Bacteremia Risk in Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

Stevens-Johnson Syndrome
Stevens-Johnson Syndrome
Prediction of sepsis via markers such as hypothermia and elevated procalcitonin may allow for its early detection and management.

For patients with Stevens-Johnson syndrome or toxic epidermal necrolysis, risk factors for bacteremia included hemoglobin ≤10 g/dL, existing cardiovascular disease, and involved body surface area of ≥10% at admission, according to a study published in the Journal of the American Academy of Dermatology. Additionally, hypothermia and procalcitonin ≥1 ug/L can be used to help detect bacteremia during a hospital stay, it was observed.

Researchers in this retrospective cohort study used data collected from 2003 to 2016 at the Singapore General Hospital to evaluate risk factors associated with bacteremia at admission, determine clinical and biochemical variables that predict positive blood cultures, and assess microbiology trends in patients with Stevens-Johnson syndrome or toxic epidermal necrolysis. Within the first 24 hours after admission, basic demographics, clinical examinations, laboratory assessments, and the severity of illness score for toxic epidermal necrolysis were completed for each patient. Blood cultures were collected at least every 48 hours but sooner if bacteremia was suspected.

Of the 176 patients included in this study, the median age was 57 years old, 59.1% were women, 33.5% had Stevens-Johnson syndrome, 37.5% had toxic epidermal necrolysis, and 29% had both Stevens-Johnson syndrome and toxic epidermal necrolysis. During hospitalization, 29.5% of patients developed bacteremia with a total of 112 microorganism occurrences. The median time to bacteremia was 9 days after epidermal detachment.

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The overall hospital mortality rate was 23.9%, and patients with bacteremia had a higher chance of intensive care unit admission (odds ratio [OR] 6.8; 95% CI, 3.1-15.0), invasive mechanical ventilation (OR 6.6; 95% CI, 2.3-18.4), requiring dialysis (OR 18.3; 95% CI, 3.9-85.3), having a longer hospital stay (P <.0005), and experiencing higher mortality (OR 4.4; 95% CI, 2.1-9.1).

Analysis of admission data indicated that risk factors associated with bacteremia were hemoglobin ≤10 g/dL (OR 2.4; 95% CI, 2.2- 2.6; P <.0001), existing cardiovascular disease (OR 2.1; 95% CI, 2.0-2.3; P <.0001), and included body surface area ≥10% (OR 14.3; 95% CI, 13.4-15.2; P <.0001). These 3 variables were used to calculate the Bacteremia Risk Score that categorized patients into low, moderate, high, and very high risk for in hospital bacteremia.

Analysis of variables recorded during blood sample collection indicated that risk factors associated with positive blood cultures were a body temperature ≤36.0°C (OR 2.4; 95% CI, 1.1-5.3; P =.03) and procalcitonin ≥1 ug/L (OR 2.4; 95% CI, 1.1-4.8; P =.02).

Limitations of this study include the retrospective nature of the study, potential referral bias, and the lack of external validation of the Bacteremia Risk Score system.

The researchers concluded that the “Bacteraemia Risk Score, derived from the presence of haemoglobin ≤10g/dL, cardiovascular disease and body surface area involved ≥10% on admission, is useful in predicting development of bacteraemia. Hypothermia and procalcitonin ≥1ug/L help in the timely detection of bacteraemia during hospitalization.”

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Koh HK, Chai ZT, Tay HW, et al. Risk factors and diagnostic markers of bacteraemia in Stevens-Johnson syndrome and toxic epidermal necrolysis: a cohort study of 176 patients [published online June 10, 2019]. J Am Acad Dermatol. doi: 10.1016/j.jaad.2019.05.096