Factors affecting mortality of Fournier's gangrene: review of 70 patients

Comparative analysis of scoring systems for predicting mortality in Fournier gangrene: single center, 15 years experience

To compare 5 published scoring systems (Fournier gangrene severity index [FGSI], Uludag FGSI [UFGSI], age-adjusted Charlson Comorbidity Index [ACCI] and the Quick Sequential Organ Failure Assessment (qSOFA) and the Laboratory Risk Indicator for Necrotizing fasciitis (LRINEC) scores and to evaluate risk factors for outcome prediction in patients with Fournier gangrene (FG). Between 2010 and 2024, 311 patients were included in the study. The data of 276 survivors and 55 non-survivors were compared. Univariate and multivariate analyses were performed to determine which of the 5 scoring systems calculated according to demographic, laboratory and clinical data predicted mortality better. In addition, a cut-off value for these scoring systems was determined by ROC analysis. The mortality rate was 17.6% in FG patients. In all 5 scoring systems, univariate analyses showed higher values in non-survivor patients, while UFGSI and FGSI scoring systems were superior to other scoring systems in multivariate analyses (p < 0.001). ROC analysis using mortality-based sensitivity and specificity revealed that the optimal cut-off values for FGSI, UFGSI, ACCI, SOFA and LRINEC should be equal to or higher than 10, 12, 4, 2 and 8, respectively. UFGSI and FGSI scores had the highest AUC values among all scores. This was followed by ACCI, qSOFAand LRINEC. For a UFGSI score ≥ 12, the sensitivity was 84%, specificity 97%, PPV 85% and NPV 97%. Among the scoring systems used to predict mortality, UFGSI was the most accurate, while LRINEC was the least accurate.

A Rare Case of Necrotizing Fasciitis in a Female With Diabetes Mellitus

Fournier's gangrene (FG) is a relatively rare yet profoundly severe disease. It predominantly affects males; however, mortality rates are comparatively elevated in females. It is a rapidly spreading, life-threatening necrotizing fasciitis that can affect all parts of the body but primarily targets the genital region and the perineum. The clinical presentation is highly characteristic of the disease and is often sufficient for reaching a definitive diagnosis. Common risk factors for the development of this condition include diabetes mellitus (DM), obesity, trauma, alcoholism, smoking, arterial hypertension (which predisposes to obstructive endarteritis), and immunosuppressive disorders, such as HIV and cancer. Prompt diagnosis and treatment are imperative for the prognosis and survival of patients. Herein, we present a case of a 33-year-old woman with a medical history of type 1 diabetes mellitus (treated with insulin), arterial hypertension, and obesity. She presented with pain and swelling in the external genitalia (right labia majora), which later progressed to severe necrotizing fasciitis. The patient underwent surgical debridement and drainage, along with intensive medical therapy.

Risk Factors for Mortality Among Patients With Fournier Gangrene: A Systematic Review

Background: Fournier gangrene (FG) is a form of necrotizing fasciitis involving the perineal, peri-anal, and genital structures, and has exceptionally high mortality rates. To help in early detection of high-risk patients, we aimed to systematically review factors associated with mortality from FG. Patients and Methods: Searches were conducted in PubMed, Embase and Scopus. In our review, a minimum of five patients were required and this was to exclude studies with exceedingly small sample sizes, such as case reports and small case series, with minimal relevance in comparison to larger scale studies. Patient characteristics, causative microbes, anatomic areas of infection, presence of comorbidities, severity scores, causes of FG, and complications were extracted and compared to identify factors related to mortality. Results: A total of 57 studies were included in the review. Across 3,646 study participants, the mortality rate of FG was 20.41%. The mean age of non-survivors was 61.27 years. There were more total male deaths, however, the mortality rate was higher in females. Diabetes mellitus was the most common comorbidity in those who died, but the highest mortality rate was seen in HIV patients (54.17%). Mortality rates did not differ widely among antibiotic agents. Regarding causative organisms, fungal infections had the highest rates of mortality (68.18%) and the most common microbe leading to death was Escherichia coli. Conclusions: Female gender, comorbidities, anatomic distribution, development of sepsis, and fungal infection all increased risk for mortality. Early identification of risk factors, and provision of appropriate treatment are crucial in reducing mortality rates of high-risk patients with FG.

Fournier's gangrene with retroperitoneal extension, a case report

BACKGROUND

Fournier's gangrene (FG) is a polymicrobial, both aerobic and anaerobic, synergistic necrotizing fasciitis of the perineal, genital, or perianal regions. It is a rapidly progressive and fulminant soft tissue infection and it is potentially fatal. Fournier's gangrene has been shown to be strongly associated with diabetes, chronic alcoholism, human immunodeficiency virus (HIV), lymphoproliferative diseases, chronic steroid abuse, and cytotoxic drugs.

CLINICAL PRESENTATION

A 25-year-old Ethiopian male patient with no previous medical history presented to the emergency department with a four-day history of perineal pain, swelling, and discharge. Associated with this he had a high-grade fever and one episode of vomiting of ingested matter. On examination, he was febrile, tachycardic, and hypotensive. He had a grossly necrotic scrotum and palpable crepitus extending to the left lower anterior abdominal wall.

CLINICAL DISCUSSION

On investigations, he had elevated leukocyte count, random blood sugar, low hemoglobin, and elevated creatinine levels. Subsequently, the patient was admitted and was started with broad-spectrum antibiotics and multiple debridements were done along with other supportive measures. Finally, the patient was discharged improved after 17 days of hospital stay.

CONCLUSION

Fournier's gangrene is a rapidly progressive, fulminant infection. Nevertheless, prompt diagnosis can be difficult and requires a high index of suspicion. Early diagnosis and appropriate management have paramount importance in reducing mortality and morbidity in these patients.

Pedicled Superficial Circumflex Iliac Artery Perforator (SCIP) flap for perineo-scrotal reconstruction following Fournier's gangrene

BACKGROUND

Fournier's gangrene is a form of necrotising fasciitis involving perineo-scrotal skin. It is treated with radical debridement, infection control and often leaves a large anatomical defect that is challenging to reconstruct. The anatomical location of the defect leads to faecal contamination, difficulties when mobilizing, and negative psychological impact. Traditional approaches for managing such defects have relied on either healing by secondary intention or skin grafting. There are few reported cases in the literature to cover such defects with a flap.

METHODS

Pedicled Superficial Circumflex Iliac Artery Perforator (SCIP) flap reconstruction was performed in three patients who had perineo-scrotal defects following debridement for Fournier's gangrene.

