Variables that predict hospital stay and the outcome of Fournier gangrene at King Abdulaziz University Hospital: a retrospective study

BACKGROUND

The aggressive nature of Fournier gangrene and the associated health issues can result in a more complex clinical course and potentially a longer hospital stay. This study aimed to assess factors that affect the length of hospital stay (LHS) and its relation to the outcome of Fournier gangrene patients.

METHODS

A retrospective study was performed at King Abdulaziz University Hospital (KAUH), Saudi Arabia, on patients diagnosed with Fournier gangrene between 2017 and 2023. Data about length of hospital stay (LHS), age, BMI, clinical and surgical data and outcome was obtained.

RESULTS

The mean age of the studied patients was 59.23 ± 11.19 years, the mean body mass index (BMI) was 26.69 ± 7.99 kg/m2, and the mean duration of symptoms was 10.27 ± 9.16 days. The most common presenting symptoms were swelling or induration (64%), 88% had comorbidities with diabetes mellitus (DM) (84%), and 76% had uncontrolled DM. of patients, 24% had a poly-microbial infection, with E. coli being the most common (52%). The mean length of hospital stay (LHS) was 54.56 ± 54.57 days, and 24% of patients had an LHS of more than 50 days. Longer LHS (> 50 days) was associated with patients who did not receive a compatible initial antibiotic, whereas shorter LHS was associated with patients who received Impenem or a combination of vancomycin and meropenem as alternative antibiotics following incompatibility. Reconstruction patients had significantly longer LHS and a higher mean temperature. However, none of the studied variables were found to be predictors of long LHS in the multivariate regression analysis.

CONCLUSION

Knowledge of the values that predict LHS allows for patient-centered treatment and may be useful in predicting more radical treatments or the need for additional treatment in high-risk patients. Future multicenter prospective studies with larger sample sizes are needed to assess the needed variables and predictors of long LHS.

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.

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

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

Fournier's Gangrene: Microbiological Profile and Risk Factors for Mortality: Review of 97 Cases

Objective

Fournier's gangrene (FG) is a rare necrotizing fasciitis affecting genital and perianal areas. This study aimed to provide data on predicting factors, mortality rates, and factors affecting mortality in comparison of survivors and non-survivors in patients with FG.

Materials and Methods

This study included a retrospective analysis of patients diagnosed with FG between 2008 and 2018.

Results

A total of 97 patients with FG were included in this study. Of the patients, 72 (74%) were male. The mean age was 56.03±13.92 years, and the median was 57 (21-90). The mortality rate was 21.6%. The most frequently isolated microorganism from tissue and blood cultures was Escherichia coli (43%-42%). The median Fournier's Gangrene Severity Index (FGSI) and Uludağ FGSI (UFGSI) scores were 4 (0-20) and 5 (1-22), respectively. In the univariate model, mortality risk increases 7.18 times (p=0.001) in patients with two or more comorbidities, 1.31 times as the FGSI score increases (p<0.001), 1.28 times as the UFGSI score increases (p<0.001). When the cut-off value was set as 8 for the FGSI score, the sensitivity was 71.43%, and the specificity was 73.68%. The sensitivity was 73.43%, and the specificity was 75% when the cut-off value was set as 6 for the UFGSI score. In the univariate model, the mortality risk of those with hypotension was 6.07 times higher (p=0.003); as the platelet count increased, mortality risk decreased (odds ratio [OR]=0.99; p=0.02). The mortality risk of those hospitalized in the intensive care unit (ICU) was 16.5 times higher than those followed in the ward (p<0.001). In the multivariate model, this ratio was 6.49.

Conclusion

We concluded that FGSI and UFGSI scores could be used to predict mortality. Management of FG requires a multidisciplinary approach. Empiric treatment should include carbapenems and be de-escalated once getting the culture results. Authors from different centers should report their experiences to help reveal the ideal treatment and evaluate the consequences.

Delayed diagnosis and management of necrotizing fasciitis of the left lower leg: A case report

INTRODUCTION

Necrotizing fasciitis (NF) is a rare, severe soft tissue infection, characterized by rapid and extensive necrosis of the skin, subcutaneous tissue, and superficial and deep fascia. It is frequently misdiagnosed as other infectious diseases, leading to inappropriate treatment and potentially serious consequences. It may be complicated by septic shock and multiple organ failure with a fatal outcome.

