• Emily Z Keung, Xiaoxia Liu, Afrin Nuzhad, Christopher Adams, Stanley W Ashley, and Reza Askari.
• Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA.
• JAMA Surg. 2013 May 1; 148 (5): 419-26.

ImportanceThere is a scarcity of research on immunocompromised patients with necrotizing soft-tissue infection (NSTI).ObjectiveTo evaluate the effect of immunocompromised status in patients with NSTI.Design And SettingSingle-institution retrospective cohort study at a tertiary academic teaching hospital affiliated with a major cancer center.ParticipantsPatients with NSTI.ExposureTreatment at Brigham and Women's Hospital and Dana-Farber Cancer Institute between November 25, 1995, and April 25, 2011.Main Outcome And MeasureNecrotizing soft-tissue infection-associated in-hospital mortality.ResultsTwo hundred one patients were diagnosed as having NSTI. Forty-six were immunocompromised (as defined by corticosteroid use, active malignancy, receipt of chemotherapy or radiation therapy, diagnosis of human immunodeficiency virus or AIDS, or prior solid organ or bone marrow transplantation with receipt of chronic immunosuppression). At presentation, immunocompromised patients had lower systolic blood pressure (105 vs 112 mm Hg, P = .02), glucose level (124 vs 134 mg/dL, P = .03), and white blood cell count (6600/μL vs 17 200/μL, P < .001) compared with immunocompetent patients. Immunocompromised patients were less likely to have been transferred from another institution (26.1% vs 52.9%, P = .001), admitted to a surgical service (45.7% vs 83.2%, P < .001), or undergone surgical debridement on admission (4.3% vs 61.3%, P = .001). Time to diagnosis and time to first surgical procedure were delayed in immunocompromised patients (P < .001 and P = .001, respectively). Immunocompromised patients had higher NSTI-associated in-hospital mortality (39.1% vs 19.4%, P = .01).ConclusionsAND RELEVANCE Immunocompromised status in patients with NSTI in this study is associated with delays in diagnosis and surgical treatment and with higher NSTI-associated in-hospital mortality. At presentation, immunocompromised patients may fail to exhibit typical clinical and laboratory signs of NSTI. Physicians caring for similar patient populations should maintain a heightened level of suspicion for NSTI and consider early surgical evaluation and treatment.

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