Causative pathogens, antibiotic sensitivity, resistance patterns, and severity in a contemporary series of Fournier's gangrene

Reliability of superficial swab culture results compared with deep wound culture results in Fournier's gangrene: A retrospective study

OBJECTIVES

To compare isolates from deep wound and superficial swab cultures to evaluate the detectability of pathogens by each culture in Fournier's gangrene; and evaluate the association between microorganisms isolated from deep wounds and those isolated from blood or urine.

METHODS

Patients with Fournier's gangrene who underwent debridement between October 2006 and January 2023 were retrospectively reviewed. In addition to comparing the isolates from deep wound cultures at initial debridement with those from superficial swab, blood, and urine cultures, the relationship between the traits of the organisms from deep wounds and patient disease severity and prognosis was examined.

RESULTS

Among 25 patients, deep wound and superficial swab cultures were obtained from 25 to 18 patients, respectively. The frequency of anaerobic isolates was significantly lower in the superficial cultures than in the deep wound cultures (31/76 versus 13/56, p = 0.034). Bacteria not isolated from deep wounds were isolated from superficial cultures in 55.6 % of the patients; the concordance rate between deep and superficial cultures was 27.8 % (5/18). The positive rates of blood and urine cultures were 20.8 % and 35.7 %, respectively; all isolates from the urine and blood cultures reflected the results of the deep wound culture. No significant association was observed between the severity or mortality and the type of causative bacteria.

CONCLUSIONS

Superficial swab cultures cannot be substituted for deep wound cultures in Fournier's gangrene. Although the positivity rates for blood and urine cultures were not high, they were helpful in determining antibiotic de-escalation.

A Case of Fournier's Gangrene Following the Initiation of Dapagliflozin

Since being approved by the United States Food and Drug Administration (FDA) in 2013, sodium-glucose cotransporter-2 inhibitors (SGLT2is) have emerged as an appealing therapeutic choice for patients with diabetes due to their favorable effects on renal and cardiac health. Recent trials have further expanded the application of these drugs by showing a decrease in mortality rates among patients with both reduced and preserved ejection fraction heart failure, even in those without diabetes. Common adverse effects of SGLT2is include increased urinary frequency and urinary tract infections stemming from elevated glycosuria. Here, we present a case report involving a 66-year-old man who developed Fournier's gangrene (FG) shortly after initiating dapagliflozin - a rare but dangerous adverse effect associated with this medication.

A Disease-Specific Antibiogram to Evaluate Empiric Coverage Patterns in Fournier's Gangrene

OBJECTIVE

To analyze our local antibiogram and antibiotic resistance patterns given concern for multidrug-resistant and fungal organisms in contemporary series detailing causative organisms in Fournier's Gangrene (FG).

METHODS

All patients from 2018 to 2022 were identified from the institutional FG registry. Microorganisms and sensitivities were collected from operative tissue cultures. The primary outcome of this study was the adequacy of our empiric. Secondary outcomes included the rate of bacteremia, the concordance of blood cultures and tissue cultures, and the rate of fungal tissue infections.

RESULTS

Escherichia coli and Streptococcus anginosus were most common, identified in 12 patients each (20.0%). Enterococcus faecalis (9, 15.0%), S agalactiae (8, 13.3%) and mixed cultures without a predominant organism (9, 15.0%) were also common. A fungal organism was identified in 9 (15.0%) patients. Patients who were started on Infectious Diseases Society of America guideline adherent antibiotic regimen were not significantly different in terms of bacteremia rate (P = .86), mortality (P = .25), length of stay (P = .27), or final antibiotic duration (P = .43) when compared to those on alternative regimens. Patients with a tissue culture positive for a fungal organism were not significantly different in terms of Fournier's Gangrene Severity Index (P = .25) or length of stay (P = .19).

CONCLUSION

Local disease-specific antibiograms can be a powerful tool to guide empiric antibiotic therapy in FG. Although fungal infections are responsible for a majority of the gaps in empiric antimicrobial coverage at our institution they were present in only 15% of patients and their effect on outcomes does not justify addition of empiric antifungal agents.

The Antimicrobial Resistance Index and Fournier Gangrene Severity Index of Patients Diagnosed with Fournier's Gangrene in a Tertiary Hospital in North Eastern Romania

Background: Although rare, Fournier's gangrene is a major urological emergency. We aimed to learn more about the pathogenesis of Fournier's gangrene and assess the antibiotic resistance patterns in individuals with this disease. Methods: We retrospectively evaluated the patients diagnosed with and treated for Fournier's gangrene in a Neamt county hospital and "CI Parhon" Clinical Hospital in Iasi, Romania between 1 January 2016 and 1 June 2022. Results: We included a total of 40 patients, all males; of these, 12.5% died. In our study, in the patients that died, the adverse prognostic factors were a higher body temperature (38.12 ± 0.68 vs. 38.94 ± 0.85 °C; p = 0.009), an elevated WBC (17.4 ± 5.46 vs. 25.23 ± 7.48; p = 0.003), obesity (14.28% vs. 60%; p = 0.04), and a significantly higher FGSI (4.17 ± 2.80 vs. 9.4 ± 3.2; p = 0.0002) as well as MAR index (0.37 ± 0.29 vs. 0.59 ± 0.24; p = 0.036). These patients were more likely to have liver affections than those in the group who survived, but the difference was not significant. The most frequently identified microorganism in the tissue secretions culture was E. coli (40%), followed by Klebsiella pneumoniae (30%) and Enterococcus (10%). The highest MAR index was encountered in Acinetobacter (1), in a patient that did not survive, followed by Pseudomonas (0.85) and Proteus (0.75). Conclusions: Fournier's gangrene remains a fatal condition, a highly resistant causative microorganism that is not always correlated with a poor prognosis.

The sufficient multidisciplinary specialists under a government-led health care system associated with the downward mortality trend of Fournier's gangrene in Taiwan

OBJECTIVES

To explore the trends in Fournier's gangrene (FG) incidence and mortality rate in Taiwan and to investigate the contributing factors to such changes.

METHODS

Between 2002 and 2016, hospitalized FG patients who underwent subsequent surgical intervention were included in this retrospective study. Incidence, outcomes, age-adjusted Charlson Comorbidity Index (ACCI), hospitalization cost, surgical timing, and the number of multidisciplinary specialists involved in the first-line management of FG in each year were collected. Simple linear regression and Pearson correlation coefficient (r) were used for the subsequent analysis.