PATIENT CONCERNS

A 73-year-old woman presented with continuous itching, skin lesions, pain, and swelling of the outer side of her left leg. The patient was diagnosed with septic shock and multiorgan failure caused by left leg NF.

DIAGNOSIS

Septic shock and multiorgan failure caused by left leg NF.

INTERVENTIONS

Two surgeries were performed on the patient's leg, which effectively treated her septic shock and multiple organ dysfunction.

OUTCOMES

The patient was followed up three times after her discharge. She had a good recovery, was generally well with no significant sequelae, and returned to her regular life.

CONCLUSION

NF is an acute severe illness with high mortality. It is easily misdiagnosed, leading to delayed or erroneous treatment and serious (or potentially fatal) outcomes. Rapid and accurate diagnosis of NF is essential for patient recovery. In difficult cases, multidisciplinary consultations may be helpful. The management of NF includes early and thorough surgical debridement, antibiotics, and symptomatic treatment.

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 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.

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 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.

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.

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.

[Therapeutic factors affecting the healing process in patients with gangrene of the perineum]

Fournier gangrene is a rare and severe necrotizing fasciitis. It is burdened with high morbi-mortality, requiring early and massive medical and surgical management. Initial treatment is based on patient's resuscitation associated with surgical debridement. Subsequently, the main challenge is the healing process and its possible sequelae. Several therapeutic approaches are currently available to improve and accelerate the healing process. We conducted a retrospective study of 20 cases. The median age of our patients was 56 years. The study included 16 men and 7 women. Comorbidity was present in 15 patients. Antibiotic therapy was administered in all cases, with a median duration of 15 days. All patients underwent surgery. Iterative reviews were necessary in all patients, who needed, on average, 3 dressing changes. Colostomy was performed in 6 cases. Hyperbaric oxygen therapy was performed in 4 cases. Vacuum assisted closure was performed in 1 case. Soft tissue coverage was necessary in 2 cases. The mean duration of healing was 15 days with oxygen therapy versus 24 days in the absence of this treatment. The mean duration of hospitalization was 20 days. Four patients died. Healing process without sequelae is a therapeutic challenge. Despite the addition of new therapeutic approaches, outcomes are not satisfactory. However, multidisciplinary approach associated with oxygen therapy and vacuum assisted closure might improve patients outcomes.

Temporary Rectal Stenting for Management of Severe Perineal Wounds in Two Dogs

Perineal wounds in dogs present a challenge due to limited local availability of skin for closure and constant exposure to fecal contaminants. This report describes temporary rectal stenting in two dogs following severe perineal wounds. Dog 1 presented with a 4 × 4 cm full-thickness perineal slough secondary to multiple rectal perforations. A 12 mm internal diameter endotracheal tube was placed per-rectum as a temporary stent to minimize fecal contamination. The stent was removed 18 days after placement, and the perineal wound had healed at 32 days post-stent placement, when a minor rectal stricture associated with mild, intermittent tenesmus was detected. Long-term outcome was deemed good. Dog 2 presented with multiple necrotic wounds with myiasis, circumferentially surrounding the anus and extending along the tail. A 14 mm internal diameter endotracheal tube was placed per-rectum. The perineal and tail wounds were managed with surgical debridement and wet-to-dry and honey dressings prior to caudectomy and negative pressure wound therapy (NPWT). Delayed secondary wound closure and stent removal were performed on day six without complication. Long-term outcome was deemed excellent. Temporary rectal stenting may be a useful technique for fecal diversion to facilitate resolution of complex perineal injuries, including rectal perforation.

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.

Fournier's gangrene: Causes, presentation and survival of sixty-five patients

Objective:

To report our experience with Fournier’s Gangrene (FG) over the past eight years and evaluate the predisposing factors which affect the mortality.

Methods:

Sixty-five patients who were admitted to emergency surgical unit of our institution presenting with FG between January 2006 and August 2014 were included. The anatomical site of infective gangrene, predisposing factors, etiological factors, and outcomes were retrospectively reviewed.

