Epidemiological characteristics of Fournier's gangrene: a report of 71 patients

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.

A Case of Fournier's Gangrene in a Patient With Malignant Priapism

Fournier's gangrene is a rare and potentially life-threatening type of necrotizing fasciitis that affects the genital and perineal regions. Malignant priapism is a rare and serious medical condition characterized by persistent and painful erection of the penis that is not associated with sexual arousal or stimulation. We present a case of a 77-year-old man with concurrent Fournier's gangrene and malignant priapism. He first underwent surgical debridement to remove necrotic tissue and aspiration of blood from the corpora cavernosa. Then a palliative penectomy was performed. The patient succumbed to severe sepsis and died after 14 days of hospitalization.

Evaluation of Negative Pressure Wound Therapy in the Management of Fournier's Gangrene

Introduction Necrotizing soft tissue infections (NSTIs), including Fournier's gangrene (FG), are severe polymicrobial bacterial infections characterized by rapidly spreading inflammation and tissue necrosis. This study aims to compare the clinical outcomes of vacuum-assisted closure (VAC) dressing and conventional dressing in patients with FG. Materials and methods A prospective study was conducted from December 2020 to May 2022, including patients with clinical features suggestive of FG. Patients were divided into two groups: conventional dressing and VAC dressing. Relevant clinical data, including age, duration of hospital stay, wound status, Fournier's gangrene severity index (FGSI) scores, sepsis markers (C-reactive protein (CRP), neutrophil-to-lymphocyte ratio, and procalcitonin), and pain assessment, were recorded and compared between the two groups. Results A total of 84 patients were included in the study, with 42 patients in each group. The mean age was 57.48 ± 15.74 years in the conventional dressing group and 50.83 ± 13.95 years in the VAC dressing group. VAC dressing was associated with a significantly shorter duration of hospital stay (8.14 ± 3.13 days) compared to conventional dressing (11.36 ± 4.75 days). The average time taken for wound closure was significantly reduced in the VAC dressing group (63 ± 14.81 days) compared to the conventional dressing group (112.56 ± 13.82 days). FGSI scores showed significant improvement after debridement in both groups, with lower scores in the VAC dressing group at discharge. Sepsis markers such as CRP and serum procalcitonin exhibited a significant decrease after VAC application. Discussion The study demonstrates that VAC therapy is associated with better clinical outcomes in FG, including reduced duration of hospital stay, faster wound closure, improved FGSI scores, decreased sepsis markers, and reduced pain. These findings align with previous studies highlighting the advantages of VAC therapy over conventional dressing methods. Conclusion VAC therapy provides significant benefits in the management of FG, leading to improved clinical outcomes and patient quality of life. It offers advantages such as shorter hospital stays, faster wound closure, and reduced sepsis markers. The application of VAC dressing should be considered a valuable treatment modality for FG.

The Value of Fournier's Gangrene Scoring Systems on Admission to Predict Mortality: A Systematic Review and Meta-Analysis

OBJECTIVE

To systematically review and meta-analyze the predictive value of the Fournier gangrene severity index (FGSI), the simplified FGSI (SFGSI), and the Uludag FGSI (UFGSI) on mortality in patients affected by Fournier's Gangrene (FG).

METHODS

A search was performed in PubMed, Web of Science, Embase, and the Cochrane Library, from January 2000 to May 2023, to identify original cohorts comparing data between surviving and non-surviving FG patients. The statistical analysis consisted of two parts. First, the mean and standard deviation (SD) of the FGSI, SFGSI, and UFGSI at admission were extrapolated from each study, and the pooled mean difference (MD) with 95% confidence interval (95% CI) was obtained using the Der Simonian-Laird random-effect model. Second, to evaluate the accuracy of the FGSI, SFGSI, and UFSGI in predicting mortality, true positive (TP), false positive (FP), true negative (TN), and false negative (FN) values were extracted where possible and reported in 2 × 2 contingency tables. The sensitivity, specificity, and AUC values were pooled, and summary receiver operating characteristic (SROC) curves were constructed.

RESULTS

Overall, forty studies comprising 2257 patients were included. The pooled analysis revealed that the FGSI, SFGSI, and UFGSI values at admission were higher in non-survivors than survivors (MD: 5.53 (95% CI: 4.68-6.37); MD: 2.41 (95% CI: 1.06-3.77); and MD: 5.47 (95% CI: 3.68-7.26), respectively). Moreover, the AUC values of the FGSI, SFGSI, and UFGSI were 0.90 (95% CI: 0.87-0.92), 0.84 (95% CI: 0.80-0.87), and 0.94 (95% CI: 0.92-0.96), respectively.

