The Effect of Immune-compromising Systemic Comorbidities on Outcome Measures for Deep Fascial Space Infections

Abstract

Deep fascial space infections of the head and neck (H&N) region may result in significant patient morbidity as well as extended utilization of healthcare resources, particularly in the immunocompromised or those otherwise predisposed to infection. The purpose of this study was to evaluate the effect of systemic comorbidities and medications on outcome measures for deep fascial space infections in a tertiary care center over a 3-year period. The authors hypothesized that length of stay (LOS), readmission rate, and reoperation rate would be increased in patients with systemic comorbidities predisposing to infection.A retrospective chart review was performed for patients admitted to the sponsoring institution from January 2017 through December 2020. Cases were identified using an electronic medical record query for International Classification of Diseases (ICD-10) codes corresponding to diagnoses consistent with deep fascial space infections of the H&N region. Patients with an infection of 1 or more deep fascial spaces were included. Exclusion criteria were incomplete medical record, infections of superficial to the investing fascia, and intracranial abscesses.The analyzed variables included infection etiology; number of fascial spaces involved; medical comorbidities including human immunodeficiency virus (HIV), diabetes, active malignancy, H&N radiation, transplant history; and use of the following medications on admission: bisphosphonates, antiresorptives, biologics, tumor necrosis factor inhibitors, monoclonal antibodies, antimetabolites, and corticosteroids. The outcome measures studied were LOS, operation, reoperation, and readmission.Statistical analyses were performed using Qualtrics Stats iQ software. Bivariate analysis was performed using Chi-square test to evaluate the relationships between selected study variables. P < .05 was considered statistically significant.The initial query yielded 251 patients admitted with the included diagnoses. Of these 251 patients, 86 met the inclusion criteria. The mean number of spaces involved was 2.2±1.0 spaces. There were 18 patients (21.0%) with 1 or more of the defined comorbidities: 15 diabetes (17.4%), 3 HIV (3.5%), 2 H&N radiation (2.3%), 1 bisphosphonate (1.2%), 1 antiresorptive (1.2%), 2 biologics (2.3%), and 1 corticosteroid (1.2%). No patients included in the study had a history of transplant. Eighty-two patients (95.3%) underwent incision and drainage (I&D) under general anesthesia, and 1 patient (1.2%) underwent bedside incision and drainage under local anesthesia. Three patients (3.5%) received no surgical intervention and were treated with intravenous antibiotics alone. A total of 6 patients (7.0%) required reoperation. All 18 patients with identified comorbidities underwent I&D. The average length of stay for all patients was 3.3±2.4 days with a maximum LOS of 13 days; 6 (7.0%) patients required readmission.There was a strong statistically significant relationship between increased number of involved fascial spaces and LOS (P < .001). There was no significant relationship between any of the comorbidities and number of involved spaces, reoperation, or readmission. There was a strong statistically significant relationship between LOS and active malignancy (P = .01), H&N radiation (P < 0.001), bisphosphonate use (P = .01), and antiresorptive use (P = .01). There was no relationship between LOS and HIV, diabetes, and biologic or corticosteroid use.This study sought to identify predictors of outcome in patients with deep fascial space infections of the H&N region. The researchers found that an increased number of involved spaces, active malignancy, history of H&N radiation, and bisphosphonate/antiresorptive use are clinical indicators of LOS outcomes in patients with deep fascial space infections. However, these factors were not significantly associated with readmission or the need for reoperation.