Bronchoalveolar lavage and plasma Antithrombin and cytokines in inhalation and burn injury: a pilot study.

Systemic inflammatory response syndrome (SIRS) is initiated during the acute phase of thermal injury. The objective was to determine the SIRS impact on cytokine and Antithrombin (AT) levels in smoke inhalation and burn injury. This observational pilot study compared plasma and bronchoalveolar lavage fluid (BAL) cytokine and AT levels in the first six days post smoke inhalation and burn injury. Twenty-five patients, 14 with inhalation + burn injury > 10% total body surface area (TBSA) and 11 with inhalation injury and ≤ 10% TBSA participated. Human Th1/Th2 cytometric bead array kit from BD Biosciences Pharmingen determined cytokine levels; AT levels with Sigma Diagnostics and spectrophotometry. Results indicated no significant age difference between the two groups (42.1 ± 7.2) versus 49.6 ± 6.4 years. On admission, the inhalation group had 5.4 ± 3.9% TBSA compared to 35.0 ± 22.2% TBSA in the inhalation + burn group, P < 0.001. Comparing groups, AT plasma levels were significantly decreased (P = 0.025) and IL-2 levels significantly increased (P = 0.025) in the inhalation + burn group compared to the inhalation group; there was no significant difference in BAL AT or cytokine levels. Combined group plasma AT levels (65.41 ± 4.44%) were significantly increased compared to BAL AT levels (1.06 ± 0.71%), P < 0.001. In contrast, BAL TNF-α levels (35.61 ± 16.01 pg/ml) were significantly increased in relation to the plasma levels (4.68 ± 1.27 pg/ml), P = 0.02. On days 1-2, AT plasma levels were significantly decreased in the inhalation + burn group (41.01 ± 5.24%) compared to the inhalation group (81.02 ± 10.99%), P = 0.002. IL-6 plasma levels were higher in the inhalation + burn group compared to the inhalation group on admission, but both levels decreased by days 3-6. IL-6 BAL levels were elevated in both groups on days 1-2 and decreased by days 3-6. In the first six days of resuscitation, all plasma cytokines were increased in the two groups compared to controls. AT plasma and BAL levels were significantly reduced in both groups, contributing to the coagulopathy. Increased BAL TNF-α and IL-6 levels may have contributed to the pulmonary perturbations during the initial SIRS response in both groups.

Critical care of the burn patient: the first 48 hours.

OBJECTIVE: The goal of this concise review is to provide an overview of some of the most important resuscitation and monitoring issues and approaches that are unique to burn patients compared with the general intensive care unit population. STUDY SELECTION: Consensus conference findings, clinical trials, and expert medical opinion regarding care of the critically burned patient were gathered and reviewed. Studies focusing on burn shock, resuscitation goals, monitoring tools, and current recommendations for initial burn care were examined. CONCLUSIONS: The critically burned patient differs from other critically ill patients in many ways, the most important being the necessity of a team approach to patient care. The burn patient is best cared for in a dedicated burn center where resuscitation and monitoring concentrate on the pathophysiology of burns, inhalation injury, and edema formation. Early operative intervention and wound closure, metabolic interventions, early enteral nutrition, and intensive glucose control have led to continued improvements in outcome. Prevention of complications such as hypothermia and compartment syndromes is part of burn critical care. The myriad areas where standards and guidelines are currently determined only by expert opinion will become driven by level 1 data only by continued research into the critical care of the burn patient.

Haemophilus Influenzae contributes to morbidity but not mortality in severely burned patients.

