Impact of intravenous immunoglobulin on survival in necrotizing fasciitis with vasopressor-dependent shock: A propensity score-matched analysis from 130 US hospitals

Sameer S. Kadri, Bruce J. Swihart, Stephanie Bonne, Samuel F. Hohmann, Laura V. Hennessy, Peter Louras, Heather L. Evans, Chanu Rhee, Anthony F. Suffredini, David C. Hooper, Dean A. Follmann, Eileen M. Bulger, Robert L. Danner

Research output: Contribution to journalArticle

24 Citations (Scopus)

Abstract

Background. Shock frequently complicates necrotizing fasciitis (NF) caused by group A Streptococcus (GAS) or Staphylococcus aureus. Intravenous immunoglobulin (IVIG) is sometimes administered for presumptive toxic shock syndrome (TSS), but its frequency of use and efficacy are unclear. Methods. Adult patients with NF and vasopressor-dependent shock undergoing surgical debridement from 2010 to 2014 were identified at 130 US hospitals. IVIG cases were propensity-matched and risk-adjusted. The primary outcome was in-hospital mortality and the secondary outcome was median length of stay (LOS). Results. Of 4127 cases of debrided NF with shock at 121 centers, only 164 patients (4%) at 61 centers received IVIG. IVIG subjects were younger with lower comorbidity indices, but higher illness severity. Clindamycin and vasopressor intensity were higher among IVIG cases, as was coding for TSS and GAS. In-hospital mortality did not differ between matched IVIG and non-IVIG groups (crude mortality, 27.3% vs 23.6%; adjusted odds ratio, 1.00 [95% confidence interval, .55-1.83]; P = .99). Early IVIG (≤2 days) did not alter this effect (P = .99). Among patients coded for TSS, GAS, and/or S. aureus, IVIG use was still unusual (59/868 [6.8%]) and lacked benefit (P = .63). Median LOS was similar between IVIG and non-IVIG groups (26 [13-49] vs 26 [11-43]; P = .84). Positive predictive values for identifying true NF and debridement among IVIG cases using our algorithms were 97% and 89%, respectively, based on records review at 4 hospitals. Conclusions. Adjunctive IVIG was administered infrequently in NF with shock and had no apparent impact on mortality or hospital LOS beyond that achieved with debridement and antibiotics.

Original languageEnglish (US)
Pages (from-to)877-885
Number of pages9
JournalClinical Infectious Diseases
Volume64
Issue number7
DOIs
StatePublished - Apr 1 2017

Fingerprint

Necrotizing Fasciitis
Propensity Score
Intravenous Immunoglobulins
Shock
Survival
Length of Stay
Debridement
Septic Shock
Streptococcus
Hospital Mortality
Staphylococcus aureus
Immunoglobulins
Severity of Illness Index
Surgical Shock
Clindamycin
Mortality
Comorbidity
Odds Ratio