Results:

Our cases included 8 women and 57 men. The average age of men was 51±13.9 (range 19-75) and the average age of women was 63±10.5 (range 52-76). Average hospitalization time was 9.2±6.6 days (range 5-25) days. The most frequent comorbid disease was diabetes mellitus and the most frequent etiology was perianal abscess. Colostomy was performed in 11 patients, orchidectomy in two patients, cystostomy in two patients. Notably, all of the 8 (12.3%) patients who died from FG had diabetes and low socioeconomic status. A total of six patients who died required more than one surgical debridement.

Conclusions:

Fournier’s gangrene is a severe surgical emergency, with a high mortality rate. Low socioeconomic status, diabetes and more than one debridement play a major role in mortality and morbidity.

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.

A practitioner's guide to necrotizing fasciitis

Necrotizing fasciitis (NF) is a severe bacterial infection that attacks subcutaneous fat tissues, superficial fascia, deep fascia, and muscle. NF is a rare condition with a mortality that requires nurse practitioners to be adept at identifying signs and symptoms to prompt a quick diagnosis and 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.

The evaluation of microbiology and prognosis of fournier's gangrene in past five years

OBJECTIVES

Fournier's gangrene (FG) is an devastating disease that affects the perineum and genitourinary region, and is commonly a result of poly-microbial infection. This study is aimed to determine the correlation between micrology and prognosis of FG in the past five years.

METHODS

This study was a retrospective cohort study that was designed to study the trends in micrology and prognosis of FG. From the PubMed database, articles published in the recent 5 years (from Jan1(st), 2009 to Dec 31(st), 2013) were reviewed. A total of 19 articles (each with n > 30 and with thorough data descriptions in the topic of Fournier's gangrene), were enrolled in this study. The consolidated data was further analyzed by commercial statistical software (SPSS for Windows).

RESULTS

The twenty-two studies have covered FG cases from year 1981 to 2011, with a mean duration of 9.2 years. The total number of cases is 4,365. Majority of the cases are male (84.1%). The mean age and mortality rate is 51.8 ± 5 years old and 11.1 ± 8.9%, respectivly. The most commonly found pathogen is poly-microbial organism (54%), followed by Escherichia coli (46.6%) and Streptococcus (36.8%). The major risk factors are diabetes (43.7%), Body mass index of > 30 (40.7%), and hypertension (38.1%). Mortality rate in older patient group (age > 51.8 years old) is significantly higher than those of the younger group (22% vs. 5.5%, p = 0.0001).

CONCLUSIONS

Older patients with genital or perineal pain should be examined for crepitus dermis. When a patient is diagnosed with FG, swift consultation with surgeons and administration of broad-spectrum antibiotics are required in order to save the patient's live.

Xenogenic (porcine) Acellular Dermal Matrix Promotes Growth of Granulation Tissues in the Wound Healing of Fournier Gangrene

This article investigates the application values of Xenogenic (porcine) acellular dermal matrix (XADM) in preparation of a Fournier gangrene wound bed. Thirty-six consecutive cases of patients with Fournier gangrene between 2002 and 2012 were enrolled in our department of our hospital. The patients were divided into two groups according to different methods of wound bed preparation after surgical débridement, including the experimental group (17 cases) and the control group (19 cases). The wounds in the experimental group were covered with XADM after surgical wound débridement, whereas the wounds were cleaned with hydrogen peroxide and sodium hypochlorite solution (one time/day) in the control group. The wound bed preparation time and hospital stay were then compared in the two groups. The wound preparation time was 13.64 ± 1.46 days and hospitalization period was 26.06 ± 0.83 days in the experimental XADM group. In the control group, the wound bed preparation time and hospitalization period were 22.37 ± 1.38 and 38.11 ± 5.60 days, respectively. The results showed statistical differences between these two groups. When used in wound débridement after Fournier gangrene, XADM protects interecological organizations, promotes the growth of granulation tissues, and maximally retains function and morphology of the perineum and penis.

The evaluation of microbiology and prognosis of fournier's gangrene in past five years

OBJECTIVES

Fournier's gangrene (FG) is an devastating disease that affects the perineum and genitourinary region, and is commonly a result of poly-microbial infection. This study is aimed to determine the correlation between micrology and prognosis of FG in the past five years.