RESULTS

All flaps survived with no significant postoperative complications and good functional and aesthetic outcomes were achieved. The mean age of patient was 52 years and the largest defect measured 22 × 10 cm.

CONCLUSION

The reconstruction of perineo-scrotal defects is difficult despite a range of reconstructive options. The pedicled SCIP flap offers many advantages over standard techniques. This flap is thin, pliable, and has a consistent anatomy. With continued experience, we feel that this flap could be considered the gold standard of treatment for such defects.

Fournier's Gangrene: A Rare Infectious Entity in an Adolescent with Type II Diabetes

Fournier's gangrene is a rapidly progressive necrotizing fasciitis of the perineum and external genital organs that is uncommon in the pediatric age group. We present a case report of a 17-year-old obese male with comorbidities of type II diabetes, hypertension, and tobacco use, who presented to the hospital with vague systemic symptoms and pain in the gluteal area. On examination, he was febrile and had erythema and induration of his left scrotum, perineum, and gluteal region. Imaging obtained due to rapid progression of symptoms was consistent with a diagnosis of Fournier's gangrene. He was managed with broad-spectrum antibiotics, aggressive surgical debridement, and a diverting colostomy. This case brings to light to a classically adult diagnosis that should be considered in adolescents, especially given the rising numbers of risk factors in this population, such as diabetes, obesity, and smoking.

Conceptos para la identificación y abordaje de la gangrena de Fournier

Introducción. La gangrena de Fournier es una fasciitis necrosante fulminante y progresiva, de origen infeccioso sinérgico polimicrobiano, que afecta las regiones perianal, perineal, genital y abdominal. Su incidencia es mayor en hombres, la edad promedio de presentación reportada está en los 54,7 ± 15,6 años, su mortalidad es del 3-67 %, aunque hay estudios que informan una mortalidad en hombres del 7,5 % y en las mujeres del 12,8 %. Métodos. Se hizo una revisión de la literatura en las bases de datos y fuentes de información PubMed, Scielo y Google Scholar, publicados entre 1950 y 2018, utilizando términos como "fournier gangrene", "fasciitis, necrotizing”, “wound infection”, "therapy"[subheading] y “GRADE approach". Se realizó una segunda revisión para artículos latinoamericanos en español hasta 2020 usando las mismas fuentes y palabras claves. Resultados. Se seleccionaron artículos que reportaron definiciones, datos históricos, actualizaciones en diagnóstico y terapéutica para hacer una revisión actualizada. Para el uso de las imágenes se solicitó consentimiento informado. Conclusión. La gangrena de Fournier continúa siendo una emergencia quirúrgica potencialmente letal. Gracias a las investigaciones realizadas se ha avanzado en su tratamiento, mejorando los resultados. Es importante analizar los factores de riesgo en cada paciente y su etiología para establecer el tratamiento más adecuado.

Factors affecting length of stay in Fournier's gangrene: a retrospective analysis of 10 years' data

BACKGROUND

We aimed to investigate the parameters that have an effect on the length of stay and mortality rates of patients with Fournier's gangrene.

MATERIAL AND METHODS

A retrospective review was performed on 80 patients who presented to the emergency department and underwent emergency debridement with the diagnosis of Fournier's gangrene between 2008 and 2017. The demographic and clinical characteristics, length of stay, Fournier's Gangrene Severity Index score, cystostomy and colostomy requirement, additional treatment for wound healing and the mortality rates of the patients were evaluated.

RESULTS

Of the 80 patients included in the study, 65 (81.2 %) were male and 15 (18.7 %) female. The most common comorbidity was diabetes mellitus. The mean time between onset of complaints and admission to hospital was 4.6 ± 2.5 days. As a result of the statistical analyses, it was found that Fournier's Gangrene Severity Index score, hyperbaric oxygen therapy, negative pressure wound therapy and the presence of sepsis and colostomy were significantly positively correlated with length of stay. Also it was found that the Fournier's Gangrene Severity Index score, administration of negative pressure wound therapy and the presence of sepsis were correlated with mortality.

CONCLUSION

Fournier's gangrene is a mortal disease and an emergency condition. With the improvements in Fournier's gangrene disease management, mortality rates are decreasing, but long-term hospital stay has become a new problem. Knowing the values predicting length of stay and mortality rates can allow for patient-based treatment and may be useful in treatment choice.

Which Role for Hyperbaric Oxygen Therapy in the Treatment of Fournier's Gangrene? A Retrospective Study

Purpose

In Fournier's gangrene, surgical debridement plus antimicrobial therapy is the mainstay of treatment but can cause a great loss of tissue. The disease needs long hospital stays and, despite all, has a high mortality rate. The aim of our study is to investigate if factors, such as hyperbaric therapy, can offer an improvement in prognosis.

Methods

We retrospectively evaluated data on 23 consecutive patients admitted for Fournier's gangrene at the University Hospital “P. Giaccone” of Palermo from 2011 to 2018. Factors related to length of hospital stay and mortality were examined.

Results

Mortality occurred in three patients (13.1%) and was correlated with the delay between admission and surgical operation [1.7 days (C.I. 0.9–3.5) in patients who survived vs. 6.8 days (C.I. 3.5–13.4) in patients who died (p = 0.001)]. Hospital stay was longer in patients treated with hyperbaric oxygen therapy [mean 11 (C.I. 0.50–21.89) vs. mean 25 (C.I. 18.02–31.97); p = 0.02] without an improvement in survival (p = 1.00).

Conclusion

Our study proves that a delay in the treatment of patients with Fournier's gangrene has a correlation with the mortality rate, while the use of hyperbaric oxygen therapy seems to not improve the survival rate, increasing the hospital stay instead.

Anorectal emergencies: WSES-AAST guidelines

Anorectal emergencies comprise a wide variety of diseases that share common symptoms, i.e., anorectal pain or bleeding and might require immediate management. While most of the underlying conditions do not need inpatient management, some of them could be life-threatening and need prompt recognition and treatment. It is well known that an incorrect diagnosis is frequent for anorectal diseases and that a delayed diagnosis is related to an impaired outcome. This paper aims to improve the knowledge and the awareness on this specific topic and to provide a useful tool for every physician dealing with anorectal emergencies.The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the boards of the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the WSES-AAST-WJES Consensus Conference on Anorectal Emergencies, and for each statement, a consensus among the WSES-AAST panel of experts was reached. We structured our work into seven main topics to cover the entire management of patients with anorectal emergencies and to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.