Due to a successful Haemophilus Influenzae (HIF) vaccination program, this pathogen is no longer a major contributor to childhood morbidity and mortality. The effect on adult acquisition of HIF is unknown. The purpose of this study was to determine HIF infection frequency in severely burned patients. In a 62-month period, there were 1486 admissions. Twenty-four of 1,486 (1.6%) burn patients had HIF pneumonia: 16 (1%) within 72 h after injury; 8 (0.5%) patients developed it after the seventh day of hospitalization; 74 of 1,486 (5.0%) burn patients had pneumonia due to other organisms. There was no statistically significant difference between patients with HIF pneumonia and those with other pathogens with respect to age, race, sex, percent total body surface area (TBSA), inhalation injury, ventilator days, intensive care days, sepsis, or mortality. Nineteen percent of patients with HIF were<14 years of age compared to 12% in the other pneumonia group, p<0.01. HIF contributed to both an early and late pneumonia in burn patients. The organism responded to treatment and did not affect mortality.

Elevated cytokine levels in peritoneal fluid from burned patients with intra-abdominal hypertension and abdominal compartment syndrome.

BACKGROUND: Burn patients with intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) undergo vigorous resuscitation and accumulate peritoneal fluid (PF) that is a plasma ultra-filtrate. This study compared antithrombin (AT) and cytokine levels in burn patient plasma and peritoneal fluid (PF). METHODS: Twenty-nine patients were studied: 22 developed IAH and 9 progressed to ACS. Burn + inhalation injury was present in 22 patients; 5 had burn only and 2 had inhalation only. Sixteen patients died: of these, 9 survived less than 48 h due to the severity of their injuries. Flow cytometry utilized the Cytometric Bead Array kit for Human Th1/Th2 cytokines. AT levels were determined by the Accucolor method spectrophotometrically. RESULTS: All cytokine levels were significantly elevated in burn plasma and PF compared to normal plasma, p < 0.001. AT plasma levels were decreased compared to normal. AT and cytokines were present in peritoneal fluid of burn patients with IAH and ACS. Patients who died had decreased plasma levels of AT and increased IFN-gamma, IL-10, IL-6, IL-4, IL-2 peritoneal fluid levels compared to survivors. CONCLUSIONS: Peritoneal fluid may be a reservoir for cytokines during initial resuscitation and contributes to homeostatic perturbations in burn patients.

Trends in burn research as reflected in American Burn Association presentations, 1998 to 2003.

The American Burn Association (ABA) mission promotes burn care, research, rehabilitation, teaching, and prevention. Therefore, we sought to determine recent burn research trends by reviewing 1595 accepted abstracts from the Proceedings of the American Burn Association from 1998 to 2003. This study encompassed a retrospective, descriptive audit of ABA abstracts accepted for presentation, including topic, institution, accreditation status, and presentation. Overall, Shriners Hospitals for Children (SH) provided 31%, non-Shriners burn centers (N-S) provided 53%, international and nonburn center hospitals provided 13%, and multicenter ventures provided 2% of the abstracts. Abstract topics addressed most frequently in this time period were cell biology 271 (17%), general care 240 (15%), and pain 235 (15%). Multicenter trials were negligible from the period of 1998 to 2000 but increased to 3% to 4% annually since 2001. In 2003, 39 of 128 (30%) of U.S. burn centers were accredited and delivered 67% of the presentations. SH abstracts increased from 26% in 1998 to 35% in 2003, whereas the N-S decreased from 61% to 48%. Thirty-seven percent of the abstracts reported prospective studies, 28% retrospective, and basic research abstracts comprised 18%. Four SH and 91 N-S (U.S.) hospitals primarily shared the podium, although N-S presentations decreased annually since 1998. On the basis of 2003 ABA/ACS accreditation data, there was an association between accreditation and research activity. SH and N-S collaborative studies for better patient care are the trend for the future as burn centers pool data and resources.

Circulating endothelial cell levels correlate with proinflammatory cytokine increase in the acute phase of thermal injury.

