Impact of Race on Outcomes and Management of Necrotizing Soft Tissue Infections

Author(s):
Brittany Fields; Elizabeth Fox; Zachary Bennett; Sierra Fleming

Background:

Necrotizing Soft Tissue Infections (NSTI) represent major morbidity and mortality, with disproportionate effect on patients of various backgrounds. Given increased mortality among Black patients with NSTI¹ we sought to identify factors affecting time to surgical debridement and subsequent survival.

Hypothesis:

We hypothesized Black race would associate with longer time to surgical debridement and higher subsequent mortality.

Methods:

Retrospective chart review between 9/1/2015 and 9/1/2020 for adult (≥18 years) patients coded with CPT/ICD-10 codes used for NSTI was performed, totaling 1,398 encounters. Of these, 121 qualified for inclusion. Patient demographics, comorbidities, presenting characteristics, and perioperative course were assessed. All but two patients identified as Black or White, therefore, data analysis was performed using 119/121 encounters. Analysis was performed using Chi-square test for categorical values and T test for continuous variables with a 0.01 threshold for statistical significance.

Results:

Of 119 patients, 48.7% identified as female and 66.9% were ≥50 years. Most patients (68.1%) presented to the Emergency Department, and more Black patients (40.6%) were initially admitted to a non-surgical service than their White counterparts (16.6%) (p <.01). There was no difference in presenting vitals. Of patients presenting to the ED, 41.2% underwent debridement within 24 hours. Mean time to surgery was 17.7 hours for Black patients and 5.3 hours for White patients (p <.01). Despite delay to surgery, there was no statistically significant difference in number of debridements or amputation between races. Overall mortality was 12.4%, and Black patients clinically demonstrated higher mortality (17.2%) than White patients (8.2%). Of all surviving patients, 60.5% discharged to home.

Conclusions:

As early surgical debridement is definitive treatment for NSTI, factors contributing to non-surgical admissions and delay in surgery merit further investigation. Such factors include comorbidities that, if exacerbated or uncontrolled, may distract from adequate assessment of NSTI; ability to identify physical exam findings, such as erythema, on darker skin; and/or bias in addressing Black patients’ complaints (e.g., pain). Limitations include its retrospective nature and our single institution sample. Most patients eligible for inclusion identified as Black or White, so expanding the study period would allow assessment of our more diverse patient population. As more data emerges regarding increasing survival, special consideration should be given to improving subsequent quality of life for these patients.