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Hyperbaric Oxygen in Necrotizing Fasciitis

Mulla, Zuber D. Ph.D.

Plastic and Reconstructive Surgery: December 2008 - Volume 122 - Issue 6 - p 1984-1985
doi: 10.1097/PRS.0b013e31818a9b7e
Letters

Department of Obstetrics and Gynecology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, 4800 Alberta Avenue, El Paso, Texas 79905, zuber.mulla@ttuhsc.edu (Mulla)

Sir:

I read with interest the report on antimicrobial therapy with hyperbaric oxygen treatment in the setting of necrotizing fasciitis by Anwar et al.1 Their case series comprised 28 patients admitted between 1997 and 2002. Anwar and colleagues write that there is a “lack of any worthwhile articles negating the benefits of hyperbaric oxygen therapy.…”

My colleagues and I recently conducted a retrospective epidemiologic study of 216 patients hospitalized throughout Florida and discharged in 2001 with a principal discharge diagnosis of necrotizing fasciitis.2 We reported an unadjusted hospital mortality rate of 5.3 percent in patients who received hyperbaric oxygen therapy during their hospital stay and a hospital mortality rate of 11.7 percent in the patients who did not receive hyperbaric oxygen therapy (unadjusted relative risk of death for treated versus untreated patients, 0.45; p = 0.42). After controlling for age, sex, excisional debridement of the wound, diabetes, and three other demographic and clinical variables, hyperbaric oxygen treatment appeared to reduce the risk of hospital mortality by 52 percent; however, the result was not statistically significant (adjusted relative risk, 0.48; p = 0.39). The previous studies cited by Anwar et al. had sample sizes of 54 or fewer patients.1 Adjustment for confounders is difficult in small studies.

The patients treated by Anwar and colleagues received clindamycin.1 Clindamycin has been shown to reduce the odds of hospital mortality by 89 percent among patients hospitalized with invasive group A streptococcal disease who have group A streptococcal necrotizing fasciitis (adjusted odds ratio, 0.11).3 This result was statistically significant (95 percent confidence interval, 0.01 to 0.89).3

Anwar et al. make a good point about the lack of randomized controlled trials evaluating the efficacy of hyperbaric oxygen therapy in the management of necrotizing fasciitis. Future observational studies in this area should be multicenter and prospective to minimize various epidemiologic biases and facilitate the control of several confounders.

Zuber D. Mulla, Ph.D.

Department of Obstetrics and Gynecology

Paul L. Foster School of Medicine

Texas Tech University Health Sciences Center

4800 Alberta Avenue

El Paso, Texas 79905

zuber.mulla@ttuhsc.edu

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REFERENCES

1. Anwar, M. U., Haque, A. K. M. F., Rahman, J., Morris, R., and McDermott, J. Early radical surgery and antimicrobial therapy with hyperbaric oxygen in necrotizing fasciitis. Plast. Reconstr. Surg. 121: 360, 2008.
2. Mulla, Z. D., Gibbs, S. G., and Aronoff, D. M. Correlates of length of stay, cost of care, and mortality among patients hospitalized for necrotizing fasciitis. Epidemiol. Infect. 135: 868, 2007.
3. Mulla, Z. D., Leaverton, P. E., and Wiersma, S. T. Invasive group A streptococcal infections in Florida. South. Med. J. 96: 968, 2003.
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GUIDELINES

Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article’s publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor. Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/prs/.

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