Circulating endothelial cells (CECs) are increased in sickle cell disease, myocardial infarction, and acute lung injury. The purpose of this study was to determine whether CECs are a prognosticating marker for the development of pneumonia in burn patients with/without inhalation injury in addition to their relationship to proinflammatory cytokines. There were 24 patients: 6 with inhalation injury, 5 with burn only,and 13 with burn plus inhalation injury. CECs were measured by anchored cytometry (Clarient ChromaVision, San Juan Capistrano, CA). In addition, plasma levels of tumor necrosis factor-alpha, interferon-gamma, and interleukins (IL)-10, IL-6, IL-4, and IL-2 were compared with CEC levels. Patients with inhalation injury had a significant (P < .001) paucity of CECs compared with the thermally injured with inhalation. There was a statistically significant increase in inteferon-gamma, tumor necrosis factor-alpha, and IL-6, IL-4, and IL-2 compared with control patients (P < .01), with a concomitant increase in the number of CECs. The numbers of CEC levels did not prognosticate which patients would develop pneumonia. Burn patients with/without inhalation injury had concurrent increase in CECs and proinflammatory cytokines during the acute phase of injury.

Infections in diabetic burn patients.

OBJECTIVE: Diabetic burn patients comprise a significant population in burn centers. The purpose of the study was to determine the demographic characteristics of diabetic burn patients and their rate of community-acquired and nosocomial infections. RESEARCH DESIGN AND METHODS: This was a 46-month retrospective chart and patient registry review comparing diabetic with nondiabetic burn patients. Statistical analysis consisted of means +/- SD, descriptive statistics, one-way ANOVA, and chi(2) tests. RESULTS: Of 1,063 adult burn patients (aged 15-54 years), 68 (6%) diabetic burns were compared with burns of 995 adult nondiabetic patients. Of 193, 62 (32%) senior (>/=55 years of age) diabetic burns were compared with 131 nondiabetic senior burns. The major mechanism of injury for the diabetic patients was scalding and contact, in contrast to that of nondiabetic patients who were injured mainly by scalding or flame burns. Adult diabetic patients had a significantly increased frequency of foot burns compared with adult nondiabetic patients (32 of 68 [68%] versus 144 of 995 [14%], P = 0.001). Adult diabetic burns had a significant increase in sepsis (P < 0.002) and community-acquired burn wound cellulitis (P < 0.001) compared with adult nondiabetic patients; and senior diabetic patients had a significantly increased frequency of urinary tract infections compared with senior nondiabetic burn patients (P < 0.04). The most common organisms in diabetic burn infections were Streptococcus, Proteus, Pseudomonas, Candida species, and MRSA (methicillin-resistant Staphylococcus aureus). Forty-two percent of the diabetic patients were admitted during the winter months and 25% in the spring. Only 49 of 130 (38%) diabetic burn patients presented for treatment within 48 h after injury compared with 669 of 1,126 (62%) nondiabetic patients (P = 0.001). CONCLUSIONS: Peripheral neuropathy may have precipitated and delayed medical treatment in lower-extremity burns of diabetic patients. Hospitalized diabetic burn patients were also at an increased risk for nosocomial infections, which prolonged hospitalization. Diabetic patient education must include not only caution about potential burn mishaps but also educate concerning the complications from burns that may ensue.

Frequency of burn-trauma patients in an urban setting.