CONCLUSIONS

The higher scores of the FGSI, SFGSI, and UFGSI on admission were associated with mortality. Moreover, when comparing accuracy rates, the UFGSI exhibited the highest AUC value.

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.

Fournier's gangrene: Presentation and predictors of mortality in Zaria, Nigeria

Background

Fournier's gangrene is an infectious urological emergency with associated morbidity and varying rates of mortality in the world. Various predictors of mortality such as advancing age, Fournier's Gangrene Severity Index (FGSI), anatomical extent of the disease, or presence of risk factors have been studied in the literature, though with conflicting results.

Aim

The aim of the study was to determine the presentation and predictors of mortality in our environment, Nigeria.

Patients and Methods

A review of medical records of all the patients managed from April 2012 to December 2018 at a tertiary referral center in Nigeria was conducted. Data on clinical presentation, FGSI, management, and outcome were retrieved and analyzed.

Statistical Analysis

Descriptive studies using mean and standard deviation were used for continuous variables, Fischer's exact test was used to compare categorical variables among survivors and nonsurvivors, and logistic regression analysis was used to describe the relationships of these variables with mortality.

Results

The mean age of the 31 patients was 60 ± 12 years. All were men, with 9 (29.0%) patients without clinical evidence of immunosuppression or predisposing factor (idiopathic). Fourteen (45%) had documented evidence of immunosuppression. All the patients had a polymicrobial infection; however, Escherichia coli was the most common organism cultured seen in 26 (83.9%) patients. The initial empirical antibiotic regimen of choice was a combination of intravenous ceftriaxone and metronidazole in 26 (83.8%) patients and intravenous ciprofloxacin and metronidazole in 5 (16.1%) patients. Mortality was recorded in three patients representing a rate of 9.6%. Anatomical extent of the disease, anemia requiring blood transfusion, severity of infection, and FGSI were all found to be the statistically significant variable of mortality in these patients using the Fischer exact test. Furthermore, on regression analysis only the FGSI and blood transfusion were significant with P < 0.05.

Conclusion

Fournier's gangrene is a disease of the older men with a higher mortality rate when the FGSI is >9 or anemia requiring blood transfusion is present.

Fournier Gangrene as a Complication of a Perinephric Abscess After Kidney Transplant: A Case Report

Fournier gangrene is a progressive necrotizing infection of the external genitalia or perineum that constitutes a urologic emergency. Incidence of Fournier gangrene is rising because of population aging, increasing comorbidities, and widespread use of immunosuppressive therapy, including immunosuppressive regimens used in kidney transplants. This is a rapidly progressive and potentially lethal disease without treatment, and early recognition of the disease, proper management of the predisposing factors, and aggressive surgical debridement are the most essential interventions. We report a rare case of Fournier gangrene in the early postoperative period of a kidney transplant due to a perinephric abscess.

Clinical study of Maggot therapy for Fournier's gangrene

Fournier's Gangrene is a fulminating necrotizing fasciitis of the perineum and genitalia. Standard treatment involves immediate excision of all necrotic tissue, aggressive antibiotic coverage, and supportive medical care. Still, the infection is commonly fatal or disfiguring. Wound treatment with disinfected blowfly larvae (maggot debridement therapy or MDT) has been shown to be highly effective, with multiple studies demonstrating effective debridement, disinfection, and promotion of granulation tissue. MDT also has been associated with preservation of viable tissue and minimised blood loss. This report describes a prospective clinical study of MDT for Fournier's gangrene aimed to test the hypothesis that early use of maggots could decrease the number of surgical treatments required to treat Fournier's gangrene. Subjects were provided with one initial surgical excision, followed by debridement using only medical grade Lucilia sericata larvae. Only two subjects were enrolled, both diabetic men. Intensive care and culture-directed antimicrobial coverage were administered as usual. Maggot debridement was associated with the disappearance of necrotic tissue, control of infection and granulation tissue growth. In both subjects, wounds healed without requiring further surgical resection or anatomical reconstruction. Maggot therapy decreased the number of surgical procedures that otherwise would have been necessary, and led to favourable outcomes.

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.

A retrospective case series of Fournier's gangrene: necrotizing fasciitis in perineum and perianal region

Background

To describe the clinical characteristics and management for Fournier’s gangrene. Experience summary and literature references are provided for future treatment improvement.