RESULTS

The national cohort enrolled 2183 FG patients from 2002 to 2016 in Taiwan. The age-standardized incidence rate of FG was between 0.4 and 0.8 per 100 000 population, and overall mortality was 7.8% in these 15 years. We illustrated the downward trendline of FG mortality with a 0.62 coefficient of determination. The mortality of FG patients who underwent surgery within 24 h and after 24 h were found to be 8.3 ± 3.9% and 14.6 ± 25.2%, respectively (p = 0.02). The numbers of urologists, anesthesiologists, emergency doctors, and physicians per 100 000 population had a strong negative linear correlation with FG mortality (r = 0.8, p < 0.001). ACCI score had a moderate linear relationship with FG mortality (r = 0.57, p = 0.027). The hospitalization cost showed a weak linear correlation with FG mortality (r = -0.03, p = 0.92).

CONCLUSIONS

We demonstrated the downward trend of the FG mortality rate in Taiwan from 2002 to 2016. Besides underlying comorbidities and surgical timing, sufficient multidisciplinary specialists are essential for the survival benefit of FG patients in Taiwan experience.

Practice Patterns in Fournier's Gangrene in Europe and Implications for a Prospective Registry Study

BACKGROUND

Fournier's gangrene (FG) is a life-threatening, necrotizing infection. Due to the rareness of the disease, it is challenging to plan robust prospective studies. This study aims to describe current practice patterns of FG in Europe and identify implications for planning a prospective FG registry.

METHODS

Online non-validated 17-items survey among urologists treating FG in in European hospitals. Questionnaires were analyzed with LimeSurvey (LimeSurvey GmbH Hamburg, Germany).

RESULTS

229 responses from ten different European countries were submitted, and 117 (51.1%) urologists completed the questionnaire. The departments treat a mean of 4.2 (SD 3.11) patients per year. The urology department mostly takes the lead in treating FG patients (n = 113; 96.6%). The practice in FG is very heterogenic and mostly case-based all over Europe, e.g., vacuum-assisted wound closure (VAC) is mostly used (n = 50; 42.7%) as adjunct wound. The biggest challenges in FG are the short time to diagnosis and treatment, standardization and establishment of guidelines, and disease awareness. Additionally, participants stated that an international registry is an outstanding initiative, and predictive models are needed.

CONCLUSIONS

There is no standard of care in the diagnosis, treatment, and long-term care of FG all over Europe. Further research could be conducted with a prospective registry.

Regional Variations in Microbiology and Outcomes of Necrotizing Soft Tissue Infections: A Systematic Review and Meta-Analysis

Background: Frequency, microbiology, and outcomes of necrotizing soft tissue infections (NSTIs) could vary across the United States because of differences in locoregional and environmental factors. We synthesized the literature from across the regions of the United States on NSTIs in a systematic review/meta-analysis. Methods: PubMed, ProQuest, Scopus, and Web of Science databases were systematically searched and screened. DerSimonian-Laird random-effects meta-analyses were performed using 'meta' package in R to determine pooled prevalences. Meta-regression analyses examined moderator effects of risk factors. Results: Twenty-seven studies (2,242 total patients) were included. Pooled prevalences of polymicrobial and monomicrobial infections were 52.2% and 39.9%, respectively. The prevalence of monomicrobial NSTIs increased over the last two decades (p = 0.018), whereas polymicrobial infections declined (p = 0.003). Meta-regression analysis showed that most polymicrobial NSTIs were Fournier gangrene (p < 0.001), whereas monomicrobial NSTIs mostly affected extremities (p < 0.001). Staphylococcus aureus was the most common organism isolated (predominantly in the South), followed by Bacteroides spp. (predominately in the East) and Streptococcus pyogenes. Methicillin-resistant Staphylococcus aureus (MRSA) accounted for 11.9% of NSTIs, mainly in the South. The overall mortality rate was 17.8% and declined over last two decades (p < 0.001), with the lowest rate reported in the last decade at 13% without any regional differences. Conclusions: Advancement in the management of NSTIs may have contributed to the observed decline in NSTI-related mortality in the United States. However, the proportion of monomicrobial NSTIs seems to be increasing, possibly because of increased comorbidities affecting extremities. Causative organisms varied by region. Multi-center observational studies are warranted to confirm our observations.

Management of Fournier's gangrene during the Covid-19 pandemic era: make a virtue out of necessity

Background

Fournier’s gangrene (FG) is a necrotizing fasciitis caused by aerobic and anaerobic bacterial infection that involves genitalia and perineum. Males, in their 60 s, are more affected with 1.6 new cases/100.000/year. Main risk factors are diabetes, malignancy, inflammatory bowel disease. FG is a potentially lethal disease with a rapid and progressive involvement of subcutaneous and fascial plane. A multimodal approach with surgical debridement, antibiotic therapy, intensive support care, and hyperbaric oxygen therapy (HBOT) is often needed.

We present the inpatient management of an FG case during the Covid-19 pandemic period. A narrative review of the Literature searching “Fournier’s gangrene”, “necrotizing fasciitis” on PubMed and Scopus was performed.

Case presentation

A 60 years old man affected by diabetes mellitus, with ileostomy after colectomy for ulcerative colitis, was admitted to our Emergency Department with fever and acute pain, edema, dyschromia of right hemiscrotum, penis, and perineal region. Computed tomography revealed air-gas content and fluid-edematous thickening of these regions. Fournier’s Gangrene Severity Index was 9. A prompt broad-spectrum antibiotic therapy with Piperacillin/Tazobactam, Imipenem and Daptomycin, surgical debridement of genitalia and perineal region with vital tissue exposure, were performed. Bedside daily surgical wound medications with fibrine debridement, normal saline and povidone-iodine solutions irrigation, iodoform and fatty gauze application, were performed until discharge on the 40^th postoperative day. Every 3 days office-based medication with silver dressing, after normal saline and povidone-iodine irrigation and fibrinous tissue debridement, was performed until complete re-epithelialization of the scrotum on the 60^th postoperative day.

Conclusions

FG is burdened by a high mortality rate, up to 30%. In the literature, HBOT could improve wound restoration and disease-specific survival. Unfortunately, in our center, we do not have HBOT. Moreover, one of the pandemic period problems was the patient’s displacement and outpatient hospital management. For all these reasons we decided for a conservative inpatient management. Daily cleaning of the surgical wound allowed to obtain its complete restoration avoiding surgical graft and hyperbaric oxygen chamber therapy, without foregoing optimal outcomes.

