Nawijn Femke, Wassenaar Emma C E, Smeeing Diederik P J, Vlaminckx Bart J M, Reinders Jan Siert K, Wille Jan, Leenen Luke P H, Hietbrink Falco
Surgery, Universitair Medisch Centrum Utrecht, Utrecht, Netherlands.
Surgery, Sint Antonius Ziekenhuis, Nieuwegein, Netherlands.
Trauma Surg Acute Care Open. 2019 Feb 6;4(1):e000272. doi: 10.1136/tsaco-2018-000272. eCollection 2019.
Necrotizing fasciitis is a potentially lethal condition for which early and adequate treatment with surgical debridement and broad-spectrum intravenous antibiotics are essential for survival. It is hypothesized that Group A Streptococcus (GAS) necrotizing fasciitis causes exhaustion of the immune system, making these patients more susceptible for late secondary infections.
A retrospective study was conducted of all patients with necrotizing fasciitis between 2002 and 2016. Patients with necrotizing fasciitis based on macroscopic findings, positive Gram staining, culture or fresh frozen section of fascia biopsies were included. Patients with necrotizing fasciitis were divided into two groups based on the presence of GAS. Of both groups, clinical course, outcome and occurrence of late secondary infections were analyzed. For the occurrence of secondary infections, pneumonia was chosen as reference for late secondary infections.
Eighty-one patients with necrotizing fasciitis were included of which 38 (47%) had GAS necrotizing fasciitis and 43 (53%) had non-GAS necrotizing fasciitis. Patients with GAS necrotizing fasciitis were younger (50 vs. 61 years, p=0.023) and more often classified as ASA I (45% vs. 14%, p=0.002) compared with patients with non-GAS necrotizing fasciitis. In-hospital mortality rate for necrotizing fasciitis was 32%. Patients with comorbidities were more likely to die of necrotizing fasciitis compared with patients without comorbidities (OR 7.41, 95% CI 1.58 to 34.63). Twelve patients (39%) with GAS necrotizing fasciitis developed pneumonia compared with four patients (13%) with non-GAS necrotizing fasciitis (p=0.017; OR 4.42, 95% CI 1.124 to 15.79). Median time from diagnosis to development of pneumonia in patients with GAS necrotizing fasciitis was 10 days (IQR 9).
Patients with GAS necrotizing fasciitis have an increased risk to develop late secondary infections during initial treatment for necrotizing fasciitis compared with patients with necrotizing fasciitis without involvement of GAS. This suggests exhaustion of the immune system after severe GAS infection.
III.
坏死性筋膜炎是一种潜在的致命疾病，早期进行充分的手术清创治疗并使用广谱静脉抗生素是生存的关键。据推测，A组链球菌（GAS）坏死性筋膜炎会导致免疫系统耗竭，使这些患者更容易发生晚期继发感染。
对2002年至2016年间所有坏死性筋膜炎患者进行回顾性研究。纳入基于宏观表现、革兰氏染色阳性、培养或筋膜活检新鲜冰冻切片确诊为坏死性筋膜炎的患者。根据是否存在GAS将坏死性筋膜炎患者分为两组。分析两组患者的临床病程、结局及晚期继发感染的发生情况。对于继发感染的发生情况，选择肺炎作为晚期继发感染的参照。
纳入81例坏死性筋膜炎患者，其中38例（47%）为GAS坏死性筋膜炎，43例（53%）为非GAS坏死性筋膜炎。与非GAS坏死性筋膜炎患者相比，GAS坏死性筋膜炎患者更年轻（50岁对61岁，p = 0.023），且更多被分类为ASA I级（45%对14%，p = 0.002）。坏死性筋膜炎的住院死亡率为32%。与无合并症的患者相比，合并症患者死于坏死性筋膜炎的可能性更大（比值比7.41，95%置信区间1.58至34.63）。38例GAS坏死性筋膜炎患者中有12例（39%）发生肺炎，而非GAS坏死性筋膜炎患者中有4例（13%）发生肺炎（p = 0.017；比值比4.42，95%置信区间1.124至15.79）。GAS坏死性筋膜炎患者从诊断到发生肺炎的中位时间为10天（四分位间距9天）。
与非GAS累及的坏死性筋膜炎患者相比，GAS坏死性筋膜炎患者在坏死性筋膜炎初始治疗期间发生晚期继发感染的风险增加。这表明严重GAS感染后免疫系统耗竭。
III级。
