Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA.
Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.
Surg Infect (Larchmt). 2022 Jun;23(5):430-435. doi: 10.1089/sur.2022.011. Epub 2022 Apr 22.
Early debridement improves outcome in necrotizing soft tissue infection (NSTI), but there is no consensus on duration of antimicrobial therapy. We recently changed practice to discontinue antibiotic agents early with a goal of 48 hours after adequate source control. We hypothesized that discontinuing antibiotic agents after a short course is safe in the treatment of NSTI. This was a prospective study of patients with NSTI comparing short duration of antibiotic agents to a control population after a change in practice. In 2018 we began discontinuing antibiotic agents within 48 hours of source control (absence of cellulitis and no evidence of active infection). Previously, antibiotic duration was at the discretion of the attending surgeon (generally 7-10 days). Patients were excluded from analysis if they were initially debrided at a referring facility, immune compromised, or died prior to source control. Patient characteristics and outcomes were evaluated. The primary outcome was treatment failure requiring antibiotic agents to be restarted with or without further debridement of infected tissue. Secondary outcomes included the duration of antibiotic therapy after source control. We evaluated 151 patients; 119 admitted between January 1, 2011 and January 31, 2018 (PRE) and 32 admitted after January 31, 2018 (POST). Patients were not statistically different regarding characteristics, admission physiologic variables, and comorbidities. The median duration of antibiotic agents after source control in the PRE group was 180.3 hours (interquartile range [IQR], 100.7-318.8) versus 48 hours (IQR, 32.3-100.8) in the POST group (p < 0.01). Patients in each group were treated as described above, and treatment failure occurred in seven (5.9%) PRE patients and two (6.3%) POST (99.3% post hoc power at non-inferiority limit 20%, significance p < 0.05). Thirty-day all-cause mortality was not different between groups (6.7% vs. 6.3%; p = 0.94). Short-duration (48 hours) antibiotic agents after NSTI source control is as safe and effective as a longer course.
早期清创可以改善坏死性软组织感染（NSTI）的预后，但对于抗菌治疗的持续时间尚无共识。我们最近改变了治疗方法，即通过适当的源头控制，在 48 小时内尽早停止使用抗生素。我们假设，在 NSTI 治疗中，短疗程的抗生素治疗是安全的。这是一项前瞻性研究，比较了 NSTI 患者在治疗方法改变后使用短疗程抗生素与对照组的情况。2018 年，我们开始在源头控制后 48 小时内（无蜂窝织炎且无活动性感染的证据）停止使用抗生素。在此之前，抗生素的持续时间由主治外科医生决定（通常为 7-10 天）。如果患者最初在转诊机构进行清创、免疫功能低下或在源头控制前死亡，则将其排除在分析之外。评估了患者的特征和结局。主要结局是需要重新开始使用抗生素治疗的治疗失败，无论是否对感染组织进行进一步清创。次要结局包括源头控制后抗生素治疗的持续时间。我们评估了 151 名患者；119 名患者于 2011 年 1 月 1 日至 2018 年 1 月 31 日（PRE）入院，32 名患者于 2018 年 1 月 31 日（POST）后入院。两组患者在特征、入院生理变量和合并症方面无统计学差异。PRE 组中，源头控制后抗生素的中位持续时间为 180.3 小时（IQR，100.7-318.8），而 POST 组为 48 小时（IQR，32.3-100.8）（p<0.01）。两组患者均按照上述方法进行治疗，PRE 组中有 7 例（5.9%）和 POST 组中有 2 例（6.3%）患者治疗失败（非劣效性 20%的事后检验效能为 99.3%，意义 p<0.05）。两组患者 30 天全因死亡率无差异（6.7% vs. 6.3%；p=0.94）。NSTI 源头控制后，短疗程（48 小时）抗生素治疗与长疗程一样安全有效。
