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Objective: To evaluate outcomes and factors associated with in-hospital mortality among immunosuppressed patients with necrotizing soft tissue infection (NSTI). Design: Single institution retrospective cohort study. Setting: Tertiary academic hospital/cancer center. Patients: All patients with NSTI between November 25, 1995 and April 25, 2011. Main Outcome Measures: In-hospital mortality. Results: 201 patients were diagnosed with NSTI. 46 were immunosuppressed (active malignancy, chemotherapy/radiation treatment, prior solid organ/bone marrow transplant on chronic immunosuppression, steroids, HIV/AIDS). At presentation, immunocompromised patients had lower systolic blood pressure (105 vs 112mmHg, p=0.0213), glucose (124 vs 134mg/dL, p=0.0325), and white blood cell count (6.6 vs 17.2K/uL, p=0.0001). Immunocompromised patients were less likely to be transferred from another institution (26.1% vs 52.9%, p=0.0014), admitted to a surgical service (45.7% vs 83.2%, p<0.0001), and undergo surgical debridement on admission (4.4% vs 61.3%, p=0.0007). Time to diagnosis and first surgery were delayed in immunocompromised patients (table). Immunocompromised patients had higher in-hospital mortality (39.1% vs 19.4%, p=0.0097). In this patient population, pressor/inotropic requirement (p=0.0062, OR 49.32, 95% CI 3.03-803.18) and fewer surgical debridements (p=0.0028, OR 0.142, 95% CI 0.040-0.510) were independently associated with in-hospital mortality. Conclusions: Immunocompromised status in NSTI patients is associated with delay in diagnosis, delay in surgical treatment and higher in-hospital mortality. At presentation, immunocompromised patients often failed to exhibit typical clinical and laboratory signs of NSTI. It is therefore paramount that physicians caring for this patient population have a heightened level of suspicion for NSTI and consider early surgical evaluation and treatment.

Variable	All Patients (%) (n=201)	Immunosuppressed (%) (n=46)	Immunocompetent (%) (n=155)	P value
Time from presentation to diagnosis				<0.0001
<12hrs	125 (62.2)	22 (47.8)	103 (66.5)	-
12-24hrs	35 (17.4)	18 (39.1)	17 (11.0)	-
>24hrs	38 (18.9)	6 (13.1)	32 (20.6)	-
Unknown	3 (1.5)	0 (0)	3 (1.9)	-
Time from presentation to first surgery				0.0012
<12hrs	118 (58.7)	17 (37.0)	101 (65.2)	-
12-24hrs	35 (17.4)	15 (32.6)	20 (12.9)	-
>24hrs	37 (18.4)	7 (15.2)	30 (19.4)	-
No surgery	8 (4.0)	7 (15.2)	1 (0.6)	-
Unknown	3 (1.5)	0 (0)	3 (1.9)	-