BACKGROUND: Burn-trauma patient encounters constitute 5% of the emergency department population. HYPOTHESIS: A large urban hospital will treat twice as many (ie, 10%) burn-trauma patients. DESIGN: Retrospective 44-month study. SETTING: Metropolitan county hospital. PATIENTS: Population-based sample of burn-only (n = 1102), burn-trauma (n = 120), and assault burn-trauma (n = 43) patients. MAIN OUTCOME MEASURES: Frequency and demographics. RESULTS: Just under 10% (n = 120) of the burn population had burn-trauma injuries. The mean +/- SD Injury Severity Score was 12 +/- 12 in these burn-trauma patients: 4 +/- 2 in outpatients and 14 +/- 13 in inpatients. The burn-only and burn-trauma groups had similar age ranges, ethnic distribution, frequency of inhalation injury, substance abuse, malnutrition, sepsis, pneumonia, diabetes mellitus, percentage total burn surface area, number of procedures, grafted areas, and mortality. Forty-three burn-trauma patients (35.8%) sustained injuries due to assault, compared with 123 (11.2%) in the burn-only group (P<.001). Burn-trauma patients who were assaulted had a mean +/- SD Injury Severity Score of 11 +/- 10. There was a significantly increased male-female ratio among the assault burn-trauma patients (6:1) compared with the burn-trauma (3:1) and burn-only (2.3:1) groups (P<.04). Most of these injuries were caused by an unknown assailant, in connection with an automobile, a motorcycle, a bicycle, or pedestrians intentionally struck by moving vehicles, or by child abuse. The main mechanism of injury was contact in 57 burn-trauma patients (47.5%), compared with 127 (11.5%) in the burn-only group (P<.001). CONCLUSIONS: A large urban population will have an increased frequency (2-fold in our center) of burn-trauma injuries. Assault and child abuse are significant contributory factors to burn-trauma injuries in this population.

Nonoperative progressive "Bogota bag" closure after abdominal decompression.

"Bogota bags" are often used for temporary abdominal closure after damage control or staged laparotomy for trauma or release of abdominal compartment syndrome. After placement of the Bogota bag serial operative closures are required to return abdominal contents to their original location before definitive closure. Unnecessary operative procedures may be avoided when binder clips are used to facilitate the gradual approximation of the wound edges before abdominal closure.

Antithrombin (human) concentrate infusion in pediatric patients with >50% TBSA burns.

BACKGROUND: Antithrombin (human) [AT(H)] concentrate infusions have been safely utilized in adult burn patients to counteract subclinical disseminated intravascular coagulopathy and pulmonary complications. OBJECTIVE: AT(H) concentrate was given to two thermally injured pediatric patients to evaluate safety and dosage requirements. DESIGN: The first patient was a 2-year-old with 83% total burn surface area (TBSA) full thickness flame burn and severe inhalation injury. The second patient was a 14-month-old who sustained 56% TBSA deep partial and full thickness scald injury. Each child received 10 infusions of AT(H) concentrate (106 units/kg) in the first 4 days post-injury. RESULT: For these two patients, the plasma AT level (normal range: 100+/-20%) increased, respectively, from 25 and 66% on admission to 224 and 217% on day 1, 114 and 116% on day 2, and 193 and 171% on day 3. Both patients tolerated the infusions well. In one patient, the eschar on all four extremities easily peeled off the subcutaneous tissues along a natural demarcation between viable and non-viable tissue with only a 40cc estimated blood loss (EBL). CONCLUSIONS: AT(H) concentrate is tolerated in the pediatric population in the acute phase of injury. Lack of bleeding during eschar removal may be of benefit to burn excision and grafting.

Fusarium infections in burn patients: a case report and review of the literature.

Fusarium species, or saprophytic molds, are important plant pathogens and recognized as agents of human mycotic infections. Frequently superficial, deep-tissue involvement, and dissemination occurs in immunocompromised hosts with hematologic malignancies, aplastic anemia, and chemotherapy treatment. Presented in this work is a burn patient with a fatal disseminated infection in addition to a review of the literature. A 40-year-old white male acquired a 73% grease scald injury at work. His hospital course was interspersed with multiple episodes of Flavobacterium, Fusarium, Candida, Proteus, Enterococcus, coagulase-negative Staphylococcus, and Serratia infections. He underwent nine operative procedures for debridement, excision, and skin grafting. The last operative procedure included bilateral below knee amputations to halt an invasive Fusarium infection that was invading normal unburned skin. The patient died 55 days after injury. Fusarium and Aspergillus infections are frequently confused and do not have characteristic clinical features. With the prolonged survival of severely burned patients, better fungal diagnostic and treatment modalities are needed to improve outcome.

Cecal perforation in thermal injury: case report and review of the literature.

