Dear Editor, Necrotizing soft tissue infections (NSTIs) are a heterogeneous group of devastating diseases involving a wide variety of microorganisms and affecting different body areas. The need for individualized treatment strategies has been recently put forward in a prospective cohort study of 402 patients in which group A streptococcus (GAS) infections were associated with more frequent septic shock [1]. Early identification of patients with GAS-related NSTIs could prompt initiation of targeted interventions, including clindamycin and intravenous immunoglobulins (IVIg). These drugs might be associated with beneficial antitoxinic properties, but the level of evidence supporting them remains low (clindamycin) or highly controversial (IVIg) [2, 3]. The only randomized clinical trial evaluating the effect of IVIg specifically in patients with NSTI could not demonstrate a benefit on a composite outcome of death and quality-of-life evaluation at 6 months [4]. As previously commented [5], only 15% (n = 13/87) of included patients eventually had a microbiologically proven GAS NSTI. This was a major limitation and early identification of patients with a high probability of GASassociated NSTIs would thus be crucial for further studies evaluating similar interventions. A secondary analysis of a retrospective cohort including 224 patients admitted to our center for NSTI between 2006 and 2017 was conducted [6]. In accordance with the most recent guidelines, only patients with surgically confirmed NSTI were included (i.e., macroscopic appearance of tissues during operation as swollen, dull gray with a thin, brownish exudate with or without necrosis). Admission characteristics and microbiological documentation based on surgical samples, blood cultures, or subcutaneous puncture were recorded. We compared patients with a documented GAS infection to other patients regarding admission characteristics. A multivariable logistic regression model was used to identify admission characteristics associated with a subsequent GAS documentation. Among 224 patients, 60 (27%) had a GAS infection, which was monomicrobial in 39 (17%) cases. Overall, 134 (59.8%) patients were admitted to the intensive care unit during their stay, of whom 113 during the first 24 h. Ninety-one (41%) patients presented with shock (i.e., required vasopressors), and 89 (40%) required mechanical ventilation. Sixty days after admission, 51 (23%) patients had died, including 10 (17%) with GAS, and 41 (25%) with non-GAS infections (p = 0.255, Mann-Whitney test). Admission characteristics associated with GAS infections by univariable analysis were non-steroidal antiinflammatory drug treatment before admission and leukocytosis as a continuous variable. Those inversely associated with GAS infections were immunodeficiency, the nosocomial onset of infection, and an abdominoperineal location (Table 1). After multivariable analysis, only immunodeficiency (adjusted odds ratio (aOR) = 0.29 [0.10–0.74], p = 0.015) and an abdominoperineal location (aOR = 0.06 [0.00–0.30], p = 0.007) remained associated

中文翻译：

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早期识别 A 组链球菌相关坏死性皮肤和软组织感染高危患者：一项回顾性队列研究

亲爱的编辑， 坏死性软组织感染 (NSTI) 是一组异质性的破坏性疾病，涉及多种微生物并影响身体的不同部位。最近，一项针对 402 名患者的前瞻性队列研究提出了对个体化治疗策略的需求，其中 A 组链球菌 (GAS) 感染与更频繁的感染性休克相关 [1]。早期识别与 GAS 相关的 NSTI 患者可能会促使启动有针对性的干预措施，包括克林霉素和静脉注射免疫球蛋白 (IVIg)。这些药物可能具有有益的抗毒素特性，但支持它们的证据水平仍然很低（克林霉素）或极具争议性（IVIg）[2, 3]。唯一专门评估 IVIg 对 NSTI 患者效果的随机临床试验未能证明对 6 个月时死亡和生活质量评估的复合结果有益[4]。正如之前所评论的 [5]，只有 15% (n = 13/87) 的纳入患者最终患有经微生物学证实的 GAS NSTI。这是一个主要的局限性，因此早期识别出具有高可能性的 GAS 相关 NSTI 的患者对于评估类似干预措施的进一步研究至关重要。对包括 224 名 2006 年至 2017 年间入住我们中心的 NSTI 患者在内的回顾性队列进行了二次分析 [6]。根据最新的指南，只包括经手术证实的 NSTI 患者（即手术期间组织的宏观外观如肿胀、暗灰色，有薄薄的褐色渗出液，有或没有坏死）。记录基于手术样本、血培养或皮下穿刺的入院特征和微生物记录。我们将有记录的 GAS 感染患者与其他患者的入院特征进行了比较。多变量逻辑回归模型用于识别与后续 GAS 文件相关的入院特征。在 224 名患者中，60 名 (27%) 患有 GAS 感染，其中 39 名 (17%) 为单一微生物感染。总体而言，134 名 (59.8%) 患者在住院期间入住重症监护室，其中 113 名在前 24 小时内入住。91 名 (41%) 患者出现休克（即需要血管加压药），89 名 (40%) 需要机械通气。入院 60 天后，51（23%）名患者死亡，包括 10 (17%) 名 GAS 和 41 (25%) 名非 GAS 感染（p = 0.255，Mann-Whitney 检验）。通过单变量分析与 GAS 感染相关的入院特征是入院前非甾体抗炎药治疗和白细胞增多作为连续变量。与 GAS 感染呈负相关的是免疫缺陷、院内感染和腹会阴部位（表 1）。多变量分析后，只有免疫缺陷（调整后的比值比 (aOR) = 0.29 [0.10–0.74]，p = 0.015）和腹会阴部位（aOR = 0.06 [0.00–0.30]，p = 0.007）仍然相关 通过单变量分析与 GAS 感染相关的入院特征是入院前非甾体抗炎药治疗和白细胞增多作为连续变量。与 GAS 感染呈负相关的是免疫缺陷、院内感染和腹会阴部位（表 1）。多变量分析后，只有免疫缺陷（调整后的比值比 (aOR) = 0.29 [0.10–0.74]，p = 0.015）和腹会阴部位（aOR = 0.06 [0.00–0.30]，p = 0.007）仍然相关 通过单变量分析与 GAS 感染相关的入院特征是入院前非甾体抗炎药治疗和白细胞增多作为连续变量。与 GAS 感染呈负相关的是免疫缺陷、院内感染和腹会阴部位（表 1）。多变量分析后，只有免疫缺陷（调整后的比值比 (aOR) = 0.29 [0.10–0.74]，p = 0.015）和腹会阴部位（aOR = 0.06 [0.00–0.30]，p = 0.007）仍然相关