METHODS

This study was a retrospective cohort study that was designed to study the trends in micrology and prognosis of FG. From the PubMed database, articles published in the recent 5 years (from Jan1(st), 2009 to Dec 31(st), 2013) were reviewed. A total of 19 articles (each with n > 30 and with thorough data descriptions in the topic of Fournier's gangrene), were enrolled in this study. The consolidated data was further analyzed by commercial statistical software (SPSS for Windows).

RESULTS

The twenty-two studies have covered FG cases from year 1981 to 2011, with a mean duration of 9.2 years. The total number of cases is 4,365. Majority of the cases are male (84.1%). The mean age and mortality rate is 51.8 ± 5 years old and 11.1 ± 8.9%, respectivly. The most commonly found pathogen is poly-microbial organism (54%), followed by Escherichia coli (46.6%) and Streptococcus (36.8%). The major risk factors are diabetes (43.7%), Body mass index of > 30 (40.7%), and hypertension (38.1%). Mortality rate in older patient group (age > 51.8 years old) is significantly higher than those of the younger group (22% vs. 5.5%, p = 0.0001).

CONCLUSIONS

Older patients with genital or perineal pain should be examined for crepitus dermis. When a patient is diagnosed with FG, swift consultation with surgeons and administration of broad-spectrum antibiotics are required in order to save the patient's live.

Fournier's Gangrene as a Postoperative Complication of Inguinal Hernia Repair

Fournier's gangrene is the necrotizing fasciitis of perianal, genitourinary, and perineal regions. Herein, we present a case of scrotal Fournier's gangrene as a postoperative complication of inguinal hernia repair. A 51-year-old male with giant indirect hernia is presented. Patient underwent inguinal hernia repair, and after an unproblematic recovery period, he was discharged. He applied to our outpatient clinic on the fifth day with swollen and painful scrotum and it turned out to be Fournier's gangrene. Polypropylene mesh was not infected. Patient recovered and was discharged after repeated debridements. Basic principles in treatment of Fournier's gangrene are comprised of initial resuscitation, broad-spectrum antibiotics therapy, and early aggressive debridement. In the management of presented case, aggressive debridement was made right after diagnosis and broad-spectrum antibiotics were given to the hemodynamically stable patient. In these circumstances, the important question is whether we could prevent occurrence of Fournier's gangrene.

Management of necrotizing skin and soft tissue infections

Although rare, necrotizing skin and soft tissue infections can be devastating infections that are difficult to diagnose and challenging to manage. Clinical presentation is often insidious, and a low index of suspicion is critical. Various diagnostic tools, such as scoring systems or imaging techniques, have been introduced, but none is convincingly superior to sound clinical judgment. Early diagnosis allows early adequate therapy that includes antibiotic therapy, critical care support, specific interventions such as intravenous immunoglobulin in selected patients and, most importantly, early source control. Empirical antibiotic therapy should cover a broad range of both Gram-negative and Gram-positive aerobic and anaerobic microorganisms, and clindamycin is recommended when group A Streptococcus is a suspected pathogen.

Fournier's gangrene caused by Actinomyces funkei, Fusobacterium gonidiaformans and Clostridium hathewayi

We report the first case of Fournier's gangrene caused by three unusual anaerobic organisms: Actinomyces funkei, Fusobacterium gonidiaformans and Clostridium hathewayi. The infection occurred in a 73-year-old man without typical risk factors for the development of Fournier's gangrene. Clinical outcome was good after prolonged antibiotic treatment and extensive debridement of the perineum. The case suggests that A. funkei, F. gonidiaformans and C. hathewayi should be considered as potential pathogens of Fournier's gangrene. Human infections caused by these organisms are very rare but can be underestimated because correct identification is very difficult, especially in polymicrobial infections such as Fournier's gangrene.

Fournier’s gangrene: outcome analysis of 62 consecutive cases

Objectives:

The objective of this article is to study the outcome of management of 62 consecutive cases of Fournier’s gangrene (FG).

Patients and methods:

We conducted an observational study of all cases of FG admitted to the Urology and General Surgery departments of Farwaniya Hospital, Kuwait, between 2004 and 2013. We recorded the laboratory and clinical findings on admission. Operative and postoperative data were also recorded.