Gastrointestinal complications in burn patients include ileus, constipation, hemorrhage from ulcerations, ischemic bowel, and rarely, perforations. Patients with hypotensive episodes and sepsis are at risk for developing ischemic bowel disease. There have been three reports in the literature of cecal perforation in burn patients. We present an additional case and review of the literature.

Vacuum-assisted closure use in calciphylaxis.

Calciphylaxis-induced chronic wounds are difficult to heal. The value of vacuum-assisted closure (VAC) was assessed in two patients with calciphylaxis. Two middle-aged females with type 2 diabetes were transferred to the burn unit with a clinical diagnosis of necrotizing fasciitis, although the pathologic diagnosis was calciphylaxis. With extensive debridement, antibiotics, and meticulous wound care, one patient had progressive necrosis of her skin from 18 to 48% TBSA, whereas the other progressed from 5 to 10% TBSA only. The patient with the smaller chronic wound healed well and left the hospital at 72 days after admission. Although there was some success with the use of VAC, the patient with the extensive progressive wounds developed a fungal wound infection that did not respond to treatment; she died 78 days after initiation of burn center treatment. Some disadvantages to the usefulness would be extensive contiguous wounds and the lack of an intact skin surface. The VAC system was of value in healing wounds resulting from calciphylaxis.

A pilot study comparing percutaneous decompression with decompressive laparotomy for acute abdominal compartment syndrome in thermal injury.

Abdominal Compartment Syndrome (ACS) has multiple causes, and decompressive laparotomy has been the most frequent modality to prevent worsening cardiovascular, respiratory, and renal function. This pilot study evaluated the utility of percutaneous drainage (PD) of peritoneal fluid compared with decompressive laparotomy in burn patients. A 26-month review was conducted. Nine of 13 (69%) study patients developed intra-abdominal hypertension (IAH) that progressed to abdominal compartment syndrome in 4 (31%). All were treated with PD using a diagnostic peritoneal lavage catheter. Peritoneal fluid analysis revealed a sterile plasma ultrafiltrate with electrolyte and other chemistries reflecting patient serum levels. Five patients underwent PD successfully, and their IAH did not progress to ACS. Four patients with greater than 80% TBSA and severe inhalation injury did not respond to PD and required decompressive laparotomy. There was no evidence of bowel edema, ischemia, or necrosis. All patients requiring decompressive laparotomies died either from sepsis or respiratory failure. Percutaneous decompression is a safe and effective method of decreasing IAH and preventing ACS in patients with less than 80% TBSA thermal injury.

Burn prevention in Zambia: a work in progress.

The aim of this study was to assess both burn prevention knowledge and the effectiveness of educational intervention in alleviating the current knowledge deficit in Zambian youth. In one rural Zambian district, a burn prevention program was implemented in June 2011. Children at two elementary schools completed a 10-question survey that aimed to assess knowledge regarding burn injuries. After completing the survey, children received a burn and fire safety presentation and a burn prevention coloring book. Children were reassessed in May 2012 using the same survey to determine program efficacy and knowledge retention. Burn knowledge assessments were also completed for children at other schools who did not receive the burn prevention program in 2011. Logistic regression analysis was used for statistical adjustment for confounding variables. Between June 2011 and May 2012, 2747 children from six schools were assessed for their burn knowledge, with 312 of them resurveyed after educational intervention since initial survey. Reassessed children performed significantly better on three questions after controlling for confounders. They did better on five questions but their performance on these failed to achieve statistical significance. Children performed significantly worse on one concept about first aid treatment of a burn. A majority of the children demonstrated knowledge deficit in three concepts, even after educational intervention. There is a large variation in first burn knowledge survey performance of children from different schools, with inconsistency between concepts. With half the questions, knowledge deficit did not improve with advancement in school grade. Low- and moderate-income countries (LMICs) face the largest burns burden. With the lack of adequate burn care facing LMICs, burn injury prevention is of particular importance in those countries. This study shows that burn educational intervention could be effective in reducing burn knowledge deficit; however, the residual deficit posteducation could still be large and potentially contributing to heightened burn injury incidence. Customized and integrated educational programs may be proposed regarding the epidemiological profile of burn knowledge deficit from various schools. This study represents one of the few reports on the effectiveness of a burn prevention program in an LMIC. Future epidemiological data will be needed from nearby healthcare facilities to determine whether this program decreased burn morbidity and mortality at the hospital level.