Sodium-Glucose Cotransporter 2 Inhibitor Use Associated With Fournier's Gangrene: A Review of Case Reports and Spontaneous Post-Marketing Cases

BACKGROUND

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are effective for glycemic control and have demonstrated cardiorenal benefits. The U.S. Food and Drug Administration (FDA) released a boxed warning in 2018 regarding the potential development of Fournier's gangrene (FG) with the use of SGLT2 inhibitors. FG is a serious perineal infection with a mortality rate of up to 88% in some cases.

OBJECTIVES

To report spontaneous post-marketing cases from the FDA Adverse Event Reporting System (FAERS) database and case reports from the literature of FG associated with the use of SGLT2 inhibitors and to determine whether correlations exist with specific agents.

METHODS

A search of the FAERS database was conducted to identify reported cases of FG associated with the use of any FDA-approved SGLT2 inhibitor between 1 March 2013 and 30 June 2020. Additionally, a literature search was conducted of PubMed, Embase, and the Cochrane library using PRISMA guidelines to identify case reports of FG with the use of SGLT2 inhibitors up to 9 October 2020.

RESULTS

A total of 491 cases from the FAERS database were included for review. Descriptive analysis depicted more cases in the empagliflozin, canagliflozin, and dapagliflozin groups than in the ertugliflozin group. Nine case reports were included from the literature review; four attributed to dapagliflozin, three to empagliflozin, and two to canagliflozin. The median ages from cases reported in the FAERS database and from the literature review were 54 and 52 years, respectively. In both datasets, males had a higher incidence of FG than females. Additional data reported include clinical outcomes and concomitant antihyperglycemic medications.

CONCLUSION

Consistent findings are noted in this systematic review and warrant further investigation to elucidate the association between SGLT2 inhibitor use and the development of FG. These results may drive enhanced prescribing patterns to consider patient-specific risk factors and timely monitoring, especially as more indications are approved related to these medications' cardiorenal protective properties.

[New aspects in Fournier's gangrene - a rapid review]

Fournier's gangrene (FG) is a sporadic, life-threatening, necrotising infection affecting the perineum, perineal region and genitals. Published literature provides hints that the outcome of this disease has failed to improve in recent years. We have therefore performed a rapid evidence synthesis by searching the database MEDLINE. The literature from 2020 was studied to identify new aspects to improve the care of FG patients and plan further therapeutic research. 18 publications were chosen for this review, 15 of these were original research and three systematic reviews. 12 were retrospective case series, 2 epidemiological studies, with one prospective clinical study, one systematic review and 2 systematic reviews, together with a meta-analysis. Most of the authors of the studies concluded that FG is still a severe disease with unacceptable mortality rates, so that there is urgent need for therapy improvement. New risk factors for higher mortality in FG have been identified in these studies, namely dyslipoproteinemia, diabetes mellitus, heart disease, as well as both acute and chronic kidney failure. Furthermore, 4 of the included studies investigated the association of SGLT2- and DDP4-inhibitors, which are drugs used in diabetes mellitus, and the incidence of FG. No studies reported a significant association between these drugs and FG, especially not a meta-analysis with 84 included studies. New promising concepts for wound conditioning are hyperbaric oxygenation (HBO), vacuum-assisted wound closure (VAC) and Maggot therapy (blowfly larvae). In summary, FG is still a severe disease, the prognosis has not improved in recent years and so there is an urgent need for improved therapy. This could only be achieved with further research in FG. In our opinion and due to the rarity of FG, this would be possible with a national registry study. For example, it might be possible to calculate risk stratification from this registry to identify patients who would benefit from treatment in a centre or with special wound conditioning.

The Diagnosis and Management of Life-threatening Urologic Infections

Genitourinary infections are commonly encountered and managed in inpatient, outpatient, and emergency settings. Fournier's gangrene, emphysematous pyelonephritis, and obstructive pyelonephritis represent the most serious urologic infections and have a high risk of mortality if not managed promptly. Due to the rarity of these infections, the evidence for specific treatment strategies is scattered. This review aims to provide comprehensive, evidence-based recommendations for the diagnosis and management of these life-threatening urologic infections.

[Contemporary practice patterns in the treatment of Fournier's gangrene in German academic medicine and their implications for planning a registry study]

Hintergrund

Die Fournier-Gangrän (FG) ist ein seltenes, aber lebensbedrohliches Krankheitsbild, dessen Prognose in den letzten Jahren nicht wesentlich verbessert werden konnte.

Ziel der Arbeit

Primäres Studienziel ist die Deskription der Therapiesituation von FG an deutschen Universitätskliniken. Als sekundäres Studienziel sollen Faktoren identifiziert werden, die mit einer erhöhten Letalität assoziiert sind. Außerdem sollen die Daten zur Planung einer Registerstudie dienen.

Material und Methoden

Es wurde ein Fragebogen mit 29 Fragen an die Mitglieder des Verbands Universitätsklinika Deutschlands sowie eine 3‑malige Erinnerung zur Studienteilnahme im Zeitraum April bis Juni 2020 versandt. Die Datenverwaltung und statistische Analyse erfolgte mit SPSS 26.0 (SPSS Inc., Chicago, Il, USA).

Ergebnisse

Die Antwortrate betrug 88,9 %. Im Median werden jährlich 5 Patienten mit einem medianen Alter von 60 Jahren an deutschen Universitätsklinika mit der Diagnose FG therapiert. Insgesamt stellt sich die Therapiesituation sehr heterogen dar, insbesondere hinsichtlich der empirischen Erstantibiose. Ein signifikanter Risikofaktor für eine Letalität > 20 % konnte identifiziert werden: Intensivaufenthalt von größer gleich 10 Tagen (p = 0,039). Die Hälfte (50,0 %) der Befragten geben an, dass sich die Prognose der Erkrankung nicht wesentlich verbessert hat. Weiterhin halten viele der Befragten die Letalität für inakzeptabel hoch, daher befürworten 84,4 % eine Registerstudie. Aus den Kommentaren der Befragten konnten zahlreiche Vorschläge sowie Implikationen für die Planung einer solchen Studie abgeleitet werden, wie z. B. die histologische Sicherung der FG.

Schlussfolgerung

Die Therapiesituation der FG ist heterogen. Allerdings sind die Therapieergebnisse weiterhin inakzeptabel und schwer prognostizierbar.

Fournier's gangrene as a rare complication in patient with uncontrolled type 2 diabetes treated with surgical debridement: A case report and literature review

•

Fournier’s gangrene (FG) is a rare disease which usually affects men. It is characterized by progressive necrotizing fasciitis.

