The Impact of Type of Immunosuppressive Medication in Necrotizing Soft Tissue Infections

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The Impact of Type of Immunosuppressive Medication in Necrotizing Soft Tissue Infections

Authors:
Manuel Castillo-Angeles, Avery Thompson, Reza Askari

Body of Abstract:
Background: Necrotizing soft tissue infections (NSTIs) are a group of uncommon but rapidly progressive bacterial infections with high morbidity and mortality. Prior research has shown that NSTI patients with immunocompromised status are at increased risk of delayed diagnosis and worse overall outcomes. However, It is uncertain if variation exists across different immunosuppressive medications. Our objective was to determine the impact of immunosuppression type on mortality and morbidity in patients with NSTI.

 

Methods: This was a retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database from 2021-2023. We included all adult patients with a diagnosis of NSTI, defined by ICD-10 Diagnosis codes for necrotizing fasciitis, gas gangrene, and Fournier’s gangrene. Immunosuppression therapy was defined as regular administration of oral or parenteral corticosteroids, anti-rejection/transplant immunosuppressants, synthetic or biologic Disease-Modifying Antirheumatic Drugs (DMARDs)/Disease-modifying drugs (DMDs), others, or combinations of the described medications within 30 days of the operative procedure. The primary outcomes were overall mortality and readmission within 30 days. Multivariate logistic regression was used to determine the association between immunosuppression type and main outcomes.

 

Results: A total of 2,480 NSTI patients were included, of which 151 (6.09%) received immunosuppressive therapy (41% received corticosteroids, 3.9% anti-rejection/transplant immunosuppressants, 10% synthetic, and 14% biologic DMARDs/DMDs). Mean age was 56.3 (SD 13.1) years, 30.5% were female, and 68.7% were White. Overall mortality was 9.5% for the entire cohort and 17.8% within the immunosuppressed group. After adjusting for clinical and demographic variables, immunosuppressive therapy was significantly associated with higher mortality (Odds Ratio [OR] 2.15, 95% Confidence Interval [CI] 1.01 – 4.57), driven by those receiving biologic DMARDs/DMDs (OR 7.10, 95% CI 1.20 – 14.19). It was also associated with higher odds of readmission (OR 2.37, 95% CI 1.21 – 4.63), particularly those receiving a combination of immunosuppressive medications (OR 4.43, 95% CI 1.55 – 12.62). 

 

Conclusions: Immunosuppression was significantly associated with worse mortality and readmission in NSTI patients. These associations were mainly driven by those patients receiving biologic DMARDs/DMDs and a combination of immunosuppressive medications, respectively. These results underscore the need for targeted updates to both preoperative and postoperative protocols to prevent complications in the NSTI population.

The Role of Adipokines in Mediating Immuno-metabolic Crosstalk in Burn Sepsis

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The Role of Adipokines in Mediating Immuno-metabolic Crosstalk in Burn Sepsis

Authors:
Stephanie Wojtowicz-Piotrowski, Ghazaleh Dadashizadeh, Marc G. Jeschke

Body of Abstract:
Background: As the leading cause of mortality in burn injury, burn-induced sepsis drives extensive metabolic and immune dysregulation. However, how these metabolic and inflammatory pathways interact to shape disease progression remains unknown. Adipokines, signalling molecules released from adipose tissue, are essential for functional metabolism, and control processes such as inflammation, insulin sensitivity and energy homeostasis in the adipose tissue and distant organs. Emerging evidence suggests that these molecules interact closely with pro- and anti-inflammatory cytokines and can influence the progression of sepsis in non-burn-related contexts. However, it is unknown whether similar adipokine-cytokine interactions contribute to the pathophysiology of sepsis post-burn. Therefore, this study aims to identify whether such interactions exist in burn-induced sepsis.

Methods: Serum samples from non-septic and septic adult burn patients were analyzed using ELISA to quantify circulating levels of the adipokines leptin (LEP), adiponectin (ADIPOQ), and resistin (RETN). Cytokine profiles corresponding to the same patients were analyzed using Multiplex assays. Spearman correlation analyses were then performed to determine associations between adipokine and cytokine levels within non-septic and septic burn patient groups.