Results:

Our study included 62 cases of FG. Patients were divided into two groups: Group A (survival) consisted of 55 cases and Group B (mortality) of seven cases. The mean duration of symptoms before admission was significantly longer in the mortality group (3.86 days versus 1.96 days in survival group) ( p < 0.05). The mean duration of symptoms until time of first debridement was also significantly longer in the mortality group (4.39 days versus 2.35 days in survival group) ( p < 0.05). There was also a statistically significant difference between the two groups regarding the percentage of the affected area in relation to total body surface area (4.6% in Group A versus 8% in Group B) ( p < 0.05). The Fournier Gangrene Severity Index score (FGSI) was significantly higher in Group B (10.26) in comparison to Group A (6) ( p < 0.01). The mean duration of hospital stay was significantly higher in the survival group (22.24 days versus 14.28 days) ( p < 0.01). Diabetes and renal failure were significantly higher in the mortality group (100% and 57.1% in Group B versus 54.5% and 9.1% in Group A, respectively) ( p < 0.05). The number of patients presenting with severe sepsis was higher in the mortality group (71.4% in Group B versus 12.7% in Group A) ( p < 0.05).

Conclusion:

We concluded that FG is a serious, potentially fatal disease. Higher mortality is related to severe sepsis on admission, renal failure, diabetes, extensive disease involving extra-genital areas and late presentation. A multidisciplinary approach in diagnosis and management of the disease can achieve good outcome with low mortality rate.

[Pathogenesis, classification and diagnosis of necrotizing soft tissue infections]

Necrotizing soft tissue infections are caused by a variety of pathogens and may affect different types of soft tissue. Even today mortality and lethality are very high. The primary symptoms of necrotizing soft tissue infections are local pain out of proportion, swelling, erythema and crepitation in cases of subcutaneous gas. A systemic inflammatory response syndrome (SIRS) is often associated. During the last decades early recognition and initiation of an adequate therapy were able to reduce lethality to an average of 20%. The physical examination remains the diagnostic gold standard and may be supported by typical findings of imaging technologies, e.g. subcutaneous gas on x-rays and laboratory tests. After diagnosis an adequate antibiotic and surgical therapy should be performed immediately.

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.

A multistep approach to manage Fournier's gangrene in a patient with unknown type II diabetes: surgery, hyperbaric oxygen, and vacuum-assisted closure therapy: a case report

INTRODUCTION

Fournier's gangrene is an infectious necrotizing fasciitis of the perineum and genital regions and has a high mortality rate. It is a synergistic infection caused by a mixture of aerobic and anaerobic organisms and predisposing factors, including diabetes mellitus, alcoholism, malnutrition, and low socioeconomic status. We report a case of Fournier's gangrene in a patient with unknown type II diabetes submitted to 24-hour catheterization 15 days before gangrene onset.

CASE PRESENTATION

The patient, a 60-year-old Caucasian man, presented with a swollen, edematous, emphysematous scrotum with a crepitant skin and a small circle of necrosis. A lack of resistance along the dartos fascia of the scrotum and Scarpa's lower abdominal wall fascia combined with the presence of gas and pus during the first surgical debridement also supported the diagnosis of Fournier's gangrene. On the basis of the microbiological culture, the patient was given multiple antibiotic therapy, combined hypoglycemic treatment, hyperbaric oxygen therapy, and several surgical debridements. After five days the infection was not completely controlled and a vacuum-assisted closure device therapy was started.

CONCLUSIONS

This report describes the successful multistep approach of an immediate surgical debridement combined with hyperbaric oxygen and negative pressure wound therapy. The vacuum-assisted closure is a well-known method used to treat complex wounds. In this case study, vacuum-assisted closure treatment was effective and the patient did not require reconstructive surgery. Our report shows that bladder catheterization, a minimally invasive maneuver, may also cause severe infective consequences in high-risk patients, such as patients with diabetes.

