Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
Introduction: Head and neck necrotizing fasciitis (NF) is a surgical emergency with high morbidity and mortality. The LRINEC score is a validated and widely used tool to stratify likelihood of necrotizing infection, and to triage cases requiring emergent operative intervention. CRP, an aspect of this tool, is a well-known inflammatory which may be used longitudinally during inpatient care. Standard monitoring of patients with NF includes attention to vital signs, sepsis scores, physical examination, and white blood count (WBC). WBC trends can often be altered in patients with NF secondary to broad-spectrum antibiotics and steroid use in cases with airway edema. In many cases, repeated imaging is required to determine if NF persists, requiring further debridement. In this database study, we aim to determine if measurement of CRP provides additional prognostic data in the management of NF of the head and neck.
Methods: A retrospective cohort study was conducted using the TriNetX Research Network, a deidentified insurance claims database. Forty-one health care organizations were recruited. Patients with NF infection, associated head and neck CT imaging, and documented resultant hospital admission were queried. A cohort with no CRP (NCRP) acquired was compared against the following 2 cohorts: (1) CRP acquired with at least 1 CRP value (ACRP) and (2) 2 or more CRP values (TCRP) acquired. Cohorts were matched for age, sex, ethnicity, tobacco use, steroid administration, and type II diabetes mellitus. Outcomes assessed were length of stay, need for debridement, and need for flap reconstruction, time on antibiotics, and incidences of imaging, all within 30 days of admission. Significance was measured at p<0.05.
Results: After matching, there were 1193 patients in NCRP and ACRP groups. Average ages were 59.5 and 58.9 years, respectively. Length of stay for ACRP was slightly longer compared to NCRP (11.0 vs. 9.75 days, p<0.01). There was increased associated risk of debridement to the level of the muscle in ACRP patients (RR 1.2, 95% CI 0.69-0.99, p=0.04) and to the level of the bone (RR 1.6, 95% CI 0.43-0.93, p=0.02). After matching, there were 708 patients in NCRP and TCRP groups. Average ages were 57.9 and 57.6, respectively. TCRP had 2.97 ± 3.17 CRP measurements during admission. The TCRP group had a slightly longer length of stay compared to NCRP (12.14 vs. 10.16 days, p<0.01). There was an increased associated risk of deep debridement in TCRP patients (RR 1.7, 95% CI 0.37-0.95, p=0.03). All other comparisons were insignificant, and flap outcomes were not assessable due to a small number of patients with the outcome. Antibiotic duration was 25.57 ± 9.77, 21.99 ± 12.14, and 28.66 ± 6.87 days for ACRP, NCRP, and TCRP patients, respectively.
Conclusions: Acquiring and trending CRP are associated with longer hospital stays, longer times on antibiotics, and deeper level of initial debridement. This is likely due to a more comprehensive approach to patients with greater disease severity. Further study is required to elucidate if monitoring CRP could be used for earlier detection of spreading infection, prompt intervention, and ultimately improved overall outcomes.