Results: Circulating adipokine profiles differed significantly between septic and non-septic burn patients. Serum LEP (p < 0.001) and RETN (p < 0.05) were significantly elevated, whereas ADIPOQ was significantly reduced (p < 0.05) in septic burn patients. In Spearman rank correlation analyses, surprisingly, neither LEP nor ADIPOQ demonstrated meaningful associations with any cytokines. Remarkably, however, RETN exhibited significant, positive correlations with nine different cytokines exclusively in septic burn patients: interleukin-10 (IL-10; rs=0.8929, p=0.01), IL-6 (rs=1, p=0.0004), granulocyte colony-stimulating factor (G-CSF; rs=0.8214, p=0.03), granulocyte-macrophage colony-stimulating factor (GM-CSF; rs=0.8857, p=0.03), IL-15 (rs =0.9643, p=0.003), IL-17 (rs=0.8571, p=0.02), IL-7, (rs=0.9643, p=0.003), IL-8 (rs=0.8571, p=0.02), and monocyte chemoattractant protein-1 (MCP-1; rs=0.8571, p=0.02). Conclusions: Here, our findings reveal RETN as a uniquely activated metabolic-immune signal in burn-induced sepsis. Unlike LEP or ADIPOQ, RETN demonstrated strong, sepsis-specific correlations with a broad network of pro- and anti-inflammatory cytokines, highlighting its potential mechanistic link between metabolic dysfunction and immune dysregulation after severe burn injury. Considering the diagnostic potential of cytokines in sepsis, the magnitude of these associations underscores the promise of RETN as both a potential diagnostic marker and therapeutic target. By uncovering this previously unrecognized adipokine-cytokine axis in burn sepsis, this study opens new avenues for targeted modulation of sepsis in burn patients.

Understanding colonization with vancomycin resistant enterococcus in patients undergoing liver transplantation at an academic medical center

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Understanding colonization with vancomycin resistant enterococcus in patients undergoing liver transplantation at an academic medical center

Authors:
Eugene Liu, Yuetan Dou, Kirandeep Bains, Ivy Godana, Michael De Vera, Hansel Fletcher, James Pappas

Body of Abstract:
Background: In a prior study, we found an association with hospital onset vancomycin resistant enterococcus blood stream infections (HO VRE BSI) and liver transplantation at our academic medical center, which could explain our high rate of HO VRE BSI among major teaching hospitals in California. VRE colonization may be the underlying factor driving this association. We sought to quantify and identify factors associated with VRE colonization in liver transplant patients.

Methods: To estimate the degree of carriage and to characterize risks for acquisition of VRE, we obtained rectal swabs of patients undergoing liver transplantation within 24 hours of transplantation and 9 days post-transplant. We also obtained an intraoperative swab of the donor common bile duct (CBD) to evaluate the donor liver as a source of VRE. Swabs were cultured and VRE isolated through selective media (CHROMagar VRE containing vancomycin).

Results: Among 12 patients undergoing liver transplantation thus far, 44% (4 of 9) had VRE at the time of transplant, and 67% (4 of 6) had VRE 9 days post-transplant, with 58% (7 of 12) with VRE at any time point. VRE was not isolated in any patient who underwent donor CBD swabbing (0 of 7). VRE colonization was also not associated with age, sex, nor with receipt of any antibiotic on simple logistic regression, although we did note a non-significant association with receipt of ampicillin as an inpatient 30 days prior to transplant (OR 10.0; 95%CI 0.65-154.40; p=0.10).

Conclusions: We found rates of VRE colonization both at the time of liver transplant (44%) and 9 days later (67%) that were higher than the expected rates as observed in a meta-analysis of pre (11.9%) and post (16.2%) liver transplant patients (Ziakas et al.). However, with donor CBD swabs negative for VRE, we found no evidence of acquisition of VRE from the donor liver. The high rate of colonization in liver transplant patients may explain the higher rate of HO VRE BSI at our institution. Ongoing surveillance of liver transplant patients, particularly for HO VRE BSI, may help to clarify this association and the mechanisms of VRE colonization.