•

A 66-year-old man with uncontrolled type 2 diabetes, obesity with BMI 38, chronic kidney failure and chronic heart failure, reported the onset of symptoms about 14 days before his hospitalization, without consulting any doctor due to Covid-19 pandemic.

•

The combination therapy of surgical debridement and antibiotics infusion was effective.

Introduction

Fournier’s gangrene is a potentially fatal emergency condition, supported by an infection of perineal and perianal region, characterized by necrotizing fasciitis with a rapid spread to fascial planes. FG, usually due to compromised host, may be sustained by many microbial pathogens.

Case report

A 66-year-old man, with a history of uncontrolled type 2 diabetes, obesity with BMI 38, chronic kidney failure and chronic heart failure, was admitted to the Emergency Department with a large area of necrosis involving the perineal and perianal regions.

Discussion

Fournier’s gangrene is favoured by hypertension, obesity, chronic alcoholism, renal and heart failure. Generally, Fournier’s gangrene needs other procedures in addition to wound debridement such as colostomy, cystostomy, or orchiectomy.

Conclusion

We report a case of FG found as complication in a patient with uncontrolled type 2 diabetes, treated with effective combination therapy with surgical debridement and antibiotics infusion.

[FOURNIER GANGRENE: AN ANALYSIS OF 15 CASES]

(Objectives) This study aimed to evaluate the clinical characteristics and the mortality risk factors of 15 patients with Fournier gangrene in the past decade at Teikyo University Hospital. (Materials and methods) We retrospectively assessed 15 patients with Fournier gangrene between May 2009 and April 2019. We compared the demographic characteristics along with several clinical variables including Fournier Gangrene Severity Index of the survivors and nonsurvivors. We also assessed the risk factors associated with mortality. (Results) All patients were men with a median age of 67 years. Among the 15 patients, 9 had diabetes mellitus (60%). Furthermore, 14 patients (93%) underwent surgical debridement, 5 (33%) required orchiectomy, 3 (20%) were treated with cystostomy for urinary diversion, and 3 (20%) needed temporary colostomy for fecal diversion. Three patients died of the disease with a mortality rate of 20%. The nonsurvivors were significantly older (p = 0.043) and had a smaller body mass index (p = 0.038) than the survivors. The scores of clinical risk models, such as the Fournier Gangrene Severity Index, were higher in nonsurvivors than in survivors, with no statistical significance presumably due to the small sample size. (Conclusions) The mortality rate for Fournier gangrene during the past decade at our institution was 20%. Fournier gangrene was a potentially fatal disease even in the 2010s.

Hyperbaric Oxygenation in the Treatment of Fournier's Gangrene: A Systematic Review

INTRODUCTION

Fournier's gangrene (FG) is a sporadic, life-threatening, necrotizing infection affecting the perineum, perineal region, and genitals. Hyperbaric oxygenation (HBO) improves tissue perfusion and promotes angiogenesis and collagen synthesis. Despite these positive effects of HBO, the indication and the effects on outcome as adjunct therapy in FG remain controversial. Consequently, we decided to perform a systematic review to compare the treatment of FG with or without the use of HBO as an adjunct therapy.

MATERIALS AND METHODS

We performed a systematic review following the recommendations provided in the Cochrane Handbook of systematic Reviews and the PRISMA reporting guidelines. Due to the paucity of data and a suspected lack of randomized controlled trials, we considered all the available information for this systematic review.

RESULTS

The literature search for primary studies yielded 79 results. Finally, 13 studies were considered, which included a total of 376 patients with FG, of whom 202 received HBO therapy. Five of these studies had a retrospective case-control design. However, these 5 studies included a total of 319 patients; 145 of these patients were treated with adjunct HBO therapy. Overall, this leads to a mortality rate of 16.6% in the HBO group and 25.9% in the non-HBO group. Overall, risk of bias was assessed as moderate to high.

CONCLUSIONS

We conclude that despite the risk of bias, HBO has potential as an adjunct in FG treatment, but it is challenging to carry out further studies, mainly due to the rareness of FG and availability of HBO.

Fournier Gangrene in the Emergency Department: Diagnostic Dilemmas, Treatments and Current Perspectives

Fournier gangrene (FG) is a rare and life-threatening urosurgical emergency characterized most often by a polymicrobial infection of the perineal, genital, or perianal region. FG has an increased incidence in male patients, patients with alcoholism, and patients with immunocompromise including human immunodeficiency virus (HIV) and uncontrolled diabetes. FG often begins as a simple abscess or cellulitis with progression to necrotizing soft tissue infection (NSTI). Delays in diagnosis and treatment confer high mortality. Early recognition and high clinical suspicion are important in making a timely diagnosis, as early manifestations are often subtle. The most significant modifiable risk factor associated with NSTI mortality is delay to surgical intervention. Coordination of both inpatient medical and surgical teams to implement appropriate therapy is vital to successful outcomes. The emergency medicine clinician must be vigilant for this condition and be aware of risk factors, prognostic indicators, and proper treatment protocols to recognize FG early and initiate appropriate management. The objective of this review is to provide updated and relevant information regarding recognition, diagnosis, and management of FG for the emergency medicine provider.

Fatal infections in andrology. Atypical clinical presentation of a Fournier's disease

BACKGROUND

Fournier disease (FD) is a worrisome infection of genital area caused by a polimicrobial infection and characterized by a rapid progression to necrosis. Scrotum, perineum and lower abdomen represent the primary sites of origin. Clinical presentation and laboratory strongly suggest FD, but if not precociously diagnosed, it may quickly evolve into septic syndrome and patient's death.

CASE REPORT

A 62 years old Caucasian male presented for fever and penile gross oedema recently occurred. No history of previous urinary tract infection, hematuria or genital trauma was referred. He did not complain any storage or voiding low urinary tract symptom (LUTS); no foci of infection in genitoperineal area was observed nor urethral discharge. The ultrasound (US) revealed a disomogeneous broad thickening of subcutaneous tissues with increased vascularity on Color-Doppler. When the penis was manipulated in order to reduce oedema, retract foreskin and evaluate the glans, clinical parametres rapidly worsened and the patient developed a septic shock with blood pressure falling down, dyspnoea and tachyarrhythmia, and he was fastly sent to Intensive Care Unit where it has been hemodynamically stabilized and subjected to antibiotic therapy. Considering the clinical absence of gangrene's foci, we opted for a conservative treatment by maintaining bladder catheter and drug therapy.