Relationship between diversional stoma and mortality rate in Fournier's gangrene: a systematic review and meta-analysis

PURPOSE

Fournier's gangrene (FG) is a rare potentially lethal necrotising infection of the perineum. While the gold standard management is early and aggressive surgical debridement, the evidence in the literature is unclear as to the role and outcomes of diversional stoma.

METHODS

A systematic review was conducted to identify studies investigating the relationship between stoma formation and FG. Meta-analyses were performed using a random-effects model.

RESULTS

Twenty-seven studies (n=1482) were included. There was no significant difference in disease severity scores between the stoma and no stoma groups. Mortality rate was significantly higher in patients who required diversional stoma (OR 1.71, 95% CI 1.13-2.59, p=0.01). Significantly more surgical procedures were performed on patients who underwent stoma formation, and the total hospital cost was also higher in this group. This study may have been limited by bias in patients with more fulminant course or sphincter damage requiring stoma as a medical necessity.

CONCLUSION

These findings suggest that the use of diversional stoma in FG is a predictor of poor outcomes. This study demonstrated that mortality rate remained high and a diversional stoma did not reduce risk of mortality as suggested by smaller case series. Its use should therefore be individualised based on disease severity and sphincter damage.

[Diagnosis and Treatment of Severe Fournier's Gangrene: Introduction of a Surgical Approach, Evaluation of Risk Factors, Microbiological Characteristics and Review of the Literature]

BACKGROUND

Fournier's gangrene is a necrotising fasciitis type I occurring in the perineal and genital region. The disease expands progressively and still has poor outcome, especially in critical ill patients. This study's focus was placed on the evaluation of risk factors and comorbidities, on the bacteriological spectrum, laboratory analyses, mortality and the course according to the algorithmic approach.

METHOD

The medical records were reviewed of 10 patients with severe Fournier's gangrene from 2010 to 2019 who underwent intensive care therapy for at least 48 hours. Ten patients with Fournier's gangrene and sepsis and intensive therapy lasting at least 48 hours were recorded and analysed descriptively.

RESULTS

The patient cohort consisted of six men and four women with a median age of 62 years (range 42 - 78 years). The median time between the onset of symptoms and hospitalisation was four days (range 3 - 5 days). The commonest aetiological event was a minor trauma. Predisposing factors included diabetes mellitus (30%) and overweight (80% BMI > 25). 90% of patients exhibited polymicrobial infection. All patients had systemic sepsis with SOFA-Score between 3 and 17 points. The mortality rate was 40%. Significant differences between surviving and deceased patients were shown by PCT, INR and aPTT (p < 0.05).

CONCLUSION

Severe Fournier's gangrene continues to be a major challenge with a high mortality rate. Only rapid diagnosis, urgent extensive surgical debridement and intensive care therapy can lead to a favourable outcome in these critically ill patients. Vacuum-assisted closure can be successfully used in the management of soft-tissue defects.

Vacuum-assisted closure device in the postoperative wound care for Fournier's gangrene: a systematic review

PURPOSE

To determine the effectiveness of Vacuum-Assisted Closure Device in the postoperative wound care for Fournier's gangrene METHODS: We performed a systematic review in the following databases: Medline (Ovid), EMBASE, and The Cochrane Central Register of Controlled Trials (CENTRAL), from inception to nowadays. We included RCTs and analytical observational studies. Meta-analysis was not possible given the clinical and methodological heterogeneity of the studies.

RESULTS

We included six studies that compared VAC treated patients and a control group. The length of stay of the VAC treated vs. the conventional dressing treated patients was higher for the VAC treated patients in all but one of the included studies. The VAC group had the highest number of surgical debridements requiring anesthesia. The conventionally treated patients had a higher number of daily dressings, and the need for additional dressing changes, without anesthesia. Two studies found significantly higher mean scores for VAS, requiring a higher need for daily analgesics for the control group patients.

CONCLUSIONS

VAC therapy is an effective method, but it is not better than conventional dressing treatment. VAC carries fewer dressing changes, less pain, and less need for analgesics, but it comes with a higher need for surgical interventions requiring anesthesia.

Fournier's gangrene - challenge for surgeon

INTRODUCTION

Fournier gangrene (FG) is life - threatening condition, defined as the necrotizing fascitis of perineum and can spread to the adjacent areas. It is rare disease and infection is caused by mixed bacterial flora, seldom by fungal infection. Risk factors are: male sex, diabetes, hypertension, malignant neoplasms, alcoholism, immunospression.

MATERIAL AND METHODS

The analysis of four group patients treateted for Fournier gangrene was made about diagnostic and therapeutic process, assessment of prognosis based on Fournier's Gangrene Severity Index).

RESULTS

All patients were males. Average age at the moment of diagnosis was 60 years. All of them had comorbidities resulting with the higher risk of susceptibility to FG. Morbitity was 50%, despite of all of patients had less than 9 points in FGSI.

DISCUSSION

The FG, despite of better diagnostic tools and technological progres remaines the significant clinical issue because of the mortality - 80%. "The golden standard" is surgical excision of necrotic tissues, antibiotics support, equation of fluid, electrolytes and base - acid balance, level of glycemia is very important. The treating results were assessed on the base of FGSI. The significance has the moment of performing the surgical intervention - it is proven, that should be carried out during 24 hours. The hyperbaric oxygen therapy is controversial. Seem to be appropriate if the infection is caused by anaerobic bacteria.

CONCLUSIONS

Fournier syndrome is significant clinical issue. Its treatment requires early surgical approach with exicision of necrotic tissues, antibiotics support and treatment of hyperbaric oxygen in some cases.

Pattern and outcome of management of Fournier's gangrene in a resource-constraint setting

INTRODUCTION

Fournier's gangrene (FG) is a necrotizing fasciitis of the external genitalia and perineum but may involve upper thigh and anterior abdominal wall.

PATIENTS AND METHODS

This is a retrospective study of 47 patients managed for FG at Usmanu Danfodiyo University Teaching Hospital from January 2001 to June 2017. Data were entered into a semi-structured pro forma and analyzed using SPSS version 20.0.

RESULTS

The mean age of the patients was 42.7 ± 19.4 years, with age range of 7 weeks to 72 years. All the patients were male. The patients had underlying urologic conditions in 27.6%, 15.0% were postoperative, 4.2% had anorectal diseases, 10.6% had medical conditions, and 42.6% were idiopathic. After resuscitation, all the patients had serial debridement, Hypertonic saline bath, broad spectrum antibiotics and wound dressing. The wound healed by secondary intention in 34.0% and 32.3% of the patients had wound closure ± skin graft. The treatment was successful in 68.0% of the patients, 15.0% left against medical advice, and 17.0% died of severe sepsis.