Vibrio vulnificus Necrotizing Soft Tissue Infection: Institutional Case Report and Ten-Year Systematic Literature Review

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Vibrio vulnificus Necrotizing Soft Tissue Infection: Institutional Case Report and Ten-Year Systematic Literature Review

Authors:
Susanna Hatcher, Kanhua Yin, Heather Klepacz, James Lau

Body of Abstract:
Background: Necrotizing soft tissue infections (NSTIs) caused by Vibrio vulnificus are rare but highly lethal. Early recognition, even in the setting of atypical presentation, is essential, as is prompt surgical debridement and initiation of appropriate antibiotics. Due to the rarity of this disease, published reports remain limited. In this study, we present an in-house case and perform a systematic literature review of all published cases from the past decade to provide a comprehensive synthesis of current knowledge

Methods: We report an 88-year-old patient with V. vulnificus NSTI who underwent emergent surgical debridement within hours of presentation but succumbed to overwhelming sepsis within 48 hours. We also reviewed eight published case reports and one case-control study involving 45 patients. Extracted data included presenting symptoms, risk factors, timing of surgical debridement, antibiotic regimens, and clinical outcomes

Results: All reported patients underwent urgent surgical debridement and received antibiotic therapy. Our patient experienced rapid deterioration, developing hemorrhagic bullae on the contralateral leg and extensive mottling of the thighs and abdomen shortly after the initial operation. She died two days after presentation despite multiple debridements and appropriate antibiotics. Among the nine case reports (including our case), most patients were middle-to-elderly aged (63 ± 17 years), predominantly male (70%), and commonly presented with hemorrhagic bullae (55%). Four reports (44%) used Gram staining to support early identification of Vibrio species. Six cases (67%) required adjustment of the antibiotic regimen after laboratory confirmation of V. vulnificus. More than half of patients (55%) died despite operative and medical management. Proximal limb involvement may also portend increased mortality. The case-control study found that liver disease and seawater/seafood exposure were significantly associated with V. vulnificus NSTI and that mortality was significantly higher compared with non-Vibrio NSTI

Conclusions: Early recognition of V. vulnificus NSTI requires careful attention to characteristic risk factors and key clinical features, including hemorrhagic bullae, rapidly progressive cellulitis, and exposure to seawater or seafood. Early Gram staining may help guide more targeted antimicrobial therapy. Emergent surgical debridement and appropriate antibiotics remain the backbone of treatment, although mortality remains high.

When Burns Lead to Silence: Catatonia — A Case Report

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When Burns Lead to Silence: Catatonia — A Case Report

Authors:
Carlos Semprun, Gabriel Bensimon, Shahriar Shahrokhi, Margarita Elloso

Body of Abstract:
Background:
Burn patients frequently develop infectious complications that can manifest with altered mental status, most commonly sepsis associated encephalopathy (SAE). This overlap can obscure the diagnosis of catatonia, a neuropsychiatric syndrome that requires distinct management. Limited literature exists describing catatonia in the setting of severe burns and concurrent infection.

Methods:
We present a 68-year-old man with a history of seizure disorder and depression who sustained 26% TBSA scald burns. Following burn excision and grafting, he developed profound psychomotor slowing, mutism, and posturing. His course was complicated by bacteremia and soft tissue infection, prompting broad infectious disease evaluation.

Results:
Despite active infections, the patient’s neurological findings including stupor, negativism, and intermittent decorticate/decerebrate posturing were disproportionate to his infectious status. Comprehensive CNS evaluation (MRI, CSF analysis, serial EEGs) showed no evidence of meningitis, encephalitis, or non convulsive status epilepticus. Infectious complications were appropriately treated with IV antibiotics; however, there was no associated improvement in mental status. Psychiatry consultation led to a diagnosis of catatonia. High dose lorazepam, escalated to 4 mg IV four times daily, resulted in progressive and complete resolution of symptoms, confirming the diagnosis.

Conclusion:
Infection related encephalopathy is common in burn patients and can mask or mimic catatonia, delaying recognition and treatment. This case highlights the importance of considering catatonia when mental status fails to improve despite adequate infection management. Early differentiation between infectious etiologies and catatonia is critical, as benzodiazepine therapy can rapidly reverse symptoms and prevent prolonged morbidity. Burn teams should maintain heightened awareness of catatonia when evaluating unexplained neurological deterioration in the context of infection.

