• Mitri K Khoury, Maryanne L Pickett, Michael W Cripps, So-Youn Park, Madjuri B Nagaraj, Tjasa Hranjec, and Sara A Hennessy.
• Department of Surgery; Division of General and Acute Care Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
• Surg Infect (Larchmt). 2020 Mar 1; 21 (2): 136-142.

Abstract Background: Necrotizing soft tissue infections (NSTI) are a surgical emergency with significant morbidity and mortality rates. It has been thought that NSTIs are best treated in large tertiary centers. However, the effect of transfer has been under-studied. We examined whether transfer status is associated with a higher mortality rate in NSTIs. Methods: We conducted a retrospective review of patients with an International Classification of Disease (ICD) code associated with NSTI seen from 2012-2015 at two tertiary care institutions. Patients transferred to a tertiary center (T-NSTI) were compared with those who were treated initially at a tertiary center (P-NSTI). The primary endpoint was in-hospital death. Results: A total of 138 patients with NSTI met our study criteria, 39 transfer patients (28.0%) and 99 (72.0%) who were treated primarily at our institutions. The mortality rate was significantly higher for T-NSTI patients than P-NSTI patients (35.9% versus 14.1%; p < 0.01) with an adjusted odds ratio of 5.33 (95% confidence interval 1.02-28.30; p = 0.04). The need for hemodialysis was an independent predictor of in-hospital death. Treatment at a Level 1 trauma center and current smoking status were independent protectors???? of in-hospital death. For the transfer patients, the timing of transfer and debridement status were not different in survivors and non-survivors. However, there was a trend toward a lower in-hospital mortality rate if patients were transferred early without prior debridement than in all other transfers (21.4% versus 40.0%; p = 0.21). The in-hospital mortality rate was significantly lower at the Level 1 trauma center than at the non-trauma tertiary center (15.5% versus 34.3%; p = 0.02). Conclusion: Transfer status is an independent predictor of in-hospital death in patients with NSTI. Larger, multi-institutional studies are needed to elucidate further what factors contribute to the higher mortality rate in these patients.

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