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

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.

Continuous veno-venous hemofiltration with oXiris hemofilters for the treatment of Fournier's gangrene: A case report series

Background

Fournier's gangrene (FG) is a severe form of necrotizing fasciitis primarily caused by gram-negative bacteria. FG can rapidly progress to septic shock, resulting in high mortality rates. In the past, the management of the inflammatory response caused by gram-negative bacteria has been limited. Continuous Veno-Venous Hemofiltration with oXiris hemofilters (oXiris-CVVH) has shown promise in adsorbing inflammatory factors and endotoxins, making it an attractive approach for treating FG. This study aims to provide insights into the characteristics of patients with FG and septic shock who have been successfully treated using oXiris-CVVH, based on a series of patient cases.

Results

This study presents the management of 4 cases in the intensive care units of a tertiary hospital in southern China. The use of oXiris-CVVH in patients with septic shock and FG yielded valuable practical insights.

Conclusion

Based on the experience gained from these 4 cases, the utilization of oXiris-CVVH demonstrated potential in reducing the Sequential Organ Failure Assessment (SOFA) score, improving prognosis, and effectively lowering the levels of lactic acid and procalcitonin (PCT) in the blood. Additionally, it facilitated a reduction in the dosage of noradrenaline. Therefore, oXiris-CVVH should be considered as an adjunctive therapy in the treatment of patients with FG and septic shock.

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

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

Fournier's gangrene in a female: A case report

Fournier's gangrene is characterized by an acute necrotic infection. The infection can occur in all parts of the body including the scrotum, penis, or perineum, and is a rare condition that is primarily reported in men and seldom in women. Existing literature suggests that it might be underreported, possibly leading to overlooked cases. Risk factors include diabetes, chronic illness, and trauma. This case involves a 52-year-old female with a 10-year medical history of diabetes mellitus, multiple healed skin lesions all over the body, and dermatitis. The presentation was a perianal swelling, which progressed into an extensive necrotizing soft tissue infection of the perineum, making a diagnosis of Fournier's gangrene. She underwent wide local debridement and was managed with antibiotics in a timely manner. The patient's clinical course and subsequent follow-up were uneventful. Uncontrolled diabetes and dermatitis significantly increase the risk of Fournier's gangrene; therefore, it should be suspected in women with such comorbid conditions. This case highlights the need for increased awareness and vigilance regarding this condition among women.

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.

Temperature-Neutrophils-Multiple Organ Failure Grading as a Prognostic Indicator in Fournier Gangrene

Background: Severity scoring systems are used widely to predict prognosis in managing various diseases and to tailor the treatment of patients in a personalized way, not in a general concept, by making a risk assessment. This study examines the importance of the Temperature-Neutrophils-Multiple Organ Failure (TNM) scoring system, a new scoring system, in evaluating the prognosis in patients with Fournier gangrene (FG). Patients and Methods: Patients who were operated on with the diagnosis of FG in our clinic between 2012 and 2022 were analyzed with a single-center cross-sectional retrospective study design. Demographic data (age, gender), pre-operative evaluation, body temperature, neutrophil ratio, presence of multiple organ failure, TNM score, and post-operative survival data were recorded. The patients were grouped as those with post-operative hospital mortality (group 1) and without (group 2). Results: The study included 167 patients. Twenty-two (13.2%) of the patients were in group 1 and 145 (86.8%) were in group 2. According to the TNM score, the frequency of stage 3-4 was higher in group 1 than in group 2 (p < 0.001). Patients ≥65 years of age had a 4.80 (95% confidence interval [CI], 1.87-12.29) times greater mortality risk than patients <65. Patients with comorbid disease had a 4.56 (95% CI, 1.47-14.14) times greater risk of mortality than patients without. Patients with TNM scores 3-4 had a 9.38 (95% CI, 3.01-29.28) times greater risk of exit than patients with scores 1-2. Conclusions: The TNM system is a new scoring system that is created quickly using simple laboratory and clinical data in patients with FG and is useful in predicting mortality. Therefore, its clinical use will benefit FG and other deep soft tissue infections.

Prognostic determinants and treatment outcomes of Fournier's Gangrene treatment in a resource-limited setting: A retrospective study

BACKGROUND

Fournier's gangrene (FG) is a destructive necrotizing infection with a generally poor prognosis. This study aims to share our experience in handling FG patients in a resource-limited setting and identify prognostic factors for FG mortality.

METHODS

A retrospective study of thirty-six patients diagnosed with FG and treated at our teaching hospital between Jun 2010 to Oct 2022 was conducted. Laboratory and nonlaboratory data and patients' outcomes were gathered. A univariate analysis was computed for identifying prognostic factors for FG mortality.