Fournier's Gangrene and Intravenous Drug Abuse: an Unusual Case Report and Review of The Literature

Fournier's gangrene is a potentially fatal emergency condition characterized by necrotizing fasciitis and supported by an infection of the external genital, perineal and perianal region, with a rapid and progressive spread from subcutaneous fat tissue to fascial planes. In this case report, a 52-year-old man, with a history of hepatitis C-virus (HCV)-related chronic liver disease and cocaine use disorder for which he was receiving methadone maintenance therapy, was admitted to the Emergency Department with necrotic tissue involving the external genitalia. Fournier's gangrene is usually due to compromised host immunity, without a precise cause of bacterial infection; here it is linked to a loco-regional intravenous injection of cocaine. A multimodal approach, including a wide surgical debridement and a postponed skin graft, was needed. Here we report this case, with a narrative review of the literature.

Necrotizing skin and soft-tissue infections in the intensive care unit

BACKGROUND

Necrotizing skin and soft-tissue infections (NSTI) are rare but potentially life-threatening and disabling infections that often require intensive care unit admission.

OBJECTIVES

To review all aspects of care for a critically ill individual with NSTI.

SOURCES

Literature search using Medline and Cochrane library, multidisciplinary panel of experts.

CONTENT

The initial presentation of a patient with NSTI can be misleading, as features of severe systemic toxicity can obscure sometimes less impressive skin findings. The infection can spread rapidly, and delayed surgery worsens prognosis, hence there is a limited role for additional imaging in the critically ill patient. Also, the utility of clinical scores is contested. Prompt surgery with aggressive debridement of necrotic tissue is required for source control and allows for microbiological sampling. Also, prompt administration of broad-spectrum antimicrobial therapy is warranted, with the addition of clindamycin for its effect on toxin production, both in empirical therapy, and in targeted therapy for monomicrobial group A streptococcal and clostridial NSTI. The role of immunoglobulins and hyperbaric oxygen therapy remains controversial.

IMPLICATIONS

Close collaboration between intensive care, surgery, microbiology and infectious diseases, and centralization of care is fundamental in the approach to the severely ill patient with NSTI. As many aspects of management of these rare infections are supported by low-quality data only, multicentre trials are urgently needed.

Incorporating Simplified Fournier's Gangrene Severity Index with early surgical intervention can maximize survival in high-risk Fournier's gangrene patients

OBJECTIVES

To determine the optimal surgical timing in high-risk patients with Fournier's gangrene by the Simplified Fournier's Gangrene Severity Index.

METHODS

From 1989 to 2018, 118 male patients diagnosed with Fournier's gangrene with complete medical records were retrospectively reviewed. Patients' demographics, laboratory parameters at initial diagnosis, Fournier's Gangrene Severity Index and Simplified Fournier's Gangrene Severity Index, and the time interval from emergency room arrival to surgical intervention were collected. The Fournier's gangrene patients were categorized into low-risk (Simplified Fournier's Gangrene Severity Index ≤2) and high-risk groups (Simplified Fournier's Gangrene Severity Index >2). Differences between the variables within the two groups were analyzed. The optimal surgical timing was analyzed with the receiver operating characteristic curve in high-risk Fournier's gangrene patients.

RESULTS

The overall mortality of 118 Fournier's gangrene patients was 14.4%. After risk stratification with the Simplified Fournier's Gangrene Severity Index scoring system, the mortality of low-risk and high-risk Fournier's gangrene patients was 1.3% and 41.0%, respectively. In the high-risk group, the time interval from emergency room arrival to surgical intervention was the only variable with a significant difference between survivors and non-survivors (P = 0.039). The optimal surgical timing was determined at 14.35 h, which allowed the highest sensitivity (0.688) and specificity (0.762) to affect mortality. The mortality was significantly lower in high-risk Fournier's gangrene patients with early surgical intervention compared with late intervention (23.8% vs 68.8%, P = 0.007).

CONCLUSIONS

The Simplified Fournier's Gangrene Severity Index is a quick and reliable screening tool for first-line physicians to identify high-risk patients with Fournier's gangrene (Simplified Fournier's Gangrene Severity Index >2) who have poor survival outcomes. We recommended early surgical intervention within 14.35 h to maximize the survival of high-risk Fournier's gangrene patients.

Desperate need for better management of Fournier's gangrene

Introduction

To compare earlier and later patient groups with Fournier's gangrene, specifically with the incidence of rising antibiotic resistance rates in mind. Primary endpoints were to compare therapy, outcomes, and resistance rates.

Material and methods

A multicentric, retrospective, multi-national study was performed. Two groups with different time frames of treatment were defined: Group 1 (n = 50) and Group 2 (n = 104). Demographics and outcomes were analysed using Student-t test, chi-square test, or Fisher exact test. Survival data were estimated using the Kaplan Meier method and compared by Log rank testing.

Results

There were no significant demographic differences. Nor was there any significant difference in therapy or outcomes in the groups except for the duration of intensive care unit treatment, which lasted a mean 6.3 days in Group 1 and 11.5 days in Group 2 (p = 0.018). Survival time did not improve over the years (p = 0.268). We fortunately did not observe an increased rate of multi-resistant organisms (p = 1.000). This study's limitations are mainly due to its retrospective study design.

Conclusions

Despite increasing antibiotic resistance rates worldwide, it was not apparent in our population. But the situation for these patients is alarming, since final outcome failed to improve over the last ten years despite more intensive critical-care therapy.

Fatal Fournier's gangrene caused by Clostridium ramosum in a patient with central diabetes insipidus and insulin-dependent diabetes mellitus: a case report

Background

Clostridium ramosum is a generally non-pathogenic enteric anaerobe, and Fournier’s gangrene is a rare necrotizing soft tissue infection with male predisposition affecting the perineum and the genital area. We report, to our knowledge, the first case of Fournier’s gangrene caused by C. ramosum in a female patient with multiple underlying conditions.

Case presentation

A 44-year-old woman with a 6-year history of insulin-dependent diabetes mellitus after total pancreatectomy and an 11-year history of central diabetes insipidus developed a pain in the genital area after a month of urinary catheter use. The lower abdominal pain worsened gradually over 2 weeks, and the pain, general fatigue, and loss of appetite prompted the patient’s hospital admission. As she had severe edema in her pelvic and bilateral femoral areas, ceftriaxone was started empirically after collecting two sets of blood cultures. On hospital day 2, CT examination revealed the presence of necrotizing faciitis in the genital and pelvic areas, and the antibiotics were changed to a combination of meropenem, vancomycin, and clindamycin. Gram-positive cocci and gram-positive rods were isolated from blood cultures, which were finally identified as Streptococcus constellatus and C. ramosum using superoxide dismutase and 16S rDNA sequencing. An emergent surgery was performed on hospital day 2 to remove the affected tissue. Despite undergoing debridement and receiving combined antimicrobial chemotherapies, the patient’s clinical improvement remained limited. The patient’s condition continued to deteriorate, and she eventually died on hospital day 8. In the present case, the underlying diabetes mellitus, urinary incontinence due to central diabetes insipidus, undernutrition, and edema served as the predisposing conditions.