Burn prevention in Zambia: a targeted epidemiological approach.

The aim of this study is to assess primary burn prevention knowledge in a rural Zambian population that is disproportionately burdened by burn injuries. A 10-question survey was completed by youths, and a 15-question survey was completed by adults. The survey was available in both English and Nyanja. The surveys were designed to test their knowledge in common causes, first aid, and emergency measures regarding burn injuries. Logistic regression analysis was used to explore relationships between burn knowledge, age, school, and socioeconomic variables. A burn prevention coloring book, based on previous local epidemiological data, was also distributed to 800 school age youths. Five hundred fifty youths and 39 adults completed the survey. The most significant results show knowledge deficits in common causes of burns, first aid treatment of a burn injury, and what to do in the event of clothing catching fire. Younger children were more likely to do worse than older children. The adults performed better than the youths, but still lack fundamental burn prevention and treatment knowledge. Primary burn prevention data from the youths and adults surveyed demonstrate a clear need for burn prevention and treatment education in this population. In a country where effective and sustainable burn care is lacking, burn prevention may be a better investment to reduce burn injury than large investments in healthcare resources.

Trends in 393 necrotizing acute soft tissue infection patients 2000-2008.

OBJECTIVE: To determine the outcomes effect of changing trends in patients with necrotizing acute soft tissue infections (NASTI) 2000-2008. METHODS: A single institution retrospective chart review of all patients treated for NASTI. RESULTS: There were 393 patients with mean age 50 years, diabetes 53%, % body surface area excised 3.5. Wounds were located on: extremity 57%, perineum 40%, trunk 26%. Wound cultures %: polymicrobial=62, Staphylococci=48, Streptococci=31. Patients developing complications %: Pulmonary=23, renal insufficiency/failure=27. During the study period, overall mortality rate remained unchanged: 30/393=7.6% (5.5% for patients first admitted by burn/trauma/acute care surgery vs. 29% for all other services, p=0.003). Significant annual increases were found in number of patients, p=0.03, male sex, p=0.000, transfer from outside hospital, p<0.001, BMI p=0.003, ventilator requirement >24h, p=0.0005, APACHE II p=0.002, and number of patients developing any complication, p=0.04. Statistically significant decreases annually were found in: days of antibiotic use, p=0.008, number of operations required for excision, p=0.02, development of non-wound infections, p=0.002, and length of stay in days (LOS), p=0.03. CONCLUSIONS: This is the largest cohort of NASTI patients from a single institution to date, demonstrating significantly shorter LOS and decreased non-wound infection rates in the face of increasing BMI and APACHE II scores. The increasing number of patients and BMI suggests a causal relationship between NASTI and obesity. Initial care by surgeons experienced in caring for these patients provides mortality rates well below the national average.

Burn injuries in eastern Zambia: impact of multidisciplinary teaching teams.