CONCLUSION

FG mainly affects men with existing urologic conditions in our environment. Aggressive debridement, hypertonic saline sitz bath, broad-spectrum antibiotics, and appropriate wound care are associated with good outcome.

Association between atherogenic dyslipidemia and fournier’s gangrene

SUMMARY OBJECTIVE We aimed to determine whether atherogenic dyslipidemia is associated with the disease and morbidity in our patients treated for Fournier’s gangrene (FG). METHODS Sixty-two patients who were treated with the diagnosis of FG at our center between 2012 and 2017 were retrospectively screened. RESULTS The triglyceride values of the patients who required reconstructive surgery were statistically significantly higher than those of the patients for whom wound debridement and primary suturing was sufficient (p:0.001). A total of 65.7% of the patients had normal triglyceride values in the group in which wound debridement and primary suturing was sufficient, while this rate was 22.2% in the group of patients who needed reconstructive surgery; the difference was statistically significant (p: 0.002). The UFGSI score of those with triglyceride values higher than the normal range was statistically significantly higher (p:0.006). The cut-off point for the triglyceride value for which Fournier’s gangrene was more morbid and the probability of reconstructive surgery need was significantly higher, i.e., >233mg. CONCLUSION Our study has demonstrated that atherogenic dyslipidemia, especially hypertriglyceridemia, is an important factor affecting morbidity and associated with high patient care costs after hospitalization and discharge in FG.

Fournier Gangrene in Men and Women: Appearance on CT, Ultrasound, and MRI and What the Surgeon Wants to Know

Fournier gangrene (FG) is a genitourinary necrotizing fasciitis that can be lethal if not promptly diagnosed and surgically debrided. The diagnosis is often made by physical examination paired with an appropriate clinical suspicion and supporting laboratory values. Imaging, particularly computed tomography (CT), plays a role in delineating involved fascial planes for operative debridement and occasionally in diagnosing FG. Less commonly, the imaging manifestations of FG may also be seen on ultrasound, radiographs, and magnetic resonance imaging. With the ubiquitous use and availability of CT, radiologists have a growing role in recognizing FG. This can be challenging in the absence of fascial gas, but a CT scoring system for necrotizing fasciitis can be helpful in making the diagnosis. Recent series suggest that this predominantly male disease has a rising incidence in women. Women with FG are more likely to be morbidly obese and have vulvar or labial involvement compared to men. Imaging mimics include ulcerative and necrotic tumors, traumatic or iatrogenic fascial gas, and vaginitis emphysematosa. The purpose of this pictorial review is to illustrate the imaging manifestations of FG and its mimics, with emphases on necrotizing fasciitis CT scoring systems and FG in women.

Etiology of Fournier gangrene as a prognostic factor in mortality: Analysis of 121 cases

OBJECTIVE

Evaluate the origin of Fournier gangrene (FG) as a prognostic factor of morbidity and mortality.

MATERIAL AND METHODS

Patients who came to our clinic with a diagnosis of FG from 2010 to 2017 were included retrospectively. Patients were categorized depending on the origin of the infection. Three severity factors were determined in each group: days of hospital stay, the FG severity index, and mortality. Logistic regression test was performed to analyze the data.

RESULTS

Of the 130 patients evaluated, the origin was established in 121 based on the clinical history and radiological and surgical findings. Thirty-five patients had an intestinal origin with a mortality of 20.68%, 46 patients had a testicular origin with a mortality of 2.22%, 12 patients had a urinary origin with a mortality of 0%, and 28 patients with a cutaneous origin with a mortality of 16.6%. The testicular origin was the most frequent (38%) in addition to presenting a lower hospital stay, a lower FG severity index, and a lower mortality than those with an intestinal origin (P=.022).

CONCLUSIONS

The origin of the infection has a significant prognostic value in the mortality of the patient.

Fournier Gangrene: A Review for Emergency Clinicians

BACKGROUND

Fournier gangrene (FG) is a rare, life-threatening infection that can result in significant morbidity and mortality, with many patients requiring emergency department (ED) management for complications and stabilization.

OBJECTIVE

This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of FG.

DISCUSSION

Although originally thought to be an idiopathic process, FG has been shown to have a strong association for male patients with advanced age and comorbidities affecting microvascular circulation and immune system function, most commonly those with diabetes or alcohol use disorder. However, it can also affect patients without risk factors. The initial infectious nidus is usually located in the genitourinary tract, gastrointestinal tract, or perineum. FG is a mixed infection of aerobic and anaerobic bacterial flora. The development and progression of gangrene is often fulminant and can rapidly cause multiple organ failure and death, although patients may present subacutely with findings similar to cellulitis. Laboratory studies, as well as imaging including point-of-care ultrasound, conventional radiography, and computed tomography are important diagnostic adjuncts, though negative results cannot exclude diagnosis. Treatment includes emergent surgical debridement of all necrotic tissue, broad-spectrum antibiotics, and resuscitation with intravenous fluids and vasoactive medications.

CONCLUSIONS

FG requires a high clinical level of suspicion, combined with knowledge of anatomy, risk factors, and etiology for an accurate diagnosis. Although FG remains a clinical diagnosis, relevant laboratory and radiography investigations can serve as useful adjuncts to expedite surgical management, hemodynamic resuscitation, and antibiotic administration.

Which Method Is Better to Provide Wound Healing in Fournier Gangrene: Dakin Solution or Conventional Antiseptic Dressings? A Retrospective Study

Fournier gangrene is described as necrotizing fasciitis involving the genital, perineal, and perianal area. Early surgical debridement of necrotic tissues, topical therapy, and antibiotics are fundamental in the treatment of Fournier gangrene. We aimed to compare the effects of Dakin solution and povidone iodine solution on patient outcomes by using the Fournier gangrene severity index (FGSI). The demographic data, comorbid diseases, local therapeutic interventions, FGSI, necessity of diverting colostomy or orchiectomy, hospitalization time, number of debridements, complications, and outcomes of 57 patients with Fournier gangrene were retrospectively analyzed. A total of 47 of 57 patients (82.5%) were male, and 10 patients (17.5%) were female, with a mean age of 62.3 ± 13.8 years (range, 27–85 years). The survivors were significantly younger than the nonsurvivors. The mean FGSI score was 4 (range, 1–9) in survivors, and mean FGSI score was 9 (range, 6–10) in nonsurvivors. FGSI score was significantly higher in the mortality group. The median hospital stay was 13 days (range, 3–34 days) in the Dakin solution group and 20 days (range, 1–41 days) in the povidone iodine group. Overall mortality rate was 17.5%. Advanced age had a statistically significant effect on mortality. The hospitalization time was significantly shorter in the Dakin solution group, and use of Dakin solution decreased the number of debridements. Dakin solution has favorable effects on hospital stay and the necessity of multiple debridements. Dakin solution seems to be a good and cost-effective choice for treatment in local wound healing.