Treatment of two cases of Fournier's gangrene and review of the literature

Fournier's gangrene is a rare polymicrobial necrotising soft tissue infection affecting the perineum and scrotum. It is rapidly progressive, destructive and associated with high morbidity and mortality. Management protocol includes prompt diagnosis, early institution of antibiotic therapy and adequate wound debridement, usually requiring multiple operations. Rapid accurate diagnosis is crucial for successful outcome, while early aggressive surgical intervention together with fluid, hemodynamic and nutritional support and broad-spectrum antibiotics are essential to reduce mortality. Dermatologists are often the first specialist consulted. Two cases of Fournier's gangrene are reported in this report. The aim of the report is to underline the importance of an immediate diagnostic approach to save patients, favoured by a close collaboration among dermatologist, surgeon and urologist.

Experience in management of Fournier's gangrene: a report of 24 cases

Fournier's gangrene (FG) is an extremely aggressive and rapidly progressive polymicrobial soft tissue infection of the perineum, anal area or genitalial regions with a high mortality rate. The objectives of this study were to share our experience with the management of this serious infectious disease over the last 15 years. This retrospective study examined 24 patients diagnosed as having FG who were admitted to our hospital between March 1996 and December 2011. The gender, age, etiology, predisposing factors, laboratory findings, treatment modality, hospitalization time and spread of gangrene of the subjects were all recorded and analyzed. The results showed that the mean age of the patients was 48.33 years, the male-to-female ratio was 5:1 and the mortality rate was 20.8% (5/24). The most common predisposing factor was diabetes mellitus in 10 patients (41.6%), followed by alcohol abuse, obesity, neoplasms and immunosuppression. The most common etiology was peri-anal and peri-rectal abscesses (45.8%), followed by lesions of urogenital origin (33.3%) and cutaneous (8.3%) origin. No local pathologies could be identified in 3 (12.5%) patients. The most commonly isolated microorganisms were Escherichia coli (62.5%), followed by Enterococcus, Pseudomonas aeruginosa and Staphylococcus aureus. The median admission Fournier's gangrene severity index (FGSI) score for survivors was 5.63±1.89 against 13.6±3.64 for non-survivors which was designed for predicting the disease severity in the series. Early diagnosis and immediate extensive surgical debridement were significant prognostic factors in the management of Fournier gangrene. Individualized reconstructive modalities for wound coverage were useful in that they repaired the tissue defect and improved the quality of life. We are led to conclude that Fournier's gangrene is a severe condition with a high mortality. The Fournier's gangrene severity index (FGSI) score at admission serves as a good predictor for the disease severity. Early diagnosis, surgical debridement and aggressive fluid therapy are significant prognostic factors in the management of Fournier gangrene. Individualized reconstructive surgery modalities for wound coverage are useful to correct the tissue defect and improve the quality of life.

[Pneumoscrotum as a consequence of long-term ventilation]

A pneumoscrotum due to long-term ventilation is a rare entity. We present the case of a 59-year-old man with adult respiratory distress syndrome (ARDS) and long-term ventilation, who required intensive care and had severe subcutaneous emphysema and a pneumoscrotum. Computed tomography revealed subcutaneous emphysema of the neck, chest, and abdomen, emphysema of the mediastinum, a pneumoperitoneum, pneumoretroperitoneum, and pneumoperineum. A puncture of the scrotum confirmed the diagnosis of a pneumoscrotum. The patient died in the course of progressive ARDS.

Multiple large infected scrotal sebaceous cysts masking Fournier's gangrene in a 32-year-old man

Extensive large sebaceous cysts on the scotum are rare and present a problem only when infected or when cosmesis is deemed unacceptable by the patient. Fournier's gangrene is an infective condition with a high death rate. We describe a case of Fournier's gangrene in a patient masked by multiple large infected scrotal sebaceous cysts. A 32-year-old man with a history of alcohol dependency, cirrhosis and multiple scrotal sebaceous cysts presented with acute scrotal pain and erythema. Necrosis of the area became evident within 12 h of his admission and an emergency surgical debridement was performed. The wound was left open to heal via secondary intention over 4 weeks without complication. Fournier's gangrene is a rapidly progressive condition and early surgical debridement is crucial to achieve satisfactory outcomes. In this case, prompt intervention allowed a large scrotal defect to heal without the need for skin grafting.

