背景：在台灣，海島地理及肝炎盛行成就了創傷弧菌的高致病率，成功的治療取決於早期診斷、合適的抗生素使用、積極外科治療、及生命徵象的支持治療，然而，對於開刀治療的時機點及免疫調節藥物的使用仍是兩個主要的挑戰及爭論，在此篇研究中，我們試著去釐清開刀治療的角色及調查腫瘤壞死因子阿爾法阻斷藥物的治療效果。

方法：在臨床實驗中，我們回顧在成功大學附設醫院中從1996年1月至2011年12月經細菌培養證實為創傷弧菌感染的個案，而那些經由開刀證實為壞死性筋膜炎的患者將被進一步分析來探討其預後因子。在動物實驗中，我們先證實了一個可模擬人類創傷弧菌軟組織感染的小鼠模式，接著我們利用這個動物模式來探討開刀治療的角色，以及恩博凍晶注射劑(Etanercept)這個抑制腫瘤壞死因子阿爾法藥物的治療效果。

結果：在臨床實驗中，我們找出病程超過3天是一個預後不良的獨立因子(OR: 10.75; 95% CI: 1.02-113.39, p = 0.048)。在動物實驗中，我們證實早期開刀治療相較於延遲開刀治療有較好的存活率，若於感染前施以恩博凍晶注射劑(Etanercept)來抑制腫瘤壞死因子阿爾法，更發現可以改善創傷弧菌感染後未開刀控制組及延遲開刀治療組的存活率。

結論：於受傷後或症狀發生3天內得到早期診斷及積極治療，是創傷弧菌所導致壞死性筋膜炎的治療目標，對於病程超過3天的壞死性筋膜炎患者，使用抑制腫瘤壞死因子阿爾法的藥物當作輔助治療可能值得我們進一步研究。

Background: In Taiwan, the aquatic environment and endemic hepatitis contribute to the high susceptibility of V. vulnificus infection. Successful treatments depend on early diagnosis, adequate antibiotics, aggressive surgical interventions, and hemodynamic supports. However, two main challenges and debates exist regarding the timing of operation and the use of immunomodulatory agents. In this study, we tried to clarify the role of surgical intervention and to investigate the therapeutic effects of TNF-α inhibitor.

Methods: In clinical study, cases of culture-confirmed V. vulnificus infection between January 1996 to December 2011 in NCKUH were reviewed. Patients with surgically confirmed necrotizing fasciitis were further analyzed to identify the prognostic factors. In animal study, we verified a mouse model to mimic V. vulnificus soft tissue infection and then investigated the role of surgical intervention and the therapeutic effects of etanercept.

Results: In clinical study, we identified the prolonged disease course longer than 3 days was an independent factor indicating a poor prognosis (OR: 10.75; 95% CI: 1.02-113.39, p = 0.048). In animal study, we demonstrated early operation had a better survival outcome compared with delayed group. Pretreatment with etanercept can not only improve the survival of the infected control group but also the delayed operation group.

Conclusions: Early diagnosis and prompt treatment within 3 days post-injury or symptom onset should be the goal for treating patients with necrotizing fasciitis caused by V. vulnificus. Adjunctive treatment to rescue patients with a prolonged disease course of necrotizing fasciitis (≧3 days) by using TNF-α inhibitor may warrant further investigation.

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