Practical Review of the Current Management of Fournier’s Gangrene

Postsurgical Pyoderma Gangrenosum Requiring Plastic Surgical Intervention: A Practical Review

Pyoderma gangrenosum is a neutrophilic dermatosis characterized by immune dysfunction and pathergy. Thus, it is frequently seen in patients with underlying systemic illnesses or postoperatively. For the performance of the debridement or closure of the resultant defect, plastic surgeons are often involved in the care of pyoderma patients. However, both procedures may exacerbate the injury. Therefore, plastic surgeons must be familiar with the presentation of postsurgical pyoderma to avoid further damage and safely repair related soft tissue defects. A systematic search of the PubMed/Medline database was performed using the following keywords: "pyoderma gangrenosum" and "surgery." This online database search has identified 656 studies published between 1958 and 2022. Only reconstructed cases of postsurgical pyoderma gangrenosum were selected. Twenty-eight patients who developed pyoderma after dermatologic, plastic, orthopedic, cardiovascular, general, or obstetric surgery were included in this study. The average time to the PG presentation and diagnosis was 5.5 and 17 days, respectively. Diagnostic scoring tools were not used, and the diagnosis was primarily based on histopathology after repeated treatment failures. The patients received split- or full-thickness skin grafts, local, pedicled, and free flaps. An estimated 82.1% underwent skin grafting, whereas 42.9% underwent flap reconstruction. In addition, 21.4% got both the graft and flap. Accurate diagnosis of PSPG, prevention of further surgical injury, and timely medical management are vital for improving patient outcomes. Reconstruction can be performed, if required. However, despite the availability of different reconstructive techniques, there is no standard approach to the management of the PSPG.

Management of Fournier's gangrene: a practical guide for clinicians

Fournier's gangrene is a localised form of necrotising fasciitis affecting the external genitalia, perineal and perianal regions. Although rare, it is associated with high rates of morbidity and mortality, so clinician awareness is essential for prompt treatment. Risk factors include diabetes mellitus, hypertension, chronic alcoholism and immunosuppression. Perineal pain in patients with sepsis should be treated with a high level of suspicion and early surgical referral is required as prompt debridement can improve outcomes. Repeated surgical intervention and antimicrobial therapy are often needed and recovery can take a long time, with a long-term impact on quality of life. This article discusses the natural history of Fournier's gangrene, aetiology, risk factors, investigations and treatments with an algorithm to support clinical practice.

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.

Fournier’s Gangrene: A Coexistence or Consanguinity of SGLT-2 Inhibitor Therapy

Background: Sodium-glucose cotransporter-2 inhibitors (SGLT2 inhibitors) are a relatively new class of medications used for the management of type II diabetes mellitus targeting the kidneys. Within the last decade, several warnings have been issued regarding the development of severe genitourinary infections, including necrotizing fasciitis, or Fournier’s gangrene, in those with pre-existing type II diabetes and concomitant use of this drug class.

Objective: The purpose of this review is to highlight and discuss the factors contributing to the development of Fournier’s gangrene, its pathogenesis, and a review of existing literature describing patient outcomes, treatment, and future directions regarding early detection of this complication.

Methods: Articles and studies addressing effective treatment adherence and key factors contributing to Fournier’s gangrene with SGLT2 inhibitors were identified by effective keyword searches in PubMed Central, Google Scholar, and Cochrane, as well as the references found within these articles.

Results: Using the keywords provided, 55 case reports, review articles, and meta-analysis reports written within the last 20 years were utilized as the source of the data presented in this systematic review article.