Preoperative CT Findings and Interobserver Reliability of Fournier Gangrene

OBJECTIVE

The objective of our study was to delineate CT findings and anatomic areas of involvement of surgically proven Fournier gangrene (FG) and determine interobserver reliability.

MATERIALS AND METHODS

This study was a single-center retrospective study of patients with FG who underwent CT before surgical débridement of FG during a 9-year period. Thirty-eight patients with FG, 17 male and 21 female patients, underwent preoperative CT. Two radiologists reviewed the CT studies and recorded findings and anatomic areas of involvement. CT findings were categorized according to a previously described CT scoring system for necrotizing fasciitis and included the presence or absence of fascial air, muscle or fascial edema, fluid tracking, lymphadenopathy, and subcutaneous edema. Cohen kappa was calculated for interobserver reliability.

RESULTS

Mean body mass index (BMI [weight in kilograms divided by height in meters squared]) was 42, and 22 of 38 (58%) patients had diabetes. Mean BMI and proportion of patients with diabetes were significantly higher in female patients (mean BMI = 46; 16/21 with diabetes) than male patients (mean BMI = 36; 6/17 with diabetes). CT studies of most patients showed fascial air (36/38 [95%], both readers 1 and 2). Interobserver reliability was substantial to almost perfect for all CT findings except lymphadenopathy, for which it was fair (κ = 0.37). Genital, perineal, and ischiorectal involvement were seen in 87% (33/38), 87% (33/38), and 32% (12/38) of patients for reader 1 and 84% (32/38), 84% (32/38), and 26% (10/38) of patients for reader 2 (κ = 0.29, penis; κ = 0.65, scrotum; κ = 0.91, vulva and labia; κ = 0.68, perineal involvement; κ = 0.80, ischiorectal involvement).

CONCLUSION

Most CT findings of FG and anatomic areas of involvement showed good interobserver reliability. A high proportion of female patients with FG were observed in this study compared with prior series.

Successful treatment following early recognition of a case of Fournier's scrotal gangrene after a perianal abscess debridement: a case report

Background

Fournier’s gangrene is an acute surgical emergency characterized by high mortality rates ranging from approximately 13% to 45%. Therefore, aggressive multidisciplinary management is necessary.

Case presentation

A 29-year-old Asian man who had undergone surgical debridement at another hospital to treat a perianal abscess 5 days earlier was admitted to our hospital for severe scrotal and perianal pain, swelling, and high fever. A physical examination revealed a perianal abscess. Furthermore, the scrotum was gangrenous and exhibited extensive cellulitis in the perineum and bilateral inguinal area. Crepitations between the skin and fascia were palpable. A diagnosis of Fournier’s gangrene was made. The patient was treated with immediate surgical debridement under general anesthesia. He received broad-spectrum antibiotics, and debridement was repeated until the wound exhibited healthy granulation. Because both testes were severely exposed, they were transpositioned back into the scrotum 1 week after surgery. The patient was discharged on the 11th postoperative day.

Conclusions

The mainstay of treatment for Fournier’s gangrene should include fluid resuscitation, broad-spectrum antibiotic therapy, intensive care, nutritional support, and early aggressive surgical debridement of all necrotic tissue.

Electronic supplementary material

The online version of this article (10.1186/s13256-018-1697-9) contains supplementary material, which is available to authorized users.

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: Clinical Presentation of 13 Cases

BACKGROUND Fournier's gangrene (FG) is a fulminant form of infective, polymicrobial, necrotizing fasciitis of the perineal, genital, and perianal regions. It commonly affects men, but women and children may also develop this type of tissue necrosis. MATERIAL AND METHODS This study is a retrospective analysis of the management of 13 cases of Fournier's gangrene, diagnosed from among about 45 000 patients (men, women, and children) treated in the Department of General, Oncological, and Functional Urology (Medical University of Warsaw) from 1995 to 2013. All patients with Fournier's gangrene underwent adequate surgical debridement of the necrotic tissues. Additional procedures (suprapubic cystostomy and orchiectomy) were necessary in 10 out of 13 (77.0%) patients. Seven out of 13 (53.8%) patients required subsequent reconstructive surgery of the scrotum. RESULTS All 13 patients were males, with a median age of 59.6 years (range: 42-68 years). The average hospital stay was 31.9 days (range: 16-46 days). None of our patients died due to Fournier's gangrene. Bacteriological cultures of samples from the wounds showed polymicrobial flora, including the following genera of aerobes and anaerobes: Escherichia, Proteus, Klebsiella, Moraxella, Gemella, Enterococcus, Streptococcus, Staphylococcus, Bacteroides, Pseudoflavonifractor, Parabacteroides, Porphyromonas, Prevotella, Peptoniphilus, Peptostreptococcus, Actinomyces, Collinsella, and Lactobacillus. CONCLUSIONS Favorable outcome of FG treatment with low morbidity and no mortality can be achieved with rapid diagnosis, urgent surgical debridement of all necrotic tissues, and broad-spectrum empirical antimicrobial therapy, usually with combined antibiotics, against aerobic and anaerobic bacteria. Prevention of uroseptic shock by treating localized infection is compulsory.

Definitive Wound Closure Techniques in Fournier's Gangrene

Necrotizing soft tissue infection of the perineum, or Fournier's gangrene (FG), is a morbid and mortal diagnosis. Despite the severity of FG, the optimal definitive wound closure strategy is unknown, as are long-term wound outcomes. A retrospective review was performed over a 3-year period at a single trauma center. Patients were managed according to our institutional approach focusing on primary wound closure and secondary intention healing in residual wounds. Overall 168 patients were included. Complete primary wound closure was accomplished in 39.9 per cent of patients. Patients undergoing primary wound closure were primarily male (89.6 vs 64.4%, P < 0.001), had lower mean sequential organ failure assessment (SOFA) scores (1.70 ± 2.30 vs 2.98 ± 3.36, P = 0.004), more often had perineum-limited FG (67.2 vs 42.6%, P = 0.003), and required fewer debridements (2.40 vs 2.79, P = 0.02). On logistic regression, predictors of primary closure included gender (odds ratio 4.643, 95% confidence interval 1.885–11.437, P = 0.001) and SOFA score (odds ratio 0.834, 95% confidence interval 0.727–0.957, P = 0.01). Wound healing rates increased over time, to an 82.1 per cent wound healing rate without further intervention at greater than six months of follow-up. Wounds healed with secondary intention ranged from 70 to 9520 cm3 and primary closure ranged from 126 to 6912 cm3, whereas wounds requiring skin grafts ranged from 405 to 16,170 cm3. Complete primary wound closure is often achievable in FG patients. Using this standardized approach to FG wound management, even large wounds and wounds undergoing secondary intention healing will often close with long-term wound care and do not require flap creation or early skin grafting.

