Taylor RAIGER, Alison ORVIN, Christian CAVENESS
Journal of Microbiology and Infectious Diseases - 2026;16(1):12-17
Background: Necrotizing soft tissue infections (NSTIs) and the associated exotoxins are associated with a high risk of mortality. Toxin coverage has been shown to decrease mortality, but the appropriate time for toxin coverage is unknown. Aim: The aim of this study is to evaluate whether starting early (<3 hours) toxin coverage improves outcomes compared to late (>3 hours) toxin coverage in relation to the initiation of broad-spectrum antibiotics. Methods: This retrospective, single-center, cohort study compared 30-day all-cause mortality in patients treated with early versus late toxin coverage for necrotizing skin infections. Adult patients admitted between January 2015 and December 2024 who had a diagnosis code of necrotizing fasciitis and were administered IV or PO clindamycin or linezolid within 72 hours of broad-spectrum antibiotics were included. The primary outcome was all-cause mortality at 30 days. Secondary outcomes included intensive care unit (ICU) length of stay (LOS), ICU-free days at 30 days, hospital LOS, acute kidney injury (AKI), Clostridioides difficile infection (CDI), serotonin syndrome, and thrombocytopenia. Results: Baseline characteristics were similar between groups. Both groups had a similar number of ICU admissions (78.4% vs. 75.6%), Charlson Comorbidity Index median of 3 interquartile range (IQR 0-6 vs. 0-7), and Quick Sequential Organ Failure Assessment median of 0 (IQR 0-2 vs. 0-2). Lower extremity was the most common location of infection (29.7% vs. 36.6%), and polymicrobial infections were the most common. Group A Streptococcus accounted for three infections in each group. There was no difference in all-cause mortality at 30 days (5.4% vs. 14.6%, p = 0.27). No differences were found in the secondary outcomes of ICU LOS, ICU-free days at 30 days, hospital LOS, rate of AKI, and thrombocytopenia. There was no incidence of serotonin syndrome and a single incidence of CDI in the early toxin coverage group. Conclusion: In this retrospective study, there was no statistically significant difference between 30-day all-cause mortality in patients who received toxin coverage in <3 hours compared to >3 hours in relation to broad-spectrum antibiotics for the treatment of NSTIs. Further studies with a larger study population are needed to determine if the time to toxin coverage impacts mortality.
