Department of Surgery, Center for Outcomes Research, University of Massachusetts Medical School, Worcester, MA 01655, USA.
Surgery. 2013 Jun;153(6):819-27. doi: 10.1016/j.surg.2012.11.026. Epub 2013 Feb 27.
Necrotizing soft-tissue infections (NSTI) are rare, potentially fatal, operative emergencies. We studied a national cohort of patients to determine recent trends in incidence, treatment, and outcomes for NSTI.
We queried the Nationwide Inpatient Sample (1998-2010) for patients with a primary diagnosis of NSTI. Temporal trends in patient characteristics, treatment (debridement, amputation, hyperbaric oxygen therapy [HBOT]), and outcomes were determined with Cochran-Armitage trend tests and linear regression. To account for trends in case mix (age, sex, race, insurance, Elixhauser index) or receipt of HBOT on outcomes, multivariable analyses were conducted to determine the independent effect of year of treatment on mortality, any major complication, and hospital length of stay (LOS) for NSTI.
We identified 56,527 weighted NSTI admissions, with an incidence ranging from approximately 3,800-5,800 cases annually. The number of cases peaked in 2004 and then decreased between 1998 and 2010 (P < .0001). The percentage of female patients decreased slightly over time (38.6-34.1%, P < .0001). Patients were increasingly in the 18- to 34-year-old (8.8-14.6%, P < .0001) and 50- to 64-year-old age groups (33.2-43.5, P < .0001), Hispanic (6.8-10.5%, P < .0001), obese (8.9-24.6%, P < .0001), and admitted with >3 comorbidities (14.5-39.7%, P < .0001). The percentage of patients requiring only one operative debridement increased somewhat (43.2-46.2%, P < .0001), whereas the use of HBOT was rare and decreasing (1.6-0.8%, P < .0001). The percentage of patients requiring operative wound closure decreased somewhat (23.5-20.8%, P < .0001). Although major complication rates increased (30.9-48.2%, P < .0001), hospital LOS remained stable (18-19 days) and mortality decreased (9.0-4.9%, P < .0001) on univariate analyses. On multivariable analyses each 1-year incremental increase in year was associated with a 5% increased odds of complication (odds ratio 1.05), 0.4 times decrease in hospital LOS (coefficient -0.41), and 11% decreased odds of mortality (odds ratio 0.89).
There were potentially important national trends in patient characteristics and treatment patterns for NSTI between 1998 and 2010. Importantly, though patient acuity worsened and complication rates increased, but LOS remained relatively stable and mortality decreased. Improvements in early diagnosis, wound care, and critical care delivery may be the cause.
坏死性软组织感染（NSTI）是一种罕见的、潜在致命的手术急症。我们研究了一个全国性的患者队列，以确定 NSTI 的发病率、治疗和结局的近期趋势。
我们通过全国住院患者样本（1998-2010 年）查询了原发性 NSTI 患者。通过 Cochran-Armitage 趋势检验和线性回归确定患者特征、治疗（清创术、截肢术、高压氧治疗[HBOT]）和结局的时间趋势。为了说明病例组合（年龄、性别、种族、保险、Elixhauser 指数）或 HBOT 对结局的影响趋势，我们进行了多变量分析，以确定治疗年份对 NSTI 死亡率、任何主要并发症和住院时间（LOS）的独立影响。
我们确定了 56527 例加权 NSTI 入院病例，发病率约为每年 3800-5800 例。病例数量在 2004 年达到峰值，然后在 1998 年至 2010 年之间下降（P <.0001）。女性患者的比例略有下降（38.6-34.1%，P <.0001）。患者年龄逐渐向 18 至 34 岁（8.8-14.6%，P <.0001）和 50 至 64 岁（33.2-43.5%，P <.0001）、西班牙裔（6.8-10.5%，P <.0001）、肥胖（8.9-24.6%，P <.0001）和患有>3 种合并症（14.5-39.7%，P <.0001）的患者增多。仅需一次清创术的患者比例略有增加（43.2-46.2%，P <.0001），而 HBOT 的使用仍然很少且呈下降趋势（1.6-0.8%，P <.0001）。需要手术伤口闭合的患者比例略有下降（23.5-20.8%，P <.0001）。尽管主要并发症发生率增加（30.9-48.2%，P <.0001），但住院 LOS 保持稳定（18-19 天），死亡率降低（9.0-4.9%，P <.0001）。在单变量分析中，每年增加 1 年与并发症发生率增加 5%（比值比 1.05）、住院 LOS 减少 0.4 倍（系数-0.41）和死亡率降低 11%（比值比 0.89）相关。
1998 年至 2010 年间，NSTI 的患者特征和治疗模式存在潜在的重要全国性趋势。重要的是，尽管患者的病情恶化，并发症发生率增加，但 LOS 相对稳定，死亡率降低。早期诊断、伤口护理和重症监护服务的改善可能是原因。