Prognostic factors and treatment outcomes for patients with Fournier's gangrene: a retrospective study

Fournier's gangrene is a gas-forming, necrotising soft tissue infection affecting the perineum. It spreads rapidly along the deep fascial planes and is associated with a high mortality rate. With a growing elderly population with comorbidities, the frequency of severe cases of Fournier's gangrene is expected to increase. We retrospectively reviewed 20 patients diagnosed with Fournier's gangrene at our institution from 2003 to 2014 and analysed data. Thirteen patients had diabetes mellitus, two had been diagnosed with liver cirrhosis, and four were chronic alcoholics. Of 15 patients admitted to an intensive care unit, 11 underwent colostomy, and 4 required skin grafts for wound healing. The wide wounds of two patients were healed using vacuum-assisted closure (VAC^® ) dressing without additional surgery. The mortality rate was 25%, and the patients whose Fournier's gangrene severity index (FGSI) score was higher than 9 points or whose blood urea nitrogen (BUN) level was higher than 50 mg/dl had a poor prognosis. In order to treat Fournier's gangrene, aggressive surgical treatment, including wide debridement and stoma creation, should be considered as soon as possible to improve survival rates. Additionally, VAC dressing is helpful in healing the wide debridement wound without additional reconstructive surgery.

Less is more? Antibiotic duration and outcomes in Fournier's gangrene

BACKGROUND

Antibiotic management of Fournier's gangrene (FG) is without evidence-based guidelines and is based on expert opinion. The effect of duration of antibiotic therapy on outcomes in FG is unknown.

METHODS

A retrospective review was performed of FG patients from 2012 to 2015 at a single institution. Patients were managed by our institutional practice of complete primary wound closure as possible, with antibiotic duration according to physician judgment. Patients were stratified into multiple durations of antibiotic administration.

RESULTS

Overall, 168 patients with FG were included. When examining multiple stratifications of antibiotic therapy of 7 days or less, 8 days to 10 days, 11 days to 14 days, or 15 days or more of antibiotics, there was no significant difference in mortality (p = 0.11), primary closure (p = 0.75), surgical site infection (SSI) (p = 0.52), or Clostridium difficile infection (p = 0.63). There were no cases of recurrent FG in any antibiotic stratification. Mortality was not increased (p = 1.00) and ability to achieve primary closure was not decreased (p = 0.08) with initial antibiotic therapy exclusive of cultured organisms.

CONCLUSION

Shorter antibiotic courses for patients in whom source control is obtained and initial antibiotic selection exclusive of many resistant organisms were not associated with worse outcomes in FG.

LEVEL OF EVIDENCE

Therapeutic, level IV.

Peri-vulvar reconstruction using internal pudendal artery perforator flap in female Fournier's gangrene

Fournier's gangrene in female patients has low incidence rate but high mortality rate compared with that in males, with many cases resulting in death at acute phase. This is due to the differences in male and female genital anatomy, which should be fully understood by physicians to increase the patient's survival rate. After crossing the acute phase of the disease by an appropriate treatment, it is important to reconstruct vaginal or vulvar defects according to the patient's three-dimensional anatomical structures. Perforator flap based on internal pudendal artery is one of the ideal reconstructive techniques to resolve the aforementioned issue. The authors intend to introduce the distinguishing characteristics of Fournier's gangrene in female patients, and the surgical techniques to reconstruct the defects after the acute phase of disease.

Fournier's gangrene: diagnosis and management aided by repeated clinical examination and ultrasound

We describe a case of a man aged 57 years admitted to our tertiary centre via his general practitioner, presenting with a 1-week history of scrotal pain, testicular swelling and fluctuance. He was initially managed in the community with flucoclaxacillin for 1 week, but failed to respond to treatment. Clinical history was suggestive of Fournier's gangrene, but initial examination was not conclusive. Repeated examination over the next hour aided diagnosis and helped to track the progression of the condition. The patient was treated with intravenous antibiotics and prepared for theatre. Since there was a delay in getting the patient to theatre, an ultrasound scan was performed to help ascertain the extent of the disease to aid surgical planning. Following successful debridement and skeletalisation of the testicles and ward recovery, he was transferred for plastic reconstruction.

Is hemoglobin A1c level effective in predicting the prognosis of Fournier gangrene?

Objectives:

To evaluate the effect of immune failure and/or diabetes mellitus (DM) association on the mortality and morbidity of the Fournier's Gangrene (FG), and interrelatedly, the usability of HbA1c level in the prediction of prognosis.

Materials and Methods:

The data of 38 patients with the diagnosis of FG were investigated retrospectively. The patients were divided into two groups as patients with DM (Group 1, n = 18) and non-diabetics (Group 2, n = 20). The patients in group 1 were also divided into two subgroups as patients with HbA1c value ≥7 (Group 1a) and HbA1c value <7 (Group 1b).

Results:

The mean age of all 38 male patients was 66.3 ± 6.4 years. The initial symptoms were scrotal rash and swelling (n = 20, 52.6%), high fever (>38°C) (n = 22, 57.8%), purulent discharge from genital or perineal areas (n = 13, 34.2%), skin bruises (n = 11, 28.9%) and general state disorder in five patients that were admitted from day care center (13.1%). DM, as the most often comorbid disease, was detected in 18 patients (47.3%). Six patients (15.7%) were deceased during the follow-up period.

Conclusion:

In the present study, the researchers determined that diabetic patients with HbA1c level of 7 or higher had worse prognosis, and increased mortality.