When Filler becomes Fulminant: Recurrent Gluteal Necrosis After Unregulated Injection in an Immunocompromised Host

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When Filler becomes Fulminant: Recurrent Gluteal Necrosis After Unregulated Injection in an Immunocompromised Host

Authors:
Robert Giglio, Kristin Chancellor, Rohit Sharma

Body of Abstract:
Background:  

Cosmetic buttock enhancement procedures, including injectable implant material, are increasingly performed outside regulated medical environments. These procedures can introduce high risk pathogens, resulting in deep soft tissue infections with significant morbidity, especially in immunocompromised patients. We present a case of recurrent, progressive gluteal and trochanteric infection secondary to prior unregulated filler injection requiring serial debridement, dermal matrix placement, and staged skin grafting.  

 

Case Presentation:  

A 59-year-old male with advanced HIV/AIDS (CD4 22), systemic sclerosis, prior pulmonary embolism, granulomatous ILD, COPD, asthma, and a long history of chronic draining wounds from non-medical grade buttock filler first entered our system in 2018. He underwent outpatient wound care followed by right-thigh excisional debridement in 2019 with subsequent split-thickness skin grafting, which healed appropriately. 

In winter 2025, his left trochanteric wound acutely worsened with foul-smelling drainage. In May 2025, operative exploration revealed devitalized infected tissue down to fascia with extensive “cheese-like” granulomatous material extending over the gluteal musculature; the defect measured 17 × 8 cm. Cultures grew Enterococcus. After initial improvement, he developed new fluctuance, heavy drainage, and eschar formation. In July 2025 he was readmitted; debridement revealed pus-filled, grossly necrotic wounds now measuring 23 × 16 cm at the left glute and 10 × 7 cm over the sacrum. Cultures showed β-hemolytic Streptococcus and Pseudomonas aeruginosa, and he was treated with piperacillin–tazobactam and metronidazole. 

Despite outpatient wound care and serial clinic debridements, progression continued. On 10/10/25 he underwent wide excisional debridement of skin, soft tissue, and fascia of the left thigh (44 × 17 cm), XCelliStem dermal matrix placement, and negative-pressure therapy. Additional operative debridements occurred on 10/15, 10/24, and 10/27 after cultures again grew Pseudomonas, prompting meropenem therapy. He underwent split-thickness skin grafting of the sacral wound with excellent take, followed by grafting of the lateral left leg on 11/24. He remains hospitalized undergoing wound-vac management with plans for transition to wet-to-dry dressings and outpatient follow-up. 

 

Conclusion:  

Non-regulated cosmetic filler injections can result in prolonged, recurrent, and anatomically extensive infections, especially in severely immunocompromised hosts. This case demonstrates the critical need for aggressive serial debridement, meticulous wound-bed preparation, culture-directed therapy, and staged reconstruction to achieve control of infection and successful closure

Worth a Snot: A pilot study examining bronchoscopy with bronchial alveolar lavage vs quantitative endotracheal aspirates for pneumonia diagnosis in the trauma and acute care surgery population.

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Worth a Snot: A pilot study examining bronchoscopy with bronchial alveolar lavage vs quantitative endotracheal aspirates for pneumonia diagnosis in the trauma and acute care surgery population.

Authors:
Hannah Paik, Thomas Schroeppel, Brett Fair, Nathan Schmoekel, Paige Clement, Alyssa Douville

Body of Abstract:
Background:

Bronchoscopy with bronchial alveolar lavage (BAL) is the gold standard for diagnosing pneumonia in acute care surgery patients. The Infectious Disease Society of America as well as the American Thoracic Society recommend against routine bronchoscopy and BAL for diagnosis of pneumonia, as this is considered an invasive and costly procedure. However, both of these organizations represent medical specialties, and the question remains: for the trauma and acute care surgical population, can a quantitative endotracheal tracheal aspirate (ETA) be used to replace bronchoscopy and BAL for both screening and diagnosis of pneumonia? We hypothesized that a quantitative ETA could be used in place of BAL as a less invasive, more cost-effective method of confirmatory diagnosis for pneumonia.

 

Methods:

A retrospective analysis of prospectively collected data was completed at a level one trauma center where BAL is routinely used to screen for community acquired pneumonia and diagnose ventilator associated pneumonia (VAP). Patients who underwent a BAL for screening or diagnostic reasons had an ETA specimen collected from a new inline suction catheter.  Quantitative cultures were performed on both the BAL and ETA samples.  Descriptive statistics were performed on the study population.  The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated for ETA using BAL as the gold standard test.   

