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
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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