Conclusions

C. ramosum is a potentially opportunistic pathogen among immunosuppressed persons and a rare cause of necrotizing fasciitis.

Risk factors for mortality in fournier's gangrene in a general hospital: use of simplified founier gangrene severe index score (SFGSI)

Objective

To evaluate risk factors for mortality in patients with Fournier's gangrene (FG), with emphasis in the Simplified Fournier Gangrene Severe Index Score (SFGSI).

Materials and Methods

This was a cross-sectional study that was carried out from January 2010 to December 2014, with 124 patients treated for FG in a General Hospital. Several clinical and laboratory variables, including SFGSI, were evaluated and correlated with mortality through univariate analysis and logistic regression.

Results

Of the 124 patients, 99 were men (79.8%), the mean age was 50.8±19.5 years and the main comorbidity was diabetes mellitus (51.6%). The mortality rate was 25.8%. Variables that presented independent correlation with mortality were the extension of the lesion to the abdomen (OR=4.0, CI=1.10-14.68, p=0.03), hematocrit (OR=0.81, CI=0.73-0.90, p<0.0001), potassium (OR=2.41, CI=1.13-5.10, p=0.02) and creatinine (OR=2.15, CI= 1.04-4.41, p=0.03). When hematocrit, potassium and creatinine were tested together, as part of the SFGSI, a >2 result was the largest of the independent predictors of mortality (OR=50.2; CI=13.18-191.47; p<0.0001).

Conclusion

The SFGSI >2 presented a higher correlation with mortality than any variable tested alone. It seems to be a promising alternative to evaluate predictors of mortality in Fournier's gangrene. The main advantage is easy applicability because it contains only three parameters and can be used immediately after patient's admission.

Fournier's Gangrene: Lessons Learned from Multimodal and Multidisciplinary Management of Perineal Necrotizing Fasciitis

Background

Fournier’s gangrene (FG) is a rapidly evolving necrotizing fasciitis of the perineum and the genital area, the scrotum as it most commonly affects man in the vast majority of cases. It is polymicrobial in origin, due to the synergistic action of anaerobes and aerobes and has a very high mortality. There are many predisposing factors including diabetes mellitus, alcoholism, immunosuppression, renal, and hepatic disease. The prognosis of the disease depends on a lot of factors including but not limited to patient age, disease extent, and comorbidities. The purpose of the study is to describe the experience of a general surgery department in the management of FG, to present the multimodal and multidisciplinary treatment of the disease, to identify predictors of mortality, and to make general surgeons familiar with the disease.

Methods

The current retrospective study is presenting the experience of our general surgery department in the management of FG during the last 20 years. The clinical presentation and demographics of the patients were recorded. Also we recorded the laboratory data, the comorbidities, the etiology, and microbiology and the therapeutic interventions performed, and we calculated the various severity indexes. Patients were divided to survivors and non-survivors, and all the collected data were statistically analyzed to assess mortality factors using univariate and then multivariate analysis.

Results

In our series, we treated a total of 24 patients with a mean age 58.9 years including 20 males (83.4%) and 4 females (16.6%). In most patients, a delay between disease onset and seeking of medical help was noted. Comorbidities were present in almost all patients (87.5%). All patients were submitted to extensive surgical debridements and received broad-spectrum antibiotics until microbiological culture results were received. Regarding all the collected data, there was no statistically significant difference between survivors and non-survivors except the presence of malignancy in non-survivors (p = 0.036) and the lower hemoglobin (p < 0.001) and hematocrit (p = 0.002) in non-survivors. However, multivariate analysis did not reveal any predictor of mortality.

Conclusion

Early diagnosis, aggressive thorough surgical treatment, and administration of the proper antibiotic treatment comprise the cornerstone for the outcome of this disease. In small populations like in the present study, it is difficult to recognize any predictors of mortality and even the severity indexes, which take into account a lot of data cannot predict mortality.

Treatment of Staphylococcus aureus Infections

Staphylococcus aureus, although generally identified as a commensal, is also a common cause of human bacterial infections, including of the skin and other soft tissues, bones, bloodstream, and respiratory tract. The history of S. aureus treatment is marked by the development of resistance to each new class of antistaphylococcal antimicrobial drugs, including the penicillins, sulfonamides, tetracyclines, glycopeptides, and others, complicating therapy. S. aureus isolates identified in the 1960s were sometimes resistant to methicillin, a ß-lactam antimicrobial active initially against a majority S. aureus strains. These MRSA isolates, resistant to nearly all ß-lactam antimicrobials, were first largely confined to the health care environment and the patients who attended it. However, in the mid-1990s, new strains, known as community-associated (CA-) MRSA strains, emerged. CA-MRSA organisms, compared with health care-associated (HA-) MRSA strain types, are more often susceptible to multiple classes of non ß-lactam antimicrobials. While infections caused by methicillin-susceptible S. aureus (MSSA) strains are usually treated with drugs in the ß-lactam class, such as cephalosporins, oxacillin or nafcillin, MRSA infections are treated with drugs in other antimicrobial classes. The glycopeptide drug vancomycin, and in some countries teicoplanin, is the most common drug used to treat severe MRSA infections. There are now other classes of antimicrobials available to treat staphylococcal infections, including several that have been approved after 2009. The antimicrobial management of invasive and noninvasive S. aureus infections in the ambulatory and in-patient settings is the topic of this review. Also discussed are common adverse effects of antistaphylococcal antimicrobial agents, advantages of one agent over another for specific clinical syndromes, and the use of adjunctive therapies such as surgery and intravenous immunoglobulin. We have detailed considerations in the therapy of noninvasive and invasive S. aureus infections. This is followed by sections on specific clinical infectious syndromes including skin and soft tissue infections, bacteremia, endocarditis and intravascular infections, pneumonia, osteomyelitis and vertebral discitis, epidural abscess, septic arthritis, pyomyositis, mastitis, necrotizing fasciitis, orbital infections, endophthalmitis, parotitis, staphylococcal toxinoses, urogenital infections, and central nervous system infections.