The American Burn Association/Children's Burn Foundation (ABA/CBF) sponsors teams who offer burn education to healthcare providers in Zambia, a sub-Saharan country. The goals of this study are 1) to acquire burn-patient demographics for the Eastern Province, Zambia and 2) to assess the early impact of the ABA/CBF-sponsored burn teams. This is a retrospective chart review of burn patients admitted in one mission hospital in Katete, Zambia, July 2002 to June 2009. July 2002 to December 2006 = data before ABA/CBF burn teams and January 2007 to June 2009 = burn care data during/after burn outreach. There were 510 burn patients hospitalized, male:female ratio 1.2:1. Average age = 15.6 years, with 44% younger than 5 years. Average TBSA burned = 11% and mean fatal TBSA = 25%. Average hospital length of stay = 16.9 days survivors and 11.6 days nonsurvivors. Most common mechanisms of burn injuries: flame (52%) and scald (41%). Ninety-two patients (18%) died and 23 (4.5%) left against medical advice. There were 191 (37.4%) patients who underwent 410 surgical procedures (range 1-13/patient). There were 138 (33.7%) sloughectomies, 118 (28.7%) skin grafts, 39 (9.5%) amputations, and 115 (28.1%) other procedures. Changes noted in the 2007 to 2009 time period: more patients had burn diagrams (48.6 vs 27.6%, P < .001), received analgesics (91 vs 84%, P = .05), resuscitation fluid (56 vs 49%, P = not significant [NS]), topical antimicrobials (40 vs 37%, P = NS), underwent skin grafting (35.5 vs 25.1%, P = NS), and underwent any operative intervention (40.6 vs 35.2%, P = NS), compared with patients treated between 2002 and 2006. This study represents the largest, most comprehensive burn data set for a sub-Saharan region in Africa. There has been a statistically significant improvement in documentation of burn size as well as administration of analgesics, validating the efficacy of the ABA/CBF-sponsored burn teams. Continued contact with burn teams may lead to increased use of resuscitation fluids, topical antimicrobials, and more patients undergoing operative intervention, translating into improved burn patient outcomes.

Long-term outcomes of patients with necrotizing fasciitis.

CONTEXT: Necrotizing fasciitis is an aggressive infection affecting the skin and soft tissue. It has a very high acute mortality. The long-term survival and cause of death of patients who survive an index hospitalization for necrotizing fasciitis are not known. OBJECTIVE: To define the long-term survival of patients who survive an index admission for necrotizing fasciitis. We hypothesize that survivors will have a shorter life span than population controls. DESIGN: Long-term follow-up of a registry of patients from 1989 to 2006 who survived a hospitalization for necrotizing fasciitis. Last date of follow-up was January 1, 2008. SETTINGS: A university-based Burn and Trauma Center. PATIENTS: A prospective registry of patients with necrotizing fasciitis has been collected from 1989 to 2006. This registry was linked to data from the Department of Health, Department of Motor Vehicles, and the University Hospital Medical Records Department in January 2008 to obtain follow-up and vital status data. INTERVENTION: None. MAIN OUTCOME MEASURES: Date and cause of death were abstracted from death certificates. Date of last live follow-up was determined from the medical record and by the last driver's license renewal. The death rate of the cohort was standardized for age and sex against 2005 statewide mortality rates. Cause of death was collated into infectious and noninfectious and compared with the statewide causes of death. Statistical analysis included standardized mortality rates, Kaplan-Meier survival curves, and Aalen's additive hazard model. RESULTS: Three hundred forty-five patients of the 377 in the registry survived at least 30 days and were analyzed. Average age at presentation was 49 years (range, 1-86; median, 49). Patients were followed up an average of 3.3 years (range, 0.0-15.7; median, 2.4). Eighty-seven of these patients died (25%). Median survival was 10.0 years (95% confidence interval: 7.25-13.11). There was a trend toward higher mortality in women. Twelve of the 87 deaths were due to infectious causes. Using three different statistical analytic techniques, there was a statistically significant increase in the long-term death rate when compared with population-based controls. Infectious causes of death were statistically higher than controls as well. CONCLUSIONS: Patients who survive an episode of necrotizing fasciitis are at continued risk for premature death; many of these deaths were due to infectious causes such as pneumonia, cholecystitis, urinary tract infections, and sepsis. These patients should be counseled, followed, and immunized to minimize chances of death. Modification of other risk factors for death such as obesity, diabetes, smoking, and atherosclerotic disease should also be undertaken. The sex difference in long-term survival is intriguing and needs to be addressed in further studies.