Poor Prognosis of Necrotizing Fasciitis Caused by Vibrio vulnificus from Nontraumatic Route

海洋弧菌經非創傷性途徑感染之壞死性筋膜炎預後較差

陳又菁(Yu-Ching Chen) ； 王又纖(Yu-Shien Wang) ； 李欣蓉(Susan Shin-Jung Lee) ； 楊國強(Kao-Chang Yang) ； 陳理維(Lee-Wei Chen)

《臺灣整形外科醫學會雜誌》 31卷1期 (2022/03) Pp. 20-34

摘要

Background: Vibrio vulnificus can cause severe infections with a high mortality rate, such as septic shock or necrotizing fasciitis. Taiwan is surrounded by the sea, has warm weather and a high prevalence of liver disease. Therefore, necrotizing fasciitis caused by V. vulnificus is a major concern on this island. Aim and objectives: The patients were classified into two groups based on their route of infection. Patients in the traumatic group had a history of trauma or wound infection. The others who ingested seafood or have an unclear history of infection were classified as the nontraumatic group. We compared the disease presentation, severity, and prognosis of patients from the different routes of infection. Materials and methods: This was a retrospective study of patients admitted from July 2004 to December 2018 in a single medical center in southern Taiwan. The patients were enrolled based on the culture reports of V. vulnificus. The data on the infection route, patient demographics, underlying disease, surgery type and timing, APACHE II score, and outcomes were collected. T-test, Chi-square test, multivariate logistic regression, and receiver operating characteristic curve analyses were performed. Results: Of the 49 infection episodes, 27 were in the nontraumatic group, while 22 were traumatic. Events in the nontraumatic group were predominantly in males, with higher APACHE II scores. Patients with bacteremia had a higher propensity to present with multiple limb lesions, which were not seen in patients in the traumatic group, and fewer patients underwent surgery. The overall mortality rate was 28.6%, which was significantly higher in the nontraumatic group than in the traumatic group (47.6% and 11.8%, respectively; p=0.018). In general, patients who died had a higher prevalence of liver cirrhosis, higher APACHE II score, and more likely to present with hypotension than patients who survived. Multivariate analysis revealed the APACHE II score (odds ratio, 1.17, P=0.020) and band form ratio (odds ratio, 1.08, P=0.034) are the risk factors significantly associating with mortality. Conclusion: Patients infected by V. vulnificus via a nontraumatic route were associated with liver cirrhosis, and increased severity at presentation, resulting in a higher mortality rate. Fewer patients underwent surgery. We should be cautious of patients suspected of having V. vulnificus infection without a history of trauma, accompanied with multiple limb lesions and positive blood cultures. The APACHE II score and band form ratio at presentation are the risk factors associating with mortality. The timing and type of surgical approach to lower the mortality rate need to be further investigated.

關鍵字

Vibrio vulnificus ； necrotizing fasciitis ； infection route ； prognosis

並列摘要

背景：海洋弧菌可造成嚴重感染如敗血症或壞死性筋膜炎，且伴隨較高的致死率。台灣位於東南亞，為氣候溫暖、四周環海的小島，再加上肝病之高盛行率，海洋弧菌感染之壞死性筋膜炎在本國為一重要議題。目的及目標：以不同感染途徑對病人做分類，分為與外傷相關之創傷性感染，及食物攝入或未知感染途徑造成之非創傷性感染，分析不同途徑是否與疾病表現、嚴重度及預後相關。材料及方法：回顧台灣南部單一醫學中心於2004年至2018年，共約15年收治之細菌培養報告為海洋弧菌的壞死性筋膜炎病人的病歷紀載，查閱其相關急診及住院病歷，收錄病人的感染途徑、年齡、性別、臨床表現、疾病嚴重度（以APACHE II分數代表）、入院至手術時間、手術方式及治療結果。以統計學方法比較兩組病人的疾病嚴重度、臨床表現、手術時間點、術式種類及預後，也一併對死亡及存活的病人族群做分析。結果：在49次感染中，27次為非創傷途徑之感染，而22次的感染與創傷相關。非創傷途徑之感染中男性較多、入院時較嚴重（APACHE II分數較高）、菌血症比例較高、且可能有多處肢體感染。在這族群中僅一半（55%）的病人接受手術，而創傷性感染的病人接受手術達90%。整體的死亡率為28%，其中非創傷性感染的病人死亡率遠高於另一組病人（分別為47.6%與11.8%（p=0.018））。就死亡及存活的病人做分析，死亡之病人有較高比率有肝硬化、免疫低下、到院時較嚴重（APACHEII分數較高）且低血壓比率較高。多變數分析顯示僅入院時的APACHEII分數（odds ratio, 1.19, P=0.008）可預測死亡率。結論：海洋弧菌經由非創傷途徑感染之壞死性筋膜炎的病人，到院時表現較嚴重，死亡率也較高。較嚴重的病情也使較少的病人適合接受手術。對於懷疑創傷弧菌感染，卻無明顯外傷相關病史的病人，若又伴隨多處肢體病灶、或血液培養陽性，則預後較差，以本研究結果死亡率達四成，需儘早使用涵蓋創傷弧菌之抗生素。可再進一步研究手術時機及手術術式，以降低此種感染症之死亡率。