Fournier Gangrene Caused by Candida albicans in an Infant After Cardiac Surgery

Fournier gangrene is a rare, rapidly progressive, life-threatening condition. We report a 23-day-old boy with pulmonary atresia and ventricular septal defect treated surgically, who developed Fournier gangrene. Emergency surgery was performed with tissue sampling for microbiological examination. Candida albicans was confirmed; caspofungin followed by fluconazole was administered with excellent results.

Fournier's gangrene: a fulminant subcutaneous infection

A 73-year-old man with a history of diabetes was urgently referred to our emergency department because of severe pain of his genitalia and pubical region. Physical examination revealed an extensive subcutaneous emphysema and edema of his abdomen. Computer tomography confirmed an extensive necrotizing fasciitis, diagnosed as Fournier's gangrene. Despite the efforts made, the patient did not survive. And a review of the medical approach of this short of a life-threatening form of necrotizing soft tissue infection with a high mortality rate.

Evaluation of LRINEC Scale Feasibility for Predicting Outcomes of Fournier Gangrene

BACKGROUND

Fournier gangrene (FG) is a fulminant necrotizing infection of the perineal, perianal, and periurethral tissues. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) scale is used for diagnosis of necrotizing fasciitis. However, data on its relevance and usefulness in FG are lacking. The aim of this study was to evaluate the utility of the LRINEC scale in predicting the outcome of FG.

METHODS

This retrospective case study included 41 patents with FG treated at our institution from 2000 to 2013. The patients were divided into survivors and non-survivors.

RESULTS

The mortality rate was 22%. The median age (75 vs. 62.5 y; p = 0.013), rate of co-existing diabetes mellitus (66.7% vs. 3.1%; p < 0.001), and median affected skin surface (4% vs. 1%; p < 0.001) were greater in the non-survivors. Seven of nine patients (77.8%) who did not survive (compared with 37.5% who survived) had a polymicrobial infection (p = 0.032). Of all the causative pathogens isolated, Proteus mirabilis was more common in non-survivors (55.6% vs. 6.3%; p = 0.001). The median calculated LRINEC score for survivors was 5 compared with 10 for the non-survivors (p < 0.001). Regression analysis showed that all the aforementioned variables, except for polymicrobial culture, were significant risk factors for predicting death. The area under the receiver operating characteristic curve for the LRINEC score was the highest, 0.976 (95% confidence interval 0.872-0.999; p < 0.0001), and the cut-off value was ≥9 with 93.7% specificity and 100% susceptibility for the prediction of a lethal outcome.

CONCLUSIONS

The LRINEC score could be used for prediction of disease severity and outcomes. A threshold of 9 could be a high-value predictor of death during the initial evaluation of patients with FG.

Bromine, bear-claw scratch fasciotomies, and the Eagle effect: management of group A streptococcal necrotising fasciitis and its association with trauma

Necrotising fasciitis is a rare, but potentially fatal, soft-tissue infection. Historical depictions of the disease have been described since classical times and were mainly recorded in wartime reports of battle injuries. Although several different species of bacteria can cause necrotising fasciitis, perhaps the most widely known is group A streptococcus (GAS). Infection control, early surgical debridement, and antibiotic therapy are now the central tenets of the clinical management of necrotising fasciitis; these treatment approaches all originate from those used in wars in the past 150 years. We review reports from the 19th century, early 20th century, and mid-20th century onwards to show how the management of necrotising fasciitis has progressed in parallel with prevailing scientific thought and medical practice. Historically, necrotising fasciitis has often, but not exclusively, been associated with penetrating trauma. However, along with a worldwide increase in invasive GAS disease, recent reports have cited cases of necrotising fasciitis following non-combat-related injuries or in the absence of antecedent events. We also investigate the specific association between GAS necrotising fasciitis and trauma. In the 21st century, molecular biology has improved our understanding of GAS pathogenesis, but has not yet affected attributable mortality.

Hyperbaric Oxygen Therapy as an Adjuvant Therapy for Comprehensive Treatment of Fournier's Gangrene

OBJECTIVES

To compare simple conventional treatment with the addition of hyperbaric oxygen therapy (HBOT) to conventional therapies in the treatment of Fournier's gangrene (FG).

METHODS

A retrospective study of clinical data was performed by reviewing 28 cases of FG from January 2004 to December 2013 at Xiangya Hospital, Central South University. Among them, 12 patients were treated with the conventional therapy (non-HBOT group) and the other 16 cases were combined with hyperbaric oxygen therapy besides conventional therapy (HBOT group). All patients were followed up for 2 months to assess the therapeutic effect. The analyzed data included age, Fournier gangrene severity index (FGSI) score, number of surgical debridement, indwelling drainage tube time, length of stay (LOS), effective time, and curative time.

RESULTS

The mortality rate was lower in the HBOT group at 12.5% (2/16) compared to the non-HBOT group, which was 33.3% (4/12). The difference in the number of surgical debridement, indwelling drainage tube time, and curative time between were significantly lower in the HBOT group compared to the non-HBOT group.

CONCLUSIONS

Our preliminary research suggests that the effect of combining hyperbaric oxygen therapy with conventional therapy offers considerable advantage in the management of Fournier's gangrene. Multicenter studies with a larger sample size are required to confirm these observations.

The evaluation of microbiology and prognosis of fournier's gangrene in past five years

OBJECTIVES

Fournier's gangrene (FG) is an devastating disease that affects the perineum and genitourinary region, and is commonly a result of poly-microbial infection. This study is aimed to determine the correlation between micrology and prognosis of FG in the past five years.

METHODS

This study was a retrospective cohort study that was designed to study the trends in micrology and prognosis of FG. From the PubMed database, articles published in the recent 5 years (from Jan1(st), 2009 to Dec 31(st), 2013) were reviewed. A total of 19 articles (each with n > 30 and with thorough data descriptions in the topic of Fournier's gangrene), were enrolled in this study. The consolidated data was further analyzed by commercial statistical software (SPSS for Windows).

RESULTS

The twenty-two studies have covered FG cases from year 1981 to 2011, with a mean duration of 9.2 years. The total number of cases is 4,365. Majority of the cases are male (84.1%). The mean age and mortality rate is 51.8 ± 5 years old and 11.1 ± 8.9%, respectivly. The most commonly found pathogen is poly-microbial organism (54%), followed by Escherichia coli (46.6%) and Streptococcus (36.8%). The major risk factors are diabetes (43.7%), Body mass index of > 30 (40.7%), and hypertension (38.1%). Mortality rate in older patient group (age > 51.8 years old) is significantly higher than those of the younger group (22% vs. 5.5%, p = 0.0001).

