Neutrophil to Lymphocyte and Platelet to Lymphocyte Ratios Are More Effective than the Fournier's Gangrene Severity Index for Predicting Poor Prognosis in Fournier's Gangrene

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.

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

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

Measures of Admission Immunocoagulopathy as an Indicator for In-Hospital Mortality in Patients with Necrotizing Fasciitis: A Retrospective Study

Necrotizing fasciitis is a rapidly progressive infection with a high mortality rate. Pathogens evade the host containment and bactericidal mechanisms by hijacking the coagulation and inflammation signaling pathways, leading to their rapid dissemination, thrombosis, organ dysfunction, and death. This study examines the hypothesis that measures of immunocoagulopathy upon admission could aid in the identification of patients with necrotizing fasciitis at high risk for in-hospital mortality.

Methods

Demographic data, infection characteristics, and laboratory values from 389 confirmed necrotizing fasciitis cases from a single institution were analyzed. A multivariable logistic regression model was built on admission immunocoagulopathy measures (absolute neutrophil, absolute lymphocyte, and platelet counts) and patient age to predict in-hospital mortality.

Results

The overall in-hospital mortality rate was 19.8% for the 389 cases and 14.6% for the 261 cases with complete measures of immunocoagulopathy on admission. A multivariable logistic regression model indicated that platelet count was the most important predictor of mortality, followed by age and absolute neutrophil count. Greater age, higher neutrophil count, and lower platelet count led to significantly higher risk of mortality. The model discriminated well between survivors and non-survivors, with an overfitting-corrected C-index of 0.806.

Conclusions

This study determined that measures of immunocoagulopathy and patient age at admission effectively prognosticated the in-hospital mortality risk of patients with necrotizing fasciitis. Given the accessibility of neutrophil-to-lymphocyte ratio and platelet count measurements determined from a simple complete blood-cell count with differential, future prospective studies examining the utility of these measures are warranted.

Level of Evidence

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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

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

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

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

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

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.

Mortality associated with Fournier's gangrene remains unchanged over 25 years

OBJECTIVES

To report a case series of Fournier's gangrene (FG) from our institution, and to investigate its mortality over the past 25 years.

PATIENTS AND METHODS

Case notes of men presenting to our institution from 2013 to 2016 with FG were reviewed. As well as age, diabetic history, length of stay, length of stay in critical care, and mortality; we calculated (where possible) the Uludag Fournier's Gangrene Severity Index (UFGSI). Published studies and cases series reporting the mortality rates for FG were reviewed from 1993 to 2018. The size of the study, country of origin, average age and gender ratio were collected, alongside mortality.

RESULTS

Two of the 11 patients treated for FG at out institution died within 90 days of admission, a mortality rate of 18%. Predicted mortality was significantly higher. A total of 173 publications were identified from the Medical Literature Analysis and Retrieval System Online (MEDLINE) database published between 1993 and 2018, reporting data from 1975 to 2018. Analysis of heterogeneity, by both time and precision, supported exclusion of four retrospective coded database-driven studies from the analysis. From the remaining studies, mortality ranged from 0% to 42%. Of the 6152 reported cases, there were 1220 deaths, giving an overall mortality rate of 19.8%. There was no evidence of a significant change in the mortality rate for FG over time (P = 0.996).

CONCLUSIONS

In our case series, the mortality rate for FG was 18%, despite a higher predicated mortality (based on UFGSI scores). The treatment of FG remains appropriate resuscitation, aggressive surgical debridement, and critical care management. Perceived high risk of mortality should not deter aggressive management. Mortality due to FG does not appear to have changed over the past 25 years, and is estimated at 19.8%. In studies identifying cases of FG, careful attention should be paid to case definition, particularly when cases are being abstracted retrospectively from large coded databases.