Intensive Care Medicine

, Volume 38, Issue 7, pp 1143–1151 | Cite as

Hyperbaric oxygen therapy in necrotising soft tissue infections: a study of patients in the United States Nationwide Inpatient Sample

  • Chai R. SohEmail author
  • Ricardo Pietrobon
  • John J. Freiberger
  • Sophia T. Chew
  • Dimple Rajgor
  • Mihir Gandhi
  • Jatin Shah
  • Richard E. Moon



Necrotising soft tissue infection (NSTI) is a deadly disease associated with a significant risk of mortality and long-term disability from limb and tissue loss. The aim of this study was to determine the effect of hyperbaric oxygen (HBO2) therapy on mortality, complication rate, discharge status/location, hospital length of stay and inflation-adjusted hospitalisation cost in patients with NSTI.


This was a retrospective study of 45,913 patients in the Nationwide Inpatient Sample (NIS) from 1988 to 2009.


A total of 405 patients received HBO2 therapy. The patients with NSTI who received HBO2 therapy had a lower mortality (4.5 vs. 9.4 %, p = 0.001). After adjusting for predictors and confounders, patients who received HBO2 therapy had a statistically significantly lower risk of dying (odds ratio (OR) 0.49, 95 % confidence interval (CI) 0.29–0.83), higher hospitalisation cost (US$52,205 vs. US$45,464, p = 0.02) and longer length of stay (LOS) (14.3 days vs. 10.7 days, p < 0.001).


This retrospective analysis of HBO2 therapy in NSTI showed that despite the higher hospitalisation cost and longer length of stay, the statistically significant reduction in mortality supports the use of HBO2 therapy in NSTI.


Hyperbaric oxygen therapy Healthcare cost and utilisation project National inpatient sample Necrotising soft tissue infections 



We wish to thank Dr. Tam C. Ha (Ph.D., Division of Clinical Trials and Epidemiological Sciences, National Cancer Centre, Singapore) for reading the manuscript and providing her valuable comments. Institutional (financial) support was received from Duke-NUS Graduate Medical School.


