title: Impact of Intravenous Immunoglobulin on Survival in Necrotizing Fasciitis With Vasopressor-Dependent Shock: A Propensity Score-Matched Analysis From 130 US Hospitals.
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.
authors.affiliation: Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland.|Division of Infectious Diseases, Massachusetts General Hospital, Boston.
authors.forename: Sameer S
authors.initials: SS
authors.lastname: Kadri
authors.affiliation: Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland.
authors.forename: Bruce J
authors.initials: BJ
authors.lastname: Swihart
authors.affiliation: Department of General Surgery, Barnes Jewish Hospital, St Louis, Missouri.
authors.forename: Stephanie L
authors.initials: SL
authors.lastname: Bonne
authors.affiliation: Vizient, and.|Department of Health Systems Management, Rush University, Chicago, Illinois.
authors.forename: Samuel F
authors.initials: SF
authors.lastname: Hohmann
authors.affiliation: Department of Surgery, Harborview Medical Center, Seattle, Washington; and.
authors.forename: Laura V
authors.initials: LV
authors.lastname: Hennessy
authors.affiliation: Department of Surgery, Harborview Medical Center, Seattle, Washington; and.
authors.forename: Peter
authors.initials: P
authors.lastname: Louras
authors.affiliation: Department of Surgery, Harborview Medical Center, Seattle, Washington; and.
authors.forename: Heather L
authors.initials: HL
authors.lastname: Evans
authors.affiliation: Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts.
authors.forename: Chanu
authors.initials: C
authors.lastname: Rhee
authors.affiliation: Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland.
authors.forename: Anthony F
authors.initials: AF
authors.lastname: Suffredini
authors.affiliation: Division of Infectious Diseases, Massachusetts General Hospital, Boston.
authors.forename: David C
authors.initials: DC
authors.lastname: Hooper
authors.affiliation: Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland.
authors.forename: Dean A
authors.initials: DA
authors.lastname: Follmann
authors.affiliation: Department of Surgery, Harborview Medical Center, Seattle, Washington; and.
authors.forename: Eileen M
authors.initials: EM
authors.lastname: Bulger
authors.affiliation: Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland.
authors.forename: Robert L
authors.initials: RL
authors.lastname: Danner
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D019115:Fasciitis, Necrotizing / Q000150:complications* / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D057216:Propensity Score; D012189:Retrospective Studies; D012720:Severity of Illness Index; D012769:Shock / Q000150:complications* / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality; D012772:Shock, Septic / Q000150:complications / Q000188:drug therapy / Q000401:mortality; D013211:Staphylococcus aureus; D013297:Streptococcus pyogenes; D016896:Treatment Outcome; D014481:United States; D055815:Young Adult
chemical_list: D016756:Immunoglobulins, Intravenous
keywords: intravenous immunoglobulin; necrotizing fasciitis.; toxic shock