Long-term quality of life in necrotizing soft-tissue infection survivors: a monocentric prospective cohort study

Abstract

Background: Compared to other life-threatening infection survivors, long-term health-related quality of life (QOL) of patients surviving necrotizing soft-tissue infections (NSTI) and its determinants are little known. In this monocentric prospective cohort including NSTI survivors admitted between 2014 and 2017, QOL was assessed during a phone interview using the 36-Item Short-Form Health Survey (SF-36), the Hospital Anxiety and Depression (HAD), the activity of daily living (ADL), instrumental ADL (IADL) scales and the Impact of Event Scale-Revised (IES-R). The primary outcome measure was the SF-36 physical component summary (PCS). NSTI patients were compared according to intensive care unit (ICU) admission status. ICU survivors were matched on SAPS II with non-NSTI related septic shock survivors.

Results: Forty-nine NSTI survivors were phone-interviewed and included in the study. Median PCS was decreased compared to the reference population [- 0.97 (- 2.27; - 0.08) SD]. Previous cardiac disease was the only variable associated with PCS alteration [multivariate regression coefficient: - 8.86 (- 17.64; - 0.07), p = 0.048]. Of NSTI survivors, 15.2% had a HAD-D score ≥ 5 and 61.2% an IES-R score ≥ 33. ICU admission was not associated with lower PCS [35.21 (25.49-46.54) versus (vs) 41.82 (24.12-51.01), p = 0.516], but with higher IES-R score [14 (7.5-34) vs 7 (3-18), p = 0.035] and a higher proportion of HAD-D score ≥ 5 (28.6 vs 4.0%, p = 0.036). Compared to non-NSTI septic shock-matched controls, NSTI patients had similar PCS [33.81 (24.58; - 44.39) vs 44.87 (26.71; - 56.01), p = 0.706] but higher HAD-D [3.5 (1-7) vs 3 (1.5-6), p = 0.048] and IES-R scores [18 (8-35) vs 8 (3-19), p = 0.049].

Conclusions: Long-term QOL in NSTI survivors is severely impaired, similarly to that of non-NSTI septic shock patients for physical compartments, but with more frequent depressive and/or post-traumatic stress disorders. Only ICU admission and previous cardiac disease were predictive of QOL impairment.

Keywords: Critical care; Intensive care unit; Necrotizing fasciitis; Necrotizing soft-tissue infection; Outcome; Quality of life; SF-36; Septic shock.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1

Study flowchart. Necrotizing soft tissue infection (NSTI) survivors (n  =  49) admitted (n  =  24) or not (n  =  25) to the intensive care unit (ICU) were included in the study. First, association of admission characteristics to the long-term health-related quality of life (QOL) of all NSTI survivors was assessed. Then, in order to explore the impact of both NSTI itself and of ICU admission on QOL, NSTI patients admitted to the ICU (n  =  24) were compared to: (1) non-ICU-admitted (n  =  25) NSTI patients; and (2) ICU-admitted non-NSTI septic shock patients (n  =  32) after SAPS II matching. The 24 NSTI patients admitted to the ICU were matched according to SAPS II on a 1:1 ratio for 10 patients and a 1:2 ratio for 11 patients, with 3 patients finding no match, to a total of 32 non-NSTI septic shock patients

Fig. 2

SF-36 questionnaire results in exposed (ICU-admitted NSTI survivors) and non-exposed (non-NSTI septic shock survivors) patients. A Comparison of the physical (PCS) and mental (PCS) component summaries of the SF-36 questionnaire between patients surviving necrotizing soft tissue infections (“ICU-admitted NSTI”, dark blue) and patients surviving a septic shock from other cause (“non-NSTI septic shock”, light blue). Results are centered on the value of 50 (dashed line; values  >  or  <  50 reflected values higher or lower than age-sex standardized French values). *p values come from a mixed logistic regression with adjustment for sex, SAPS II and the time between ICU discharge and phone interview, with pair as a random effect. B Comparison of each subdomain of the SF-36 questionnaire between patients surviving necrotizing soft tissue infections (“ICU-admitted NSTI”, dark blue) and patients surviving a septic shock from other cause (“non-NSTI septic shock”, light blue). The “physical functioning”, “role physical”, “bodily pain”, and “general health” subdimensions pertain to the PCS aggregate component, the “vitality”, “social functioning”, “mental health”, and “role emotional” subdimensions pertain to the MCS aggregate component. *Stands for statistical significance with p value  <  0.05 from comparing between groups the standard deviations of each score standardized for age and sex, by mixed logistic regression adjusted for sex, age and the time between ICU discharge and phone interview, with pair as a random effect. NSTI necrotizing soft-tissue infection; MCS mental component summary; PCS physical component summary; SF-36 36-Item Short-Form Health Survey

Fig. 3

SF-36 questionnaire results in NSTI survivors admitted (black) or not admitted (gray) to the ICU. A Comparison of the physical (PCS) and mental (PCS) component summaries of the SF-36 questionnaire between patients surviving necrotizing soft tissue infections admitted (“ICU-admitted NSTI”, black) or non-admitted to the ICU (“non-ICU-admitted NSTI”, gray). Results are centered on the value of 50 (dashed line; values  >  or  <  50 reflected values higher or lower than age-sex standardized French values).*p values come from comparing between groups the standard deviations of each score standardized for age and sex. B Comparison of each subdomain of the SF-36 between patients surviving necrotizing soft tissue infections admitted (“ICU-admitted NSTI”, black) or non-admitted to the ICU (“non-ICU-admitted NSTI”, gray). The “Physical functioning”, “role physical”, “bodily pain”, and “general health” subdimensions pertain to the PCS aggregate component, the “vitality”, “social functioning”, “mental health”, and “role emotional” subdimensions pertain to the MCS aggregate component. *Stands for statistical significance with p value  <  0.05 from comparing between groups the standard deviations of each score standardized for age and sex. MCS mental component summary; PCS physical component summary; SF-36 36-Item Short-Form Health Survey; ICU intensive care unit