients. Unfortunately, limited information on nursing in TEN/SJS patients has been published in the current literature. Nursing research is needed to improve the complex nursing care required for these rare patients. Therefore, the objective was to assess nursing problems in TEN patients in a burn centre setting over a 30-year period.

METHODS

The data for this study were gathered retrospectively from nursing records of all patients with TEN/SJS admitted to Burn Centre Rotterdam between January 1987 and December 2016. Dutch burn centres were recently accepted as expertise centres for TEN patients. Nursing problems were classified using the classification of nursing problems of the Dutch Nursing Society.

RESULTS

A total of 69 patients were admitted with SJS/TEN. Fifty-nine patient files were available. The most frequently reported nursing problems (>20% of the patients) were wounds, threatened or disrupted vital functions, dehydration or fluid imbalance, pain, secretion problems and fever. Furthermore, TEN-specific nursing problems were documented, including oral mucosal lesions and ocular problems. The highest number of concomitant nursing problems occurred during the period between days three and 20 after onset of the disease and varied by nursing problem.

CONCLUSIONS

The most frequently reported nursing problems involved physical functions, especially on days three to 20 after onset of the disease. With this knowledge, we can start nursing interventions early in the treatment, address problems at the first sign and inform patients and their families or relatives of these issues early in the disease process. A next step to improve nursing care for TEN patients is to acquire knowledge on the optimal interventions for nursing problems.

Stevens-Johnson syndrome and toxic epidermal necrolysis: a retrospective descriptive study

BACKGROUND

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare and potentially life-threatening mucocutaneous reactions. Given their rarity, limited cohort studies have been done. The aim of this study is to evaluate and compare the demographics, etiology, management, clinical and laboratory characteristics, complications, and outcome of SJS/TEN patients seen by the inpatient dermatology service at the University of Puerto Rico.

METHODS

A retrospective review of 30 cases with identified diagnosis of SJS, overlap SJS/TEN, or TEN who were consulted to the Dermatology Department of the University of Puerto Rico from 2006 to 2017.

RESULTS

A total of 24 adult and six pediatric cases were reviewed. Females were predominant with a female to male ratio of 1.3 : 1. The most frequent offending drugs identified were antibiotics (56.7%), anticonvulsants (23.3%), and nonsteroidal anti-inflammatory drugs (NSAIDs) (16.7%) with the most frequent antibiotic identified being trimethoprim/sulfamethoxazole (23.3%). Seventy percent of patients experienced at least one complication, most often of infectious etiology (80.1%). During hospital course, 73% received pharmacologic therapy (23% received IVIG alone, 17% received steroids alone, and 33% both) versus 27% which received only supportive care. Mortality rate in this study was 13.8%. When comparing SCORTEN at day one of admission, deceased cases had a mean SCORTEN at day 1 of 4.0, while survivors had an average of 1.54 (P < 0.001).

CONCLUSION

Antibiotics followed by anticonvulsants were the most frequently offending drugs identified within this study.

Treatment of partial-thickness burns with a tulle-gras dressing and a hydrophilic polyurethane membrane: a comparative study

OBJECTIVE

The purpose of this revisited study was to compare the clinical efficacy and long-term scar evaluation of a hydrophilic polyurethane membrane (HPM), Omiderm (Omikron Scientific Ltd., Rehovot, Israel) and an antimicrobial tulle-gras dressing (TGD), Bactigras (Smith & Nephew) in the management of partial-thickness burns.

METHOD

Patients with partial-thickness burns were enrolled in this prospective study. Burn areas were divided into two areas and both dressings were applied to each field at the same time. Time to full re-epithelialisation and scar evaluation were compared using the Vancouver Scar Scale (VSS).

RESULTS

A total of 21 patients, mean age 36.8 years, with 22 burns areas participated. The results showed that there is no statistically significant difference in terms of full epithelialisation time in the application of either dressing (p>0.05). However, with deep dermal burns, the HPM provided slightly faster epithelialisation (p>0.05). A VSS assessment showed no statistically significant difference (p>0.05) between applying either dressing materials.

CONCLUSION

This study indicated that both dressings had the same effectiveness in treatment of partial-thickness burn wounds. However, the use of the HPM, especially in deep dermal second-degree burns, should be one of the first-line clinical choices, based on the advantages discerned by this study.

Stevens-Johnson syndrome/toxic epidermal necrolysis caused by cefadroxil in a cat

Case summary

A 5-year-old, spayed female, indoor-only domestic shorthair cat was referred with an acute history of multifocal cutaneous and mucocutaneous erosive-ulcerative lesions and skin detachment. The lesions occurred on the seventh day of therapy with cefadroxil. Erosive-ulcerative and occasionally crusted lesions were apparent on the medial and lateral canthus of both eyes, ventral neck, abdomen, perivulvar region, periungual skin and medial aspect of the front and hindlimbs. Diffuse and severe exfoliation was present on the dorsum and tail base and in both external ear canals. The cat was also dehydrated, tachycardic and febrile. Histopathological examination revealed extensive epidermal ulceration, interface dermatitis with vacuolar degeneration, apoptosis at multiple epidermal levels and basal, suprabasal and spinous dermoepidermal detachment. The histopathological diagnosis was consistent with Stevens–Johnson syndrome/toxic epidermal necrolysis (SJS/TEN). The recently reported Algorithm of Drug Causality in Epidermal Necrolysis (ALDEN), currently used in human medicine, was applied and a score of +6 was calculated; this supported the view that SJS/TEN in this cat was very likely to be associated with cefadroxil administration.

Relevance and novel information

This clinical communication reports cefadroxil as a very probable cause of SJS/TEN in a cat; the ALDEN was applied in this case and supported diagnosis.

Morbidity and Mortality of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis in United States Adults

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening disorders. Our study objective was to describe the incidence, costs of care, length of stay, comorbidities, and mortality of SJS and TEN in US adults. The Nationwide Inpatient Sample 2009-2012, containing a 20% sample of all US hospitalizations, was analyzed. We used a validated approach involving International Classification of Disease, 9th edition, Clinical Modification codes to identify SJS, SJS/TEN, and TEN (n = 2,591, n = 502, and n = 564, respectively). The mean estimated incidences of SJS, SJS/TEN, and TEN were 9.2, 1.6, and 1.9 per million adults per year, respectively. SJS/TEN was associated with nonwhite race, particularly Asians (odds ratio = 3.27, 95% confidence interval = 3.02-3.54) and blacks (odds ratio = 2.01, 95% confidence interval = 1.92-2.10). Significantly prolonged length of stay and higher costs of care (SJS: 9.8 ± 0.3 days, $21,437 ± $807; SJS/TEN: 16.5 ± 1.0 days, $58,954 ± $5,238; TEN: 16.2 ± 1.0 days, $53,695 ± $4,037) were observed compared with all other admissions (4.7 ± 0.02 days, $11,281 ± $98). Mean adjusted mortality was 4.8% for SJS, 19.4% for SJS/TEN, and 14.8% for TEN. SJS, SJS/TEN, and TEN pose a substantial health care burden. Predictors of mortality included increasing age, increasing number of chronic conditions, infection (septicemia, pneumonia, tuberculosis), hematological malignancy (non-Hodgkin's lymphoma, leukemia), and renal failure (P ≤ 0.03 for all). Further studies are needed to confirm mortality findings to improve prognostication of SJS/TEN.