The Role of Burn Centers in the Treatment of Necrotizing Soft-Tissue Infections: A Nationwide Dutch Study

Abstract

Patients with extensive and complex wounds due to Necrotizing Soft-Tissue Infections (NSTI) may be referred to a burn center. This study describes the characteristics, outcomes, as well as diagnostic challenges of these patients. Patients admitted to three hospitals with a burn center for the treatment of NSTI in a 5-year period were included. Eighty patients (median age 54 years, 60% male) were identified, of whom 30 (38%) were referred by other centers, usually after survival of the initial septic phase. Those referred from other centers, compared to those primarily admitted to the study hospitals, were more likely to have group A streptococcal involvement (62% vs 35%, p = .02), larger wounds (median 7% vs 2% total body surface area, p < .001), and a longer length of stay (median 49 vs 22 days, p < .001). Despite a high incidence of septic shock (50%), the mortality rate was low (12%) for those primarily admitted. Approximately half (53%) of the patients were initially misdiagnosed upon presentation, which was associated with delay to first surgery (16 hours vs 4 hours, p < .001). Those initially misdiagnosed had more (severe) comorbidities, and less frequently reported pain or blue livid discoloration of the skin. This study underlines the burn centers' function as referral centers for extensively affected patients with NSTI. Besides the unique wound and reconstructive expertise, the low mortality rate indicates these centers provide adequate acute care as well. A major remaining challenge remains recognition of the disease upon presentation. Future studies in which factors associated with misdiagnosis are explored are needed.

Figure 1.

The distribution of different phases in which (n = 30) patients were referred to the burn centers. Five different phases were discerned. Pre-work diagnosis (patient referred before NSTI was suspected), Pre-operative (NSTI suspected, but not yet confirmed surgically), Acute post-operative (Phase from first surgery until detubation, stop of vasopression and CRP <100), Stabilization phase (detubated, no vasopression needed, CRP <100 mg/L until fist reconstructive surgery) and Reconstructive phase (from first reconstructive surgery until discharge).

Figure 2.

Prevalence of various relevant characteristics of patients presenting with NSTI, for those that were directly diagnosed correctly (n = 36) vs those initially misdiagnosed (n = 40). Differences for those marked with one asterisk (*) are statistically significant with p < .05 when comparing groups, while those marked with two asterisks (**) were also independent, significant predictors within the multivariable regression analysis.