  1. 1.
    Pizzorno R, Bonini F, Donelli A, Stubinski R, Medica M, Carmignani G (1997) Hyperbaric oxygen therapy in the treatment of Fournier’s disease in 11 male patients. J Urol 158:837–840PubMedCrossRefGoogle Scholar
  2. 2.
    Rouse TM, Malangoni MA, Schulte WJ (1982) Necrotizing fasciitis: a preventable disaster. Surgery 92:765–770PubMedGoogle Scholar
  3. 3.
    Escobar SJ, Slade JB Jr, Hunt TK, Cianci P (2005) Adjuvant hyperbaric oxygen therapy (HBO2) for treatment of necrotizing fasciitis reduces mortality and amputation rate. Undersea Hyperb Med 32:437–443PubMedGoogle Scholar
  4. 4.
    Elliott DC, Kufera JA, Myers RA (1996) Necrotizing soft tissue infections: risk factors for mortality and strategies for management. Ann Surg 224:672–683PubMedCrossRefGoogle Scholar
  5. 5.
    George M, Rueth N, Skarda D, Chipman J, Quickel R, Beilman G (2009) Hyperbaric oxygen does not improve outcome in patients with necrotizing soft tissue infection. Surg Infect (Larchmt) 10:21–28CrossRefGoogle Scholar
  6. 6.
    Jallali N, Withey S, Butler P (2005) Hyperbaric oxygen as adjuvant therapy in the management of necrotizing fasciitis. Am J Surg 189:462–466PubMedCrossRefGoogle Scholar
  7. 7.
    Sarani B, Strong M, Pascual J, Schwab CW (2009) Necrotizing fasciitis: current concepts and review of the literature. J Am Coll Surg 208:279–288PubMedCrossRefGoogle Scholar
  8. 8.
    Mindrup SR, Kealey GP, Fallon B (2005) Hyperbaric oxygen for the treatment of Fournier’s gangrene. J Urol 173:1975–1977PubMedCrossRefGoogle Scholar
  9. 9.
    Pietrobon R, Guller U, Martins H, Menezes AP, Higgins LD, Jacobs DO (2004) A suite of web applications to streamline the interdisciplinary collaboration in secondary data analyses. BMC Med Res Methodol 4:29PubMedCrossRefGoogle Scholar
  10. 10.
    Shah J, Shah A, Pietrobon R (2009) Scientific writing of novice researchers: what difficulties and encouragements do they encounter? Acad Med 84:511–516PubMedCrossRefGoogle Scholar
  11. 11.
    Deyo R, Cherkin D, Ciol M (1992) Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 45:613–619PubMedCrossRefGoogle Scholar
  12. 12.
    Rosenbaum PR, Rubin DB (1983) The central role of the propensity score in observational studies for causal effects. Biometrika 70:41–55CrossRefGoogle Scholar
  13. 13.
    Jackson RW, Waddell JP (1973) Hyperbaric oxygen in the management of clostridial myonecrosis (gas gangrene). Clin Orthop Relat Res 96:271–276PubMedGoogle Scholar
  14. 14.
    Riseman JA, Zamboni WA, Curtis A, Graham DR, Konrad HR, Ross DS (1990) Hyperbaric oxygen therapy for necrotizing fasciitis reduces mortality and the need for debridements. Surgery 108:847–850PubMedGoogle Scholar
  15. 15.
    Korhonen K, Kuttila K, Niinikoski J (1999) Subcutaneous tissue oxygen and carbon dioxide tensions during hyperbaric oxygenation: an experimental study in rats. Eur J Surg 165:885–890PubMedCrossRefGoogle Scholar
  16. 16.
    Korhonen K (2000) Hyperbaric oxygen therapy in acute necrotizing infections with a special reference to the effects on tissue gas tensions. Ann Chir Gynaecol Suppl:7–36Google Scholar
  17. 17.
    Brummelkamp W, Hogendyk J, Boerema I (1961) Treatment of anaerobic infections by drenching the tissue with oxygen under high atmospheric pressure. Surgery 49:299–302Google Scholar
  18. 18.
    Bird AD, Telfer AB (1965) Effect of hyperbaric oxygen on limb circulation. Lancet 1:355–356PubMedCrossRefGoogle Scholar
  19. 19.
    Mader JT, Brown GL, Guckian JC, Wells CH, Reinarz JA (1980) A mechanism for the amelioration by hyperbaric oxygen of experimental staphylococcal osteomyelitis in rabbits. J Infect Dis 142:915–922PubMedCrossRefGoogle Scholar
  20. 20.
    Mader J, Adams K, Wallace W, Calhoun J (1990) Hyperbaric oxygen as adjunctive therapy for osteomyelitis. Infect Dis Clin North Am 4:433–440PubMedGoogle Scholar
  21. 21.
    Mandell GL (1974) Bactericidal activity of aerobic and anaerobic polymorphonuclear neutrophils. Infect Immun 9:337–341PubMedGoogle Scholar
  22. 22.
    Hohn DC, MacKay RD, Halliday B, Hunt TK (1976) Effect of O2 tension on microbicidal function of leukocytes in wounds and in vitro. Surg Forum 27:18–20PubMedGoogle Scholar
  23. 23.
    Hunt TK, Linsey M, Grislis H, Sonne M, Jawetz E (1975) The effect of differing ambient oxygen tensions on wound infection. Ann Surg 181:35–39PubMedCrossRefGoogle Scholar