All Science Journal Classification (ASJC) codes

  • Microbiology (medical)
  • Infectious Diseases

Keywords

  • Intravenous immunoglobulin
  • Necrotizing fasciitis
  • Toxic shock

Cite this

Kadri, Sameer S. ; Swihart, Bruce J. ; Bonne, Stephanie ; Hohmann, Samuel F. ; Hennessy, Laura V. ; Louras, Peter ; Evans, Heather L. ; Rhee, Chanu ; Suffredini, Anthony F. ; Hooper, David C. ; Follmann, Dean A. ; Bulger, Eileen M. ; Danner, Robert L. / Impact of intravenous immunoglobulin on survival in necrotizing fasciitis with vasopressor-dependent shock : A propensity score-matched analysis from 130 US hospitals. In: Clinical Infectious Diseases. 2017 ; Vol. 64, No. 7. pp. 877-885.
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abstract = "Background. Shock frequently complicates necrotizing fasciitis (NF) caused by group A Streptococcus (GAS) or Staphylococcus aureus. Intravenous immunoglobulin (IVIG) is sometimes administered for presumptive toxic shock syndrome (TSS), but its frequency of use and efficacy are unclear. Methods. Adult patients with NF and vasopressor-dependent shock undergoing surgical debridement from 2010 to 2014 were identified at 130 US hospitals. IVIG cases were propensity-matched and risk-adjusted. The primary outcome was in-hospital mortality and the secondary outcome was median length of stay (LOS). Results. Of 4127 cases of debrided NF with shock at 121 centers, only 164 patients (4{\%}) at 61 centers received IVIG. IVIG subjects were younger with lower comorbidity indices, but higher illness severity. Clindamycin and vasopressor intensity were higher among IVIG cases, as was coding for TSS and GAS. In-hospital mortality did not differ between matched IVIG and non-IVIG groups (crude mortality, 27.3{\%} vs 23.6{\%}; adjusted odds ratio, 1.00 [95{\%} confidence interval, .55-1.83]; P = .99). Early IVIG (≤2 days) did not alter this effect (P = .99). Among patients coded for TSS, GAS, and/or S. aureus, IVIG use was still unusual (59/868 [6.8{\%}]) and lacked benefit (P = .63). Median LOS was similar between IVIG and non-IVIG groups (26 [13-49] vs 26 [11-43]; P = .84). Positive predictive values for identifying true NF and debridement among IVIG cases using our algorithms were 97{\%} and 89{\%}, respectively, based on records review at 4 hospitals. Conclusions. Adjunctive IVIG was administered infrequently in NF with shock and had no apparent impact on mortality or hospital LOS beyond that achieved with debridement and antibiotics.",
keywords = "Intravenous immunoglobulin, Necrotizing fasciitis, Toxic shock",
author = "Kadri, {Sameer S.} and Swihart, {Bruce J.} and Stephanie Bonne and Hohmann, {Samuel F.} and Hennessy, {Laura V.} and Peter Louras and Evans, {Heather L.} and Chanu Rhee and Suffredini, {Anthony F.} and Hooper, {David C.} and Follmann, {Dean A.} and Bulger, {Eileen M.} and Danner, {Robert L.}",
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Kadri, SS, Swihart, BJ, Bonne, S, Hohmann, SF, Hennessy, LV, Louras, P, Evans, HL, Rhee, C, Suffredini, AF, Hooper, DC, Follmann, DA, Bulger, EM & Danner, RL 2017, 'Impact of intravenous immunoglobulin on survival in necrotizing fasciitis with vasopressor-dependent shock: A propensity score-matched analysis from 130 US hospitals', Clinical Infectious Diseases, vol. 64, no. 7, pp. 877-885. https://doi.org/10.1093/cid/ciw871

Impact of intravenous immunoglobulin on survival in necrotizing fasciitis with vasopressor-dependent shock : A propensity score-matched analysis from 130 US hospitals. / Kadri, Sameer S.; Swihart, Bruce J.; Bonne, Stephanie; Hohmann, Samuel F.; Hennessy, Laura V.; Louras, Peter; Evans, Heather L.; Rhee, Chanu; Suffredini, Anthony F.; Hooper, David C.; Follmann, Dean A.; Bulger, Eileen M.; Danner, Robert L.

In: Clinical Infectious Diseases, Vol. 64, No. 7, 01.04.2017, p. 877-885.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Impact of intravenous immunoglobulin on survival in necrotizing fasciitis with vasopressor-dependent shock

T2 - A propensity score-matched analysis from 130 US hospitals

AU - Kadri, Sameer S.

AU - Swihart, Bruce J.

AU - Bonne, Stephanie

AU - Hohmann, Samuel F.

AU - Hennessy, Laura V.

AU - Louras, Peter

AU - Evans, Heather L.

AU - Rhee, Chanu

AU - Suffredini, Anthony F.

AU - Hooper, David C.