 

Results

Thirty patients received ETA and BAL quantitative specimens over the four-month study period. The majority of these patients (93%) were trauma patients.  The most common reason for ventilation was traumatic brain injury.   Most patients were male (66%) with mean age of 42 years (IQR 15,86). Of the thirty specimens compared 90% were concordant.  Organisms of the specimens were the same 100% of the time.  Patients with VAP had K. aerogenes most commonly, with other organisms including E. coli, MSSA and S. pneumoniae. When diagnosing pneumonia, the ETA was found to have a 100% sensitivity and an 88% specificity. The positive predictive value was 50% and the negative predictive value of 100%.   Overall, preliminary data demonstrates a 90% accuracy.

 

Conclusions

In this pilot study, preliminary data shows quantitative ETA could provide a less invasive and cost-effective alternative to the BAL.  More research is needed to validate the ETA and to determine what level of accuracy is clinically acceptable.

Temporal Trends in Donor Site Infection After Burn Injury

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Temporal Trends in Donor Site Infection After Burn Injury

Authors:
Parisa Oviedo, Allison Berndtson, Laura Haines, Jeanne Lee, Jarrett Santorelli

Body of Abstract:
Background: Burn patients are vulnerable to infection due to loss of skin barrier, frequent operative procedures, broad-spectrum antibiotic exposure, and prolonged critical illness. Prior studies in burn populations demonstrate that total body surface area (TBSA) and hospitalization duration are associated with multidrug-resistant organism (MDRO) infections, but temporal patterns in burn-related infections— particularly donor site infections, a significant morbidity following autografting—remain poorly characterized. We hypothesized that the prevalence of MDRO infections and donor site infections would vary by month or season.

Methods: We performed a single-institution retrospective cohort study of burn patients admitted from 2015–2019 using a burn registry at an American Burn Association verified center. Culture positivity and organism data were recorded per patient. MDRO infection was defined as the presence of one or more organism belonging to the following resistance classes: MRSA, ESBL, CRE, or VRE. Temporal variables included admission month, quarter, and year. Associations between infection prevalence and temporal measures were assessed using chi-square testing and logistic regression, with adjustment for TBSA in multivariable models.

Results: 794 burn patients, 139 (17.5%) developed an MDRO infection. MDRO prevalence did not differ by quarter (p=0.425), and quarter was not predictive of MDRO after adjusting for TBSA (p=0.762). TBSA was a strong independent predictor of MDRO infection, with each 1% increase in TBSA associated with an 8.0% increase in odds of MDRO (OR 1.080; p<0.001). No individual MDRO resistance class demonstrated significant month- or quarter-level variation (all p>0.05). In contrast, donor site infection rates varied significantly by month (p=0.003). As shown in Figure 1, the highest monthly rate occurred in February (20.0%) and August (16.2%) and the lowest rates occurred in April (1.7%) and October (2.4%). However, donor site infection did not vary by calendar quarter (p=0.345). TBSA was not significantly associated with donor site infection (p=0.904).

Conclusion: MDRO epidemiology in burn patients remained stable across seasons and years, with burn size—not temporality—predicting MDRO risk. Donor site infections showed significant month-to-month variation that was not explained by TBSA or broader seasonal categories, underscoring the need for further study into factors contributing to this month-specific variability. Further investigation should examine organism-level trends in donor site infections if wound cultures are available, and other potential drivers of this temporal variability.

The Demographics of Mesh Infections

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The Demographics of Mesh Infections

Authors:
Coleman Miller, Edwin George Mathew, Thomas Clements, Julie Holihan, Dalya Ferguson, Jonah Stulberg

Body of Abstract:
Background

The American College of Surgeons estimates that more than 600,000 ventral hernia repairs are performed in the US annually. Estimates suggest that between 2% and 10% of ventral hernia repairs result in a surgical site infection with rates based on patient factors such as body mass index, diabetes, active smoking and immunosuppression. Surgical factors such as an open versus a minimally invasive approach, influence the risk of developing a surgical site infection, and there is data to suggest that mesh location and the type of mesh used effect the ability to clear an infection with antibiotics.  However, very little is known about patients who develop chronic mesh infections that require surgical intervention. This lack of data inhibits our ability to prevent this devastating problem. The goal of this study is to describe patient and mesh characteristics associated with the development of a mesh infection requiring surgical removal.