  24. 24.
    Knighton DR, Halliday B, Hunt TK (1984) Oxygen as an antibiotic: the effect of inspired oxygen on infection. Arch Surg 119:199–204PubMedCrossRefGoogle Scholar
  25. 25.
    Kaelin CM, Im MJ, Myers RA, Manson PN, Hoopes JE (1990) The effects of hyperbaric oxygen on free flaps in rats. Arch Surg 125:607–609PubMedCrossRefGoogle Scholar
  26. 26.
    Rinaldi B, Cuzzocrea S, Donniacuo M, Capuano A, Di Palma D, Imperatore F, Mazzon E, Di Paola R, Sodano L, Rossi F (2011) Hyperbaric oxygen therapy reduces the toll-like receptor signaling pathway in multiple organ failures. Intensive Care Med 37:1110–1119PubMedCrossRefGoogle Scholar
  27. 27.
    Knighton DR, Halliday B, Hunt TK (1986) Oxygen as an antibiotic: a comparison of the effects of inspired oxygen concentration and antibiotic administration on in vivo bacterial clearance. Arch Surg 121:191–195PubMedCrossRefGoogle Scholar
  28. 28.
    Unnika V (1965) Inhibition of toxin production in Clostridium perfringens in vitro by hyperbaric oxygen. Antonie Van Leeuwenhoek 31:181–186CrossRefGoogle Scholar
  29. 29.
    Maclennan J, Macfarlane R (1945) Toxin and antitoxin studies of gas gangrene in man. Lancet 246:301–305CrossRefGoogle Scholar
  30. 30.
    Marx RE, Ehler WJ, Tayapongsak P, Pierce LW (1990) Relationship of oxygen dose to angiogenesis induction in irradiated tissue. Am J Surg 160:519–524PubMedCrossRefGoogle Scholar
  31. 31.
    Hunt TK, Pai MP (1972) The effect of varying ambient oxygen tensions on wound metabolism and collagen synthesis. Surg Gynecol Obstet 135:561–567PubMedGoogle Scholar
  32. 32.
    Clark LA, Moon RE (1999) Hyperbaric oxygen in the treatment of life-threatening soft-tissue infections. Respir Care Clin N Am 5:203–219PubMedGoogle Scholar
  33. 33.
    Brown D, Davis N, Lepawsky M, Cunningham J, Kortbeek J (1994) A multicenter review of the treatment of major truncal necrotizing infections with and without hyperbaric oxygen therapy. Am J Surg 167:485–489PubMedCrossRefGoogle Scholar
  34. 34.
    Majeski JA, Alexander JW (1983) Early diagnosis, nutritional support, and immediate extensive debridement improve survival in necrotizing fasciitis. Am J Surg 145:784–787PubMedCrossRefGoogle Scholar
  35. 35.
    Stamenkovic I, Lew PD (1984) Early recognition of potentially fatal necrotizing fasciitis: the use of frozen-section biopsy. N Engl J Med 310:1689–1693PubMedCrossRefGoogle Scholar
  36. 36.
    Boyer A, Vargas F, Coste F, Saubusse E, Castaing Y, Gbikpi-Benissan G, Hilbert G, Gruson D (2009) Influence of surgical treatment timing on mortality from necrotizing soft tissue infections requiring intensive care management. Intensive Care Med 35:847–853PubMedCrossRefGoogle Scholar
  37. 37.
    Freischlag JA, Ajalat G, Busuttil RW (1985) Treatment of necrotizing soft tissue infections: the need for a new approach. Am J Surg 149:751–755PubMedCrossRefGoogle Scholar
  38. 38.
    Kaul R, McGeer A, Low DE, Green K, Schwartz B (1997) Population-based surveillance for group A streptococcal necrotizing fasciitis: clinical features, prognostic indicators, and microbiologic analysis of seventy-seven cases. Ontario Group A Streptococcal Study. Am J Med 103:18–24PubMedCrossRefGoogle Scholar
  39. 39.
    Mohammedi I, Ceruse P, Duperret S, Vedrinne J, Bouletreau P (1999) Cervical necrotizing fasciitis: 10 years’ experience at a single institution. Intensive Care Med 25:829–834PubMedCrossRefGoogle Scholar
  40. 40.
    Weaver LK (2011) Hyperbaric oxygen in the critically ill. Crit Care Med 39:1784–1791PubMedCrossRefGoogle Scholar

Copyright information

© Copyright jointly held by Springer and ESICM 2012

Authors and Affiliations

  • Chai R. Soh
    • 1
    • 2
    Email author
  • Ricardo Pietrobon
    • 1
    • 3
  • John J. Freiberger
    • 4
  • Sophia T. Chew
    • 1
    • 2
  • Dimple Rajgor
    • 1
    • 3
  • Mihir Gandhi
    • 1
    • 5
  • Jatin Shah
    • 1
    • 3
  • Richard E. Moon
    • 3
  1. 1.Duke-NUS Graduate Medical SchoolSingaporeSingapore
  2. 2.Department of AnaesthesiologySingapore General HospitalSingaporeSingapore
  3. 3.Research on Research GroupDuke University Medical CenterDurhamUSA
  4. 4.Center for Hyperbaric Medicine and Environmental PhysiologyDuke University Medical CenterDurhamUSA
  5. 5.Singapore Clinical Research InstituteSingaporeSingapore

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