JAAD International | 2021
Delayed admission to a specialist referral center for Stevens-Johnson syndrome and toxic epidermal necrolysis is associated with increased mortality: A retrospective cohort study
Abstract
To the Editor: Stevens-Johnson syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are rare, severe cutaneous adverse drug reactions. The average mortality across the spectrum is 25%. Guidelines recommend that such cases be managed in reference centers. Our study aims to evaluate the impact of delayed admission to an SJS/TEN referral center on clinical outcomes. A retrospective cohort study was conducted from 2005 to 2018 at the Singapore General Hospital (SGH), the national referral center for SJS/TEN. Outcomes of interest included mortality, the incidence of bacteremia at SGH, ICU admission, and length of hospital stay. Admissions occurring within 4 days of skin blistering according to clinical records were considered early admissions and delayed admissions were defined as admissions occurring 5 days or more after skin blistering. The consensus of the 5-day cut-off was based on 1) a multi-center study in Europe, wherein the median admission delay was 5-7 days across several centers and 2) the natural history of SJS/TEN, where the disease evolves from initial blistering to hospitalization in 3 days, then progresses to maximum detachment in another 5 days. A total of 123 patients with SJS/TENwere included in this study. There were 93 (76%) patients with early admissions and 30 (24%) with delayed admissions. Baseline characteristics are shown in Table I. Univariate analyses demonstrated a significant difference in outcomes between early and late admission patients for mortality (14% vs 37%; P 1⁄4 .007), incidenceof bacteremia (20%vs52%;P1⁄4.001), rate of ICUadmission (14%vs 41%;P1⁄4.002), and total length of stay at SGH (166 22 vs 286 23; P 1⁄4 .01). A doseresponse relationship was demonstrated between mortality and admission delay, with mortality increasing from 15% in those admitted within 03 days, to 19% in those admitted within 4-5 days, and to 33% in those admitted within 6 days.