Methods

We conducted a case series analysis utilizing our institution’s hernia quality registry that capture 100% of the hernia repairs performed in our hernia center since August of 2021. Once a subset of cases referred to us for management of a chronic mesh infection were identified, we utilized chart review to investigate patient, hernia and mesh characteristics relevant to development of and management of a chronic mesh infection.

Results

Of the 662 patients in our database that have undergone ventral hernia repair, 17 (2.6%) of them were referred to us with a chronic mesh infection. The median age of these patients was 61 years (IQR 17) and median BMI was 36 (IQR 8.6).Nine (53%) were male, seven (41%) were diabetic and four (24%) were active smokers. In 14 (76%) patients, infected mesh was found to be in the underlay location, two (12%) patients had infected mesh in the onlay position, and one (6%) infected mesh was in the retro-rectus position. Eight (47%) patients had an enterocutaneous fistula to their infected mesh.

Conclusion

Chronic mesh infection after ventral hernia repair is a rare complication that is likely multifactorial. There is minimal quality data regarding those who develop chronic mesh infection. Further studies are needed to assess the relationship between these variables and the development of mesh infections.

The Impact of Antibiotic Escalation in Necrotizing Soft Tissue Infections: A Single Institution Experience

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The Impact of Antibiotic Escalation in Necrotizing Soft Tissue Infections: A Single Institution Experience

Authors:
Courtney Collins, Clark Ingram, Christine Dart, Anthony Gerlach, Holly Baselice, John Loftus, Jon Wisler, Anahita Jalilvand

Body of Abstract:
Introduction: Urgent surgical debridement with initial broad-spectrum antibiotics is the mainstay for achieving source control for necrotizing soft tissue infections (NSTIs). However, little is known regarding the clinical course for NSTI patients who require antibiotic escalation. This study characterizes hospital outcomes for NSTI patients requiring antibiotic escalation after debridement. Secondary objectives were determining patterns in microbial and antibiotic usage associated with escalation therapy.   

Methods: We conducted a retrospective review of 625 NSTI patients at a large volume tertiary institution (2013-2023). A chart review was conducted to obtain baseline characteristics, presentation severity, and operative, microbial and antibiotic data, and 90-day outcomes. Antibiotic escalation was determined when wound culture data prompted antibiotic change due to inadequate initial therapy. In this study, we compared granular NSTI characteristics, antibiotic usage, and clinical trajectories between patients requiring antibiotic escalation (AbxEscal, 22.6%, n =141) and those who did not (n =484). A p <0.05 was considered significant.  Results: Compared to controls, the AbxEscal group had higher median Charlson Comorbidity scores (4(2-6) vs 3(2-5), p = 0.05), more females (57% vs 44%, p = 0.009), and more often had a history of previous sepsis (18.4% vs 10.5%, p=0.01) and leukemia (4.3% vs 0.6%, p =0.005). Median SOFA scores were higher in the AbxEscal vs control cohort (3(1-5) vs 2(1-4), p<0.005). The AbxEscal group was more likely to have NSTIs of the head, neck, or trunk. There was no difference in time to debridement between groups. Microbial analysis revealed higher prevalence of MRSA (21% vs 11%, p = 0.006), VRE (12.1% vs 0%, p <0.005), ESBL (15.6% vs 0.8%, p <0.005), and fluconazole resistant candida (8.5% vs 0%, p <0.0005) for patients requiring antibiotic escalation. The most common escalated antibiotics were antifungals (69%), followed by Ertapenem (17%) and Daptomycin (17%). Compared to controls, the AbxEscal cohort was more likely to require ICU (81% vs 57%, p <0.005), undergo 3+ debridements (42% vs 19%, p<0.005), and exhibit higher in-hospital (12% vs 6%, p =0.05) and cumulative 90-day mortality (21% vs 11%, p =0.003). Antibiotic escalation remained an independent predictor of ICU length of stay (OR: 2.7, 95th CI: 1.6-4.6) and 3+ debridements (OR 2.9, 95th CI: 1.9-4.5) after controlling for SOFA, Charlson Comorbidity index and NSTI location.  Discussion: One fifth of the cohort required antibiotic escalation based on culture data and exhibited worse outcomes. Antibiotic escalation was strongly associated with index morbidity, even after adjusting for sepsis severity and comorbidities. The correlation between antibiotic escalation and resistant microbial flora may highlight an opportunity for improving initial antibiotic management in a subset of high risk NSTI patients.