Methods

We retrospectively reviewed the cases diagnosed with Fournier’s gangrene in our department from June 2016 to June 2019. Clinical data, including manifestation, diagnosis, treatment and outcomes for Fournier’s gangrene were presented.

Results

There were 12 patients enrolled in this paper, with the average age of 60 years old. It showed a male predominance with male-to-female ratio of 6:1. The average of laboratory risk indicator for necrotizing fasciitis (LRINEC) score was 10.1. Diabetes mellitus was the main predisposing disease. 11 patients received emergency debridement and 1 patient died of sepsis on the 2nd day after admission. The mortality rate was 8.3%. 6 cases developed complications, including sepsis, pneumonia, renal and heart failure. Negative pressure wound therapy (NPWT) was applied in 10 cases, while the rest 1 received normal daily dressing changes because of fecal contamination. Flaps were utilized in 2 patients to cover the defect, including one with advancement flap and one with pudendal-thigh flap, while others received secondary suture, secondary healing, skin graft or combined management. No relapse was observed during the follow-up visits.

Conclusions

Fournier’s gangrene is a life-threatening infection that requires early diagnosis and surgery intervention. The predisposing disease, clinical manifestation and LRINEC score should be taken into comprehensive consideration, which is helpful for timely diagnosis. Moreover, further successful treatment depends on the aggressive debridement, broad-spectrum antibiotics therapy, wound management and closure choice.

Fournier's Gangrene in Females: Presentation and Management at a Tertiary Center

OBJECTIVE

To report and compare presentation and management of Fournier's Gangrene (FG) in female vs male patients at a single tertiary care center.

METHODS

Patient demographics, clinical characteristics, treatments and outcomes were summarized and compared between males and females who were treated for FG from 2011 to 2018 at a single institution.

RESULTS

Of the 143 patients treated for FG at our institution, 33 (23%) were female. Female patients were predominantly white (82%), with a median (IQR) age of 55 (46, 59). Median female boby mass index (BMI) was 42.1 (32, 50.4). Female patients' wound cultures were polymicrobial mix of gram positive and gram negative organisms. Median number of debridements for females was 2 (1,3). The most common anatomic region of gangrene involvement in females was labia (76%) followed by perineum (55%) and gluteus/buttocks (42%). Mortality rate during initial admission was 6% for females. Female patients had a higher median BMI than males (42.1 vs 33.7 respectively; P = .003). FG severity index, length of hospital stay, number of debridements, and wound cultures were comparable to males. The surgical team managing initial debridements differed with females managed primarily by general surgery and males primarily by urology. Mortality rate was comparable to men (6% vs 7%, P >.05).

CONCLUSION

Female patients with FG have greater BMI but similar clinical presentation, microbiologic characteristics and mortality rate compared to men. Urologists have little involvement during initial management for females at our institution.

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.

Fournier's gangrene: a modern analysis of predictors of outcomes

Background

Fournier's gangrene (FG) is a rapidly progressing necrotizing fasciitis that carries a significant morbidity and mortality. The present study sought to identify the predisposing factors related to FG and validate the Fournier's Gangrene Severity Index (FGSI) score as a prognostic tool in the care of the Fournier's patient.

Methods

Medstar Washington Hospital Center records were searched from January 2003 to February 2015 for all patients with a diagnosis code of FG, n=42. Epidemiologic data was collected for patients and used to calculate an FGSI score.

Results

The average age was 53.45 yrs and M/F ratio was 39:1. Patients presented with an average 2.675 predisposing factors; the most common was diabetes mellitus (n=21) followed by hypertension (n=18). The most common etiology was periscrotal (n=25) next to perirectal (n=9). Streptococcus was the most common source of infection (n=14). Patients on average required three surgical interventions. The average and median hospitalization period was 19.625 and 11.5 days respectively. Eleven patients developed sepsis. Twenty-four (60%) patients experienced a complication. The overall mortality was 5% (n=2). The average FGSI on admission was 5.368. Multivariate analysis showed FGSI score correlates with more surgical intervention, longer hospitalization, sepsis, complication and mortality.

Conclusions

The FGSI score predicts a greater likelihood of more surgical interventions, longer hospitalization period, sepsis, complications and mortality within this patient population. Diabetes mellitus continues to be the most common predisposing factors in FG patients. The mortality rate of 5% is much less than the historically reported 20-30% and may reflect improved understanding and care of this aggressive disease.

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.

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.

