Location of residence and mortality for patients diagnosed with Fournier's gangrene

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

Background

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

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

Case presentation

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

Conclusions

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

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

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