CONCLUSIONS

Older patients with genital or perineal pain should be examined for crepitus dermis. When a patient is diagnosed with FG, swift consultation with surgeons and administration of broad-spectrum antibiotics are required in order to save the patient's live.

The evaluation of microbiology and prognosis of fournier's gangrene in past five years

OBJECTIVES

Fournier's gangrene (FG) is an devastating disease that affects the perineum and genitourinary region, and is commonly a result of poly-microbial infection. This study is aimed to determine the correlation between micrology and prognosis of FG in the past five years.

METHODS

This study was a retrospective cohort study that was designed to study the trends in micrology and prognosis of FG. From the PubMed database, articles published in the recent 5 years (from Jan1(st), 2009 to Dec 31(st), 2013) were reviewed. A total of 19 articles (each with n > 30 and with thorough data descriptions in the topic of Fournier's gangrene), were enrolled in this study. The consolidated data was further analyzed by commercial statistical software (SPSS for Windows).

RESULTS

The twenty-two studies have covered FG cases from year 1981 to 2011, with a mean duration of 9.2 years. The total number of cases is 4,365. Majority of the cases are male (84.1%). The mean age and mortality rate is 51.8 ± 5 years old and 11.1 ± 8.9%, respectivly. The most commonly found pathogen is poly-microbial organism (54%), followed by Escherichia coli (46.6%) and Streptococcus (36.8%). The major risk factors are diabetes (43.7%), Body mass index of > 30 (40.7%), and hypertension (38.1%). Mortality rate in older patient group (age > 51.8 years old) is significantly higher than those of the younger group (22% vs. 5.5%, p = 0.0001).

CONCLUSIONS

Older patients with genital or perineal pain should be examined for crepitus dermis. When a patient is diagnosed with FG, swift consultation with surgeons and administration of broad-spectrum antibiotics are required in order to save the patient's live.

Fournier's Gangrene: A Model for Early Prediction

Early diagnosis remains the cornerstone of management of Fournier's gangrene. As a result of variable progression of disease, identifying early predictors of necrosis becomes a diagnostic challenge. We present a scoring system based on objective admission criteria, which can help distinguish Fournier's gangrene from nonnecrotizing scrotal infections. Ninety-six patients were identified, 38 diagnosed with Fournier's gangrene and 58 diagnosed with scrotal cellulitis or abscess. Statistical analyses comparing admission vital signs, laboratory values, and imaging studies were performed and Classification and Regression Tree analysis was used to construct a scoring system. Admission heart rate greater than 110 beats/minute, serum sodium less than 135 mmol/L, blood urea nitrogen greater than 15 mg/dL, and white blood cell count greater than 15 x 103/mL were significant predictors of Fournier's gangrene. Using a threshold score of two or greater, our model differentiates patients with Fournier's gangrene from those with nonnecrotizing infections with a sensitivity of 84.2 per cent. Only 34.2 per cent of patients with Fournier's gangrene had hard signs of necrotizing infection on admission, which were not observed in patients with nonnecrotizing infections. Objective admission criteria assist in distinguishing Fournier's gangrene from scrotal cellulitis or abscess. In situations in which results of the physical examination are ambiguous, this scoring system can heighten the index of suspicion for Fournier's gangrene and prompt rapid surgical intervention.

Emergence of antibiotic-resistant bacteria in patients with Fournier gangrene

BACKGROUND

This study was conducted to investigate the bacteriology and associated patterns of antibiotic resistance Fournier gangrene.

METHODS

Patients with Fournier's gangrene from 2008 to 2012 were identified from the computerized database in a medical center in southern Taiwan. The medical records of all patients with Fournier's gangrene were reviewed retrospectively.

RESULTS

There were 61 microorganisms, including 60 bacteria and one Candida spp, isolated from clinical wound specimens from 32 patients. The most common isolates obtained were Streptococcus spp. (n=12), Peptoniphilus spp. (n=8), Staphylococcus aureus (n=7), Escherichia coli (n=7), and Klebsiella pneumoniae (n=7). Among 21 strains of gram-negative bacilli, five (23.8%) were resistant to fluoroquinolones, and three isolates were resistant to ceftriaxone. Two E. coli strains produced extended-spectrum beta-lactamase. Four of the seven S. aureus isolates were methicillin-resistant. Among 15 anaerobic isolates, nine (60%) were resistant to penicillin, and eight (53.3%) were resistant to clindamycin. Four (26.7%) isolates were resistant to metronidazole. The only independent risk factor associated with mortality was inappropriate initial antibiotic treatment (p=0.021).

CONCLUSION

Antibiotic-resistant bacteria are emerging in the clinical setting of Fournier gangrene. Clinicians should use broad-spectrum antibiotics initially to cover possible antibiotic-resistant bacteria.

Predictive factors for mortality in Fournier' gangrene: a series of 59 cases

AIMS

Fournier's gangrene (FG) is the necrotizing fasciitis of the perineum and genital area and presents a high mortality rate. The aim was to assess prognostic factors for mortality, create a new mortality predictive scale and compare it with previously published scales in patients diagnosed with FG in our Emergency Department.

METHODS

Retrospective analysis study between 1998 and 2012.

RESULTS

Of the 59 patients, 44 survived (74%) (S) and 15 died (26%) (D). Significant differences were found in peripheral vasculopathy (S 5 [11%]; D 6 [40%]; P=.023), hemoglobin (S 13; D 11; P=.014), hematocrit (S 37; D 31.4; P=.009), white blood cells (S 17,400; D 23,800; P=.023), serum urea (S 58; D 102; P<.001), creatinine (S 1.1; D 1.9; P=.032), potassium (S 3.7; D 4.4; P=.012) and alkaline phosphatase (S 92; D 133; P=.014). Predictive scores: Charlson index (S 1; D 4; P=.013), severe sepsis criteria (S 16 [36%]; D 13 [86%]; P=.001), Fournier's gangrene severity index score (FGSIS) (S 4; D 7; P=.002) and Uludag Fournier's Gangrene Severity Index (UFGSI) (S 9; D 13; P=.004). Independent predictive factors were peripheral vasculopathy, serum potassium and severe sepsis criteria, and a model was created with an area under the ROC curve of 0.850 (0.760-0.973), higher than FGSIS (0.746 [0.601-0.981]) and UFGSI (0.760 [0.617-0.904]).

CONCLUSIONS

FG showed a high mortality rate. Independent predictive factors were peripheral vasculopathy, potassium and severe sepsis criteria creating a predictive model that performed better than those previously described.