Presentation and Diagnosis of Fournier Gangrene

Necrotizing fasciitis is a severe type of necrotizing soft tissue infection involving the superficial fascia and subcutaneous tissues. Fournier gangrene, a type of necrotizing fasciitis, affects the genitalia or perineum. Although a rare health condition, Fournier gangrene can result in significant morbidity and unnecessary mortality following delay in diagnosis and management. We provide a review of relevant presenting features to aid diagnosis and allow timely surgical management of this serious infectious condition.

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.

Analysis of prognostic factors affecting mortality in Fournier's gangrene: A study of 72 cases

INTRODUCTION

Fournier's gangrene is a rapidly progressing necrotizing fasciitis of the perineum and genital area associated with a high mortality rate. We presented our experience in managing this entity and identified prognostic factors affecting mortality.

METHODS

We carried out a retrospective study of 72 patients treated for Fournier's gangrene at our institution between January 2005 and December 2014. Patients were divided into survivors and non-survivors and potential prognostic factors were analyzed.

RESULTS

Of the 72 patients, 64 were males (89%) and 8 females (11%), with a mean age of 51 years. The most common predisposing factor was diabetes mellitus (38%). The mortality rate was 17% (12 patients died). Statistically significant differences were not found in age, gender, and predisposing factors, except in heart disease (p = 0.038). Individual laboratory parameters significantly correlating with mortality included hemoglobin (p = 0.023), hematocrit (p = 0.019), serum urea (p = 0.009), creatinine (p = 0.042), and potassium (p = 0.026). Severe sepsis on admission and the extent of affected surface area also predicted higher mortality. Others factors, such as duration of symptoms before admission, number of surgical debridement, diverting colostomy and length of hospital stay, did not show significant differences. The median Fournier's Gangrene Severity Index (FGSI) was significantly higher in non-survivors (p = 0.002).

CONCLUSION

Fournier's gangrene is a severe surgical emergency requiring early diagnosis and aggressive therapy. Identification of prognostic factors is essential to establish an optimal treatment and to improve outcome. The FGSI is a simple and valid method for predicting disease severity and patient survival.

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.

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.

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.

Predictors of Mortality and Limb Loss in Necrotizing Soft Tissue Infections

Necrotizing soft tissue infections (NSTIs) require prompt diagnosis and treatment. Early identification of patients at greatest risk of limb amputation and death may help in targeting aggressive medical and surgical management. The aim of this study was to assess predictors of limb loss and mortality in patients with NSTI based on admission variables. We performed a retrospective review of two hospitals that care for a large volume of patients with NSTI. Univariate and multi-variable analyses were used to determine the association of admission biochemical markers to limb loss and mortality. Of 174 patients with NSTI, there were 19 deaths (10.9%) and 42 required amputations (24.1%). Multivariable logistic regression analysis revealed that only arterial lactate was predictive for both mortality (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.1 to 2.0; P = 0.009) and limb loss (OR, 1.3; 95% CI, 1.0 to 1.7; P = 0.02). In patients with a suspected NSTI, an arterial lactate should be ordered early on to guide aggressive therapeutic interventions and to provide information with regard to long-term outcomes of amputation and death that is needed for early discussion with the patient and family.

Fournier's gangrene: our experience with 50 patients and analysis of factors affecting mortality

INTRODUCTION

Fournier's gangrene is a rare, rapidly progressive, necrotizing fasciitis of the external genitalia and perineum. Case series have shown a mortality rate of 20% to 40% with an incidence of as high as 88% in some reports. In this study we aimed to share our experience in the management of Fournier's gangrene and to identify risk factors that affect mortality.

METHODS

The medical records of 50 patients with Fournier's gangrene who presented at the University Hospital Hassan II of Fez from January 2003 to December 2009 were reviewed retrospectively to analyze the outcome and identify the risk factors and prognostic indicators of mortality.

RESULTS

Ten males and five females were enrolled in the study. The mean age was 54 years (range 23-81). The most common predisposing factor was diabetes mellitus (34%). E. coli was the most frequent bacterial organisms cultured. All patients were treated with a common approach of resuscitation, broad-spectrum antibiotics, and wide surgical excision. The mortality rate was 24%. The advanced age, renal failure on admission, extension of infection to the abdominal wall, occurrence of septic shock and need for postoperative mechanical ventilation are the main prognostic factors of mortality. In multivariate analysis, none of these variables is an independent predictor of mortality.

CONCLUSIONS

Fournier's gangrene is still a very severe disease with high mortality rates. Early recognition of infection associated with invasive and aggressive treatment is essential for attempting to reduce these prognostic indices.