Contemporary diagnosis and management of Fournier's gangrene

Fournier's gangrene, an obliterative endarteritis of the subcutaneous arteries resulting in gangrene of the overlying skin, is a rare but severe infective necrotizing fasciitis of the external genitalia. Mainly associated with men and those over the age of 50, Fournier's gangrene has been shown to have a predilection for patients with diabetes as well as people who are long-term alcohol misusers. The nidus for the synergistic polymicrobial infection is usually located in the genitourinary tract, lower gastointestinal tract or skin. Early diagnosis remains imperative as rapid progression of the gangrene can lead to multiorgan failure and death. The diagnosis is often made clinically, although radiography can be helpful when the diagnosis or the extent of the disease is difficult to discern. The Laboratory Risk Indicator for Necrotizing Fasciitis score can be used to stratify patients into low, moderate or high risk and the Fournier's Gangrene Severity Index (FGSI) can also be used to determine the severity and prognosis of Fournier's gangrene. Mainstays of treatment include rapid and aggressive surgical debridement of necrotized tissue, hemodynamic support with urgent resuscitation with fluids, and broad-spectrum parental antibiotics. After initial radical debridement, open wounds are generally managed with sterile dressings and negative-pressure wound therapy. In cases of severe perineal involvement, colostomy has been used for fecal diversion or alternatively, the Flexi-Seal Fecal Management System can be utilized to prevent fecal contamination of the wound. After extensive debridement, many patients sustain significant defects of the skin and soft tissue, creating a need for reconstructive surgery for satisfactory functional and cosmetic results.

Rectal cancer and Fournier’s gangrene - current knowledge and therapeutic options

Fournier’s gangrene (FG) is a rapid progressive bacterial infection that involves the subcutaneous fascia and part of the deep fascia but spares the muscle in the scrotal, perianal and perineal region. The incidence has increased dramatically, while the reported incidence of rectal cancer-induced FG is unknown but is extremely low. Pathophysiology and clinical presentation of rectal cancer-induced FG per se does not differ from the other causes. Only rectal cancer-specific symptoms before presentation can lead to the diagnosis. The diagnosis of rectal cancer-induced FG should be excluded in every patient with blood on digital rectal examination, when urogenital and dermatological causes are excluded and when fever or sepsis of unknown origin is present with perianal symptomatology. Therapeutic options are more complex than for other forms of FG. First, the causative rectal tumor should be removed. The survival of patients with rectal cancer resection is reported as 100%, while with colostomy it is 80%. The preferred method of rectal resection has not been defined. Second, oncological treatment should be administered but the timing should be adjusted to the resolution of the FG and sometimes for the healing of plastic reconstructive procedures that are commonly needed for the reconstruction of large perineal, scrotal and lower abdominal wall defects.

Fournier's gangrene: A retrospective analysis of 26 cases in a Canadian hospital and literature review

We performed a systematic review of all cases of Fournier's Gangrene (FG) at our hospital over a 12-year period. A total of 26 cases were assessed. Our goal was to determine the mortality rate and to identify risk factors associated with FG. We also wanted to examine three potential prognostic factors in relation to patient survival, including the time delay from emergency room admission to surgery, the initial extent of the disease, and the impact of more than one debridement procedure under general anesthesia. The time between emergency room admission and the beginning of surgical debridement was not statistically different between survivors and non-survivors. The extent of surgical debridement was close to the margin of statistical significance (p = 0.07) and can be considered an index of the extent of the disease. FG extending to the thighs or to the abdominal wall carries a worse prognosis. The number of surgical debridement procedures done under anesthesia was statistically different between survivors and non-survivors. Patients were 4.8 times more at risk of dying if they are required to have more than one surgical debridement under general anesthesia. This presumably reflects persistent gangrene following initial surgical debridement, fluid resuscitation, and wide spectrum antibiotic treatment.

Fournier's Gangrene: A Summary of 10 Years of Clinical Experience

We aimed to present our clinical experience with FG treatment. Fournier's gangrene (FG) is a rare but serious disease characterized by progressive necrosis in the genitourinary and perineal region. The retrospective study included 43 patients. Patients were divided into 2 groups as survivors and nonsurvivors. Included in the analysis were data pertaining to demographics, predisposing factors, comorbidities, results of bacteriologic analyses, number of debridements, duration of treatment, FG Severity Index (FGSI) score, fecal diversion methods (trephine ostomy or Flexi-Seal Fecal Management System-FMS), and dressing methods (wet or negative aspiration system). In the nonsurvivor group, urea, WBC, and age were significantly higher, whereas albumin, hematocrit, platelet count, and length of hospital stay (LOHS) were significantly lower compared to the survivor group. Mean FGSI was lower in survivors in comparison with nonsurvivors (5.00 ± 1.86 and 10.00 ± 1.27, respectively; P < 0.001). We conclude that FGSI is an important predictor in the prognosis of FG. Vacuum-assisted closure (VAC) should be performed in compliant patients in order to enhance patient comfort by reducing pain and the number of dressings. Fecal diversion should be performed as needed, preferably by using FMS. The trephine ostomy should be the method of choice in cases where an ostomy is necessary.

Clinical efficacy of vacuum-sealing drainage in treatment of Fournier's gangrene

AIM: To assess the clinical effects of vacuum-sealing drainage technology in the treatment of Fournier's gangrene.

METHODS: Forty patients with Fournier's gangrene treated from September 2013 to September 2014 at our hospital were randomly divided into either an observation group or a control group. The observation group was treated by vacuum-sealing drainage, and the control group was treated by conventional debridement. Fournier's gangrene severity index (FGSI), debridement frequency, time to body temperature recovery, healing situation and hospitalization time were compared for the two groups.

RESULTS: FGSI on days 7 and 14 after treatment was significantly lower in the observation group than in the control group (P < 0.05). The average debridement times in the observation group was 3.8, significantly less than that in the control group (P < 0.05). Body temperature recovery was faster in the observation group (P < 0.05). All the 20 patients in the observation group were cured, including 17 cases of wound healing after secondary suture under local anesthesia and 3 cases of healing after inguinal flap grafting. Sixteen patients in the control group were cured, and 4 cases died. The hospitalization time was significantly shorter in the observation group (P < 0.05).

CONCLUSION: Vacuum-sealing drainage is an effective method for the treatment of Fournier's gangrene.

Scrotal reconstruction using a superficial circumflex iliac artery perforator flap following Fournier's gangrene

Fournier's gangrene is a type of necrotising fasciitis around the scrotum and perineum. Because of its aggressive nature, patients should be treated with broad-spectrum antibiotics and emergency, radical debridement during the acute phase. After recovering from the acute phase, reconstruction of the scrotal and perineal soft tissue defects is needed and is often challenging. Traditionally, various reconstruction methods have been used, including skin grafts, fasciocutaneous flaps and musculocutaneous flaps, each with its pros and cons. We successfully covered a wide scrotal defect using a superficial circumflex iliac artery perforator flap, which has not been previously reported for this indication. The design and operative technique are introduced in this study.

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.