Fournier's gangrene: etiology and outcome analysis of 41 patients

INTRODUCTION

Fournier's gangrene (FG) is the necrotizing fasciitis of the perineum and genital area with high mortality.

MATERIALS AND METHODS

A retrospective review included 41 patients diagnosed with FG in our hospitals from 1995 to 2010, divided into survivors and nonsurvivors. We analyzed anamnestic, clinical and laboratory data.

RESULTS

The mortality rate was 36.6% (15/41 patients). Elevated heart and respiratory rates, high serum creatinine, low serum bicarbonate, pre-existing kidney disease, and higher median extent of affected body surface were associated with higher mortality. Severe sepsis on admission and hypotension below 90 mm Hg were also predictive for higher mortality. The median FG severity index (FGSI) score was higher in nonsurvivors (11 compared to 6, p < 0.0001). No cases of testicular necrosis were noted.

CONCLUSION

Besides standard clinical and laboratory parameters included in the FGSI calculation, higher extent of affected body surface area and presence of hypotension on admission were also positively associated with mortality.

Fournier's Gangrene: Conventional Dressings versus Dressings with Dakin's Solution

Purpose. Fournier's gangrene is a fulminant and destructive inflammation of the scrotum, penis, and perineum. The objective of this study was to compare 2 different approaches to wound management after aggressive surgical debridement. Methods. Data from 14 patients with Fournier's gangrene were retrospectively collected (2005–2011). Once the patients were stabilized following surgery, they were treated with either daily antiseptic (povidone iodine) dressings (group I, n = 6) or dressings with dakin's solution (sodium hypochloride) (group II, n = 8). Results. The mean age of the patients was 68.2 ± 7.8 (55–75) years in group I and 66.9 ± 10.2 (51–79) years in group II. Length of hospital stay was 13 ± 3.5 (7–16) days in group I and 8.9 ± 3.0 (4–12) days in group II (P < 0.05). The number and rate of mortality was 1/6 (16.7%) in group I, and 1/8 (12.5%) in group II. Conclusions. The hospitalization time can be reduced with the use of dakin's solution for the dressings in the treatment of FG. Also, dressings with dakin's solution seems to have favorable effects on morbidity and mortality. Consequently dakin's solution may alter the treatment of this disastrous disease by reducing cost, morbidity and mortality.

Gangrène des organes génitaux externes (GOGE): traitement chirurgical et reconstruction plastique

Buts

Présenter notre contribution à la reconstruction chirurgicale de la gangrène des organes génitaux externes (GOGE), selon les lésions.

Matériel et méthodes

Il s’agit d’une étude rétroprospective, portant sur 14 patients traités et guéris dans le service d’urologie du CHU de Cocody à Abidjan, de GOGE entre janvier 2000 et juin 2009.

Résultats

L’âge moyen des patients était de 39 (20–67) ans. Tous étaient des hommes de race noire. Ils présentaient tous un tableau infectieux traité par une réanimation hydroélectrolytique et une triantibiothérapie. Les lésions cutanées observées intéressaient les organes génitaux externes (OGE) dans neuf cas (64,29 %), puis le scrotum et le périnée dans cinq cas (35,71 %). Toutes les lésions cutanées ont été décapées, suivies de pansements locaux. Ainsi, 14 patients (100 %) ont été guéris, complètement cicatrisés, dont trois cas (21,43 %) de lésions scrotales minimes qui ont cicatrisé spontanément à la suite de pansement uniquement, neuf patients (64,29 %) ont cicatrisé à la suite de suture sans tension de la peau scrotale après débridement, décollement, enfin deux patients (14,28 %) avaient cicatrisé après une greffe de peau mince prélevée à la face interne de la cuisse pour plaie périnéopénoscrotale étendue, d’une part, et, d’autre part, pour une perte complète du fourreau pénien. Conclusion: La GOGE est une affection grave, qui réalise, d’une part, une toxi-infection traitée par une réanimation et une triantibiothérapie, d’autre part, des lésions cutanées plus ou moins étendues nécessitant débridement, décapage, pansement, puis une reconstruction chirurgicale plastique qui restaure un environnement pénoscrotal adéquat qui ne compromette pas la qualité des rapports sexuels ainsi que la fonction de reproduction des testicules, surtout chez le sujet jeune.