AU - Follmann, Dean A.

AU - Bulger, Eileen M.

AU - Danner, Robert L.

PY - 2017/4/1

Y1 - 2017/4/1

N2 - Background. Shock frequently complicates necrotizing fasciitis (NF) caused by group A Streptococcus (GAS) or Staphylococcus aureus. Intravenous immunoglobulin (IVIG) is sometimes administered for presumptive toxic shock syndrome (TSS), but its frequency of use and efficacy are unclear. Methods. Adult patients with NF and vasopressor-dependent shock undergoing surgical debridement from 2010 to 2014 were identified at 130 US hospitals. IVIG cases were propensity-matched and risk-adjusted. The primary outcome was in-hospital mortality and the secondary outcome was median length of stay (LOS). Results. Of 4127 cases of debrided NF with shock at 121 centers, only 164 patients (4%) at 61 centers received IVIG. IVIG subjects were younger with lower comorbidity indices, but higher illness severity. Clindamycin and vasopressor intensity were higher among IVIG cases, as was coding for TSS and GAS. In-hospital mortality did not differ between matched IVIG and non-IVIG groups (crude mortality, 27.3% vs 23.6%; adjusted odds ratio, 1.00 [95% confidence interval, .55-1.83]; P = .99). Early IVIG (≤2 days) did not alter this effect (P = .99). Among patients coded for TSS, GAS, and/or S. aureus, IVIG use was still unusual (59/868 [6.8%]) and lacked benefit (P = .63). Median LOS was similar between IVIG and non-IVIG groups (26 [13-49] vs 26 [11-43]; P = .84). Positive predictive values for identifying true NF and debridement among IVIG cases using our algorithms were 97% and 89%, respectively, based on records review at 4 hospitals. Conclusions. Adjunctive IVIG was administered infrequently in NF with shock and had no apparent impact on mortality or hospital LOS beyond that achieved with debridement and antibiotics.

AB - Background. Shock frequently complicates necrotizing fasciitis (NF) caused by group A Streptococcus (GAS) or Staphylococcus aureus. Intravenous immunoglobulin (IVIG) is sometimes administered for presumptive toxic shock syndrome (TSS), but its frequency of use and efficacy are unclear. Methods. Adult patients with NF and vasopressor-dependent shock undergoing surgical debridement from 2010 to 2014 were identified at 130 US hospitals. IVIG cases were propensity-matched and risk-adjusted. The primary outcome was in-hospital mortality and the secondary outcome was median length of stay (LOS). Results. Of 4127 cases of debrided NF with shock at 121 centers, only 164 patients (4%) at 61 centers received IVIG. IVIG subjects were younger with lower comorbidity indices, but higher illness severity. Clindamycin and vasopressor intensity were higher among IVIG cases, as was coding for TSS and GAS. In-hospital mortality did not differ between matched IVIG and non-IVIG groups (crude mortality, 27.3% vs 23.6%; adjusted odds ratio, 1.00 [95% confidence interval, .55-1.83]; P = .99). Early IVIG (≤2 days) did not alter this effect (P = .99). Among patients coded for TSS, GAS, and/or S. aureus, IVIG use was still unusual (59/868 [6.8%]) and lacked benefit (P = .63). Median LOS was similar between IVIG and non-IVIG groups (26 [13-49] vs 26 [11-43]; P = .84). Positive predictive values for identifying true NF and debridement among IVIG cases using our algorithms were 97% and 89%, respectively, based on records review at 4 hospitals. Conclusions. Adjunctive IVIG was administered infrequently in NF with shock and had no apparent impact on mortality or hospital LOS beyond that achieved with debridement and antibiotics.

KW - Intravenous immunoglobulin

KW - Necrotizing fasciitis

KW - Toxic shock

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U2 - https://doi.org/10.1093/cid/ciw871

DO - https://doi.org/10.1093/cid/ciw871

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