Healthcare trajectory of critically ill patients with necrotizing soft tissue infections: a multicenter retrospective cohort study using the clinical data warehouse of Greater Paris University Hospitals

Abstract

Background Necrotizing skin and soft tissue infections (NSTIs) are rare but serious and rapidly progressive infections characterized by necrosis of subcutaneous tissue, fascia and even muscle. The care pathway of patients with NSTIs is poorly understood. A better characterization of the care trajectory of these patients and a better identification of patients at risk of a complicated evolution, requiring prolonged hospitalization, multiple surgical re-interventions, or readmission to the intensive care unit (ICU), is an essential prerequisite to improve their care. The main objective of this study is to obtain large-scale data on the care pathway of these patients. We performed a retrospective multicenter observational cohort study in 13 Great Paris area hospitals, including patients hospitalized between January 1, 2015 and December 31, 2019 in the ICU for surgically confirmed NSTIs. Results 170 patients were included. The median duration of stay in ICU and hospital was 8 (3–17) and 37 (14–71) days, respectively. The median time from admission to first surgical debridement was 1 (0–2) day but 69.9% of patients were re-operated with a median of 1 (0–3) additional debridement. Inter-hospital transfer was necessary in 52.4% of patients. 80.2% of patients developed organ failures during the course of ICU stay with 51.8% of patients requiring invasive mechanical ventilation, 77.2% needing vasopressor support and 27.7% renal replacement therapy. In-ICU and in-hospital mortality rates were 21.8% and 28.8%, respectively. There was no significant difference between patients with abdomino-perineal NSTIs (n = 33) and others (n = 137) in terms of in-hospital or ICU mortality. Yet, immunocompromised patients (n = 43) showed significantly higher ICU and in-hospital mortality rates than non-immunocompromised patients (n = 127) (37.2% vs. 16.5%, p = 0.009, and 53.5% vs. 20.5%, p < 0.001). Factors associated with a complicated course were the presence of a polymicrobial infection (adjusted odds ratio [aOR = 3.18 (1.37–7.35); p = 0.007], of a bacteremia [aOR = 3.29 (1.14–9.52); p = 0.028] and a higher SAPS II score [aOR = 1.05 (1.02–1.07); p < 0.0001]. 62.3% of patients were re-hospitalized within 6 months. Conclusion In this retrospective multicenter study, we showed that patients with NSTI required complex management and are major consumers of care. Two-thirds of them underwent a complicated hospital course, associated with a higher SAPS II score, a polymicrobial NSTI and a bacteremia.

Necrotizing soft tissue infections in critically ill neutropenic patients: a French multicentre retrospective cohort study

“…Our study has some strengths, including its multicentre design, with participating centres having developed specific multidisciplinary care bundle for NSTI [ 23 ]. The comparison to a multicentre cohort of non-neutropenic NSTI patients allowed us to assess the clinical and microbiological characteristics of neutropenic patients [ 10 ].…”

“…Then, we acknowledge that the association of G-CSF with survival could suffer from a risk of immortal time bias, although the delay between ICU admission and this therapeutic intervention was very short and we considered G-CSF as a time-dependent variable, thus making this risk theoretical. In our study we compared neutropenic patients to a previously described cohort of non-neutropenic patients [ 10 ]. The data of the non-neutropenic patients were obtained from a retrospective search in the French national hospital database in 13 centres from the Assistance Publique—Hôpitaux de Paris (APHP) network, while neutropenic patients were from 6 AP-HP centres and 12 other French hospitals.…”

“…A previously published cohort of 165 non-neutropenic patients with histologically confirmed NSTIs admitted from 2015 to 2019 in the ICUs of 13 Great Paris area hospitals was used for comparison [ 10 ]. These patients were selected using the French national hospital database with the 10th International Classification of Disease diagnostic codes for “necrotizing skin and soft tissue infections”.…”

Severe skin infections

“…Patient transfer should be considered if early surgery cannot be performed locally [24,25]. Postoperative reassessment, ideally including a second-look surgery, is warranted for all patients, either to make the diagnosis in case of initially reassuring surgical findings but no subsequent clinical improvement, or to perform further tissue debridement (a median of 2–3 surgeries are required per patient) [1,26 ▪ ,27].…”

“…Better describing the care trajectory of these patients and being able to identify patients at risk of a complicated course, requiring prolonged hospitalization, multiple surgical re-interventions, or ICU readmission, is an essential prerequisite to improve their care. A recent retrospective cohort [26 ▪ ] showed that NSTI patients admitted to the ICU are important consumers of hospital care. Indeed, they frequently required multiple surgeries, the median duration of ICU and total hospital stay were 8 and 37 days respectively, with 62% of re-hospitalization within 6 months, including 10% in the ICU.…”