Diagnosis, management and outcomes of necrotising soft tissue infection within a Plastic and Reconstructive Surgery unit

BACKGROUND AND AIMS

Necrotising soft tissue infection (NSTI) is an extremely serious condition that relies on a high index of suspicion, prompt diagnosis and emergent radical surgical treatment. We explored the presentation, management and outcomes of NSTI within our department. We also assessed the potential benefit of using risk predictor scoring system.

METHODS

Retrospective review using departmental electronic database and hospital records.

RESULTS

Twenty-four patients were treated for NSTI within our department between 2004 and 2010. Seventeen presented in our hospital to various surgical and medical teams. All patients presented with pain, swelling, erythema and tenderness at palpation. Only 40% of necrotising fasciitis and 28.6% of Fournier's gangrene were diagnosed as NSTI at initial assessment. Average mean interval time from admission to primary surgery was 17.7 h and 4 h from diagnosis to primary surgery. There were four mortalities. The average risk predictor Laboratory Risk Indicator for Necrotising Fasciitis score was 7.9. Significant morbidities post-operatively included bowel stoma, long-term urinary catheter and new diagnoses of carcinomas.

CONCLUSION

Physicians and surgeons need to be suspicious of NSTI in severe cases of soft tissue infection to prevent delay in diagnosis and life-saving treatment. Scoring system can be used judiciously as adjunct to aid diagnosis.

Prospective evaluation of risk factors for mortality in patients of Fournier's gangrene: A single center experience

Introduction:

Fournier's gangrene is an aggressive disease with high morbidity and mortality. The aim of this study was to assess risk factors associated with mortality among patients of Fournier's gangrene.

Materials and Methods:

Between May 2011 and September 2012, all patients of Fournier's gangrene treated at our center were included in the study. All patients underwent emergency surgical debridement and received broad spectrum intravenous antibiotics. Their baseline characteristics, treatment, and follow-up data were recorded and analyzed.

Results:

A total of 30 patients were included in the study. Of these, six patients (20%) died during the treatment. Age <55 years, total leukocyte count <15000 cumm, extent of the area involved, septic shock at admission, visual analog scale (VAS) <7 at admission, and Fournier gangrene severity index (FGSI) score <8 at admission were significantly associated with increased mortality.

Conclusion:

In patients of Fournier's gangrene, increased age, total leukocyte count, extent of the area involved, septic shock at admission, VAS score, and FGSI score at admission have a significant association with mortality.

Case report of penile corporal Fournier's gangrene

Fournier's gangrene is a severe necrotising infection of the perineum. It is believed that the thick penile fascia restricts the penetration of infection and spares the internal structures. We present an unusual case of a 59-year-old apparently healthy man presenting with penile corporal Fournier's gangrene with no known predisposing or precipitating factors. His initial presentation was peno-scrotal pain, swelling and priapism with normal-looking skin surrounding his genitals. After the imaging studies, he was discovered with gas in his genital tissues which was leading to the priapism. Upon debridement his corporal muscle was found to be necrosed and he ended up having a penectomy. Histopathology confirmed the diagnosis. The patient, however, made a good recovery and was referred to the plastic surgeons for functional reconstructive surgery.

Fournier's gangrene

Fournier's gangrene (FG) is a synergistic polymicrobial gangrenous infection of the perineum, scrotum and penis which is characterised by obliterative endarteritis of the subcutaneous arteries, resulting in gangrene of the subcutaneous tissue and the overlying skin. FG affects all ages and both genders, with a male preponderance. It is a rare but life-threatening disease, and despite therapeutic advances in recent years, the mortality rate is 3%-67%, with an incidence of 1:7500-1:750,000. Anorectal, genitourinary and cutaneous sources of infection are the most common causes of FG, with diabetes mellitus being the most common risk factor. The clinical condition presents evolution from 2 to 7 days and is characterised by uneasiness, local swelling and discomfort, fever, crepitus and sometimes frank septic shock. Current imaging techniques for initial evaluation of the disease include radiography, Ultrasonography (USG), Computed Tomography (CT) and Magnetic Resonance Imaging (MRI). However, the diagnosis of FG is usually clinical and imaging can be helpful in uncertain diagnosis and when clinical findings are ambiguous. Treatment of FG is based on a multimodal approach which includes intensive fluid resuscitation to stabilise the patient and correction of electrolyte imbalance, if any. This is followed by extensive debridements and resections in order to remove all necrotic and infected tissue, wide spectrum antibiotics and reconstructive surgery, whenever required. However, despite all the advances in treatment today, FG remains a surgical emergency, hence, early recognition with aggressive haemodynamic stabilisation, parenteral broad spectrum antibiotics and urgent surgical debridement are the mainstay of treatment.

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

OBJECTIVE

To identify the causative pathogens and evaluate the antibiotic sensitivity, resistance patterns, and virulence in a contemporary series of patients with Fournier's gangrene.

MATERIALS AND METHODS

The medical records of 41 consecutive cases of Fournier's gangrene were evaluated. The patient demographics, causative pathogens, antibiotic sensitivity, and resistance patterns were assessed. The Fournier's gangrene severity index and length of stay were analyzed statistically to determine any differences by causative pathogen.

RESULTS

A total of 122 pathogens were cultured. The wound cultures were polymicrobial for 34 patients (83%). Most common pathogens cultured were Bacteroides sp (43.9%), Escherichia coli (36.6%), and Prevotella sp (34.1%). E coli was resistant to fluoroquinolones and trimethoprim/sulfamethoxazole in 13.3%, and 40% of isolates respectively. The wound cultures were monomicrobial for 7 patients (17.0%). A monomicrobial isolate of methicillin-resistant Staphylococcus aureus was cultured that was susceptible to clindamycin and trimethoprim/sulfamethoxazole. Resistance to ampicillin-sulbactam was seen in Providencia sp, Klebsiella sp, E coli, and methicillin-resistant S aureus. Resistance to ceftriaxone and gentamicin was seen in methicillin-resistant S aureus and E coli, respectively. No resistance to clindamycin was demonstrated. No statistically significant difference was detected between the Fournier's gangrene severity index or length of stay and the causative pathogens.

CONCLUSION

Fournier's gangrene remains a community-acquired polymicrobial infection, with anaerobic bacteria as the most common causative pathogens. Candida and methicillin-resistant S aureus are emerging causative pathogens, but methicillin-resistant S aureus remains sensitive to clindamycin and trimethoprim/sulfamethoxazole. Although resistance was demonstrated by some causative pathogens, together, the currently recommended broad-spectrum antibiotics adequately covered all pathogens. Coverage with agents such as fluconazole, vancomycin, or piperacillin-tazobactam is indicated in patients at risk of fungal or hospital-acquired organisms.