Horn Christopher B, Wesp Brendan M, Fiore Nicholas B, Rasane Rohit K, Torres Marlon, Turnbull Isaiah R, Ilahi Obeid N, Punch Laurie J, Bochicchio Grant V
Department of Surgery, Washington University , St Louis, Missouri.
Surg Infect (Larchmt). 2017 Oct;18(7):793-798. doi: 10.1089/sur.2017.164. Epub 2017 Aug 29.
Necrotizing soft-tissue infections (NSTIs) result in significant morbidity and mortality rates, with as many as 76% of patients dying during their index admission. Published data suggest NSTIs rarely involve fungal infections in immunocompetent patients. However, because of the recent recognition of fungal infections in our population, we hypothesized that such infections frequently complicate NSTIs and are associated with higher morbidity and mortality rates.
A prospectively maintained Acute and Critical Care Surgery (ACCS) database spanning 2008-2015 and including more than 7,000 patients was queried for patients with NSTIs. Microbiologic data, demographics, and clinical outcomes were abstracted. Risk factors and outcomes associated with NSTI with positive intra-operative fungal cultures were determined. Frequencies were compared by χ and continuous variables by the Student t-test using SPSS. Because the study included only archived data, no patient permission was needed.
A total of 230 patients were found to have NSTIs; 197 had intra-operative cultures, and 21 (10.7%) of these were positive for fungi. Fungal infection was more common in women, patients with higher body mass index (BMI), and patients who had had prior abdominal procedures. There were no significant differences in demographics, co-morbidities, or site of infection. The majority of patients (85.7%) had mixed bacterial and fungal infections; in the remaining patients, fungi were the only species isolated. Most fungal cultures were collected within 48 h of hospital admission, suggesting that the infections were not hospital acquired. Patients with positive fungal cultures required two more surgical interventions and had a three-fold greater mortality rate than patients without fungal infections.
This is the largest series to date describing the impact of fungal infection in NSTIs. Our data demonstrate a three-fold increase in the mortality rate and the need for two additional operations. Consideration should be given to starting patients on empiric anti-fungal therapy in certain circumstances.
坏死性软组织感染（NSTIs）会导致显著的发病率和死亡率，多达76%的患者在首次入院期间死亡。已发表的数据表明，在免疫功能正常的患者中，NSTIs很少涉及真菌感染。然而，由于我们最近认识到我们人群中存在真菌感染，我们推测此类感染经常使NSTIs复杂化，并与更高的发病率和死亡率相关。
查询了一个前瞻性维护的急性和重症监护手术（ACCS）数据库，该数据库涵盖2008 - 2015年，包括7000多名患者，以查找患有NSTIs的患者。提取微生物学数据、人口统计学数据和临床结果。确定与术中真菌培养阳性的NSTI相关的危险因素和结果。使用SPSS通过χ检验比较频率，通过学生t检验比较连续变量。由于该研究仅包括存档数据，因此无需患者许可。
共发现230例患者患有NSTIs；197例进行了术中培养，其中21例（10.7%）真菌培养呈阳性。真菌感染在女性、体重指数（BMI）较高的患者以及既往有腹部手术史的患者中更为常见。在人口统计学、合并症或感染部位方面没有显著差异。大多数患者（85.7%）有细菌和真菌混合感染；其余患者中，真菌是唯一分离出的菌种。大多数真菌培养是在入院后48小时内采集的，这表明感染不是医院获得性的。真菌培养阳性的患者需要多进行两次手术干预，死亡率是无真菌感染患者的三倍。
这是迄今为止描述真菌感染对NSTIs影响的最大系列研究。我们的数据表明死亡率增加了两倍，并且需要额外进行两次手术。在某些情况下，应考虑对患者开始经验性抗真菌治疗。