RESULT

The main age was 68.30 ± 5.61years and most (69.4%) were older than 65 years. The overall survival was 63.9% and the mortality rate was 36.1%. Univariate analysis showed that advanced age (p = 0.02), delayed in hospital presentation (p = 0.024), involvement of larger area (p = 0.001), a history of diabetes mellitus (p < 0.006), end-stage renal disease (p = 0.018), heart failure (p = 0.005), cerebrovascular accident (p = 0.003), liver cirrhosis (p = 0.001), presence of multiple comorbidities (p = 0.001), septic conditions at admission (p = 0.048), need for mechanical ventilation (p = 0.001), hypoalbuminemia (p < 0.001), and elevated blood urea nitrogen (p = 0.002) were found to be risk factors for mortality in patients with FG.

CONCLUSIONS

Fournier's gangrene is a fulminant condition with a high mortality rate, especially in resource-limited settings. In this study, the mortality rate was 36.1%. Advanced age, delayed in hospital presentation, involvement of larger area, a history of diabetes mellitus, end-stage renal disease, heart failure, cerebrovascular accident, liver cirrhosis, presence of multiple comorbidities, septic conditions at admission, need for mechanical ventilation, hypoalbuminemia, and elevated blood urea nitrogen were associated with FG mortality.

Treatment outcome of Fournier's gangrene and its associated factors: A retrospective study

INTRODUCTION

Fournier's gangrene (FG) is a rapidly progressive necrotizing infection that affects the perineal and abdominal regions and is known for its high mortality rate. This study aims to present the practical experience of managing FG patients and identify factors that may affect their clinical outcomes.

MATERIALS AND METHODS

A retrospective study was conducted from April 2009 to December 2020 at General Military Hospital in Sana'a, Yemen including 26 patients who were diagnosed with FG and treated on. Data on demographic characteristics, time to admission, surgical intervention, and treatment outcomes were collected. Univariate analysis was performed to determine factors that affect patient outcomes.

RESULT

The mean age of the patients was 65.77 ± 5.04 years, and 65.4% of them were over the age of 65. Most patients (57.7%) presented after five days of experiencing symptoms, and 65.4% were in septic conditions. Of the patients, 17 (65.4%) survived, and the total mortality rate was 34.6%. Univariate analysis showed that delayed presentation (p = 0.001), a history of diabetes mellitus (p < 0.001), end-stage renal disease (p < 0.001), heart failure (p < 0.001), cerebrovascular accident (p = 0.032), liver cirrhosis (p < 001), presence of multiple comorbidities (p < 001), involvement of lager area (p < 001), septic conditions (p = 0.009), advanced age (p = 0.018), and intensive care unit admission (p = 0.002) were found to be risk factors for mortality in patients with FG.

CONCLUSIONS

FG is a potentially life-threatening medical condition, even with aggressive and specialized treatment. Our study revealed a mortality rate of 34.6%. Factors such as older age, the presence of multiple comorbidities, septic conditions, the abdominal spread of the disease, intensive care unit admission, and delayed presentation contribute to higher mortality rates.

The role of quick Sepsis-related Organ Failure Assessment score as simple scoring system to predict Fournier gangrene mortality and the correlation with Fournier's Gangrene Severity Index: Analysis of 69 patients

Objective

Fournier's gangrene is a rare but life-threatening infection disease with high mortality rate. The quick Sepsis-related Organ Failure Assessment (qSOFA) is a new and simpler scoring system that may identify patients with suspected infection who are at greater risk for a poor outcome. The purpose of this study was to find out role of qSOFA in determining prognosis of Fournier's gangrene patients.

Methods

This study is a case control with retrospective review of Fournier's gangrene patients treated at Hasan Sadikin Hospital from January 2013 to December 2017 who met inclusion criteria. Participants were divided into two groups according to qSOFA score as high qSOFA (2-3) and low qSOFA (0-1).

Results

From 69 patients, the mortality rate was 24.6%. The sensitivity of qSOFA score to predict mortality was 88.2%; the specificity was 94.2%; positive predictive value was 83.3%; negative predictive value was 96.1%; positive likelihood ratio was 15.2; negative likelihood ratio was 0.12; and the area under the receiver operating characteristic curve of qSOFA was 94.2%. There was significant association between qSOFA scale and mortality with p-value of 0.0001. The qSOFA score has strong positive correlation with Fournier's Gangrene Severity Index (p<0.0001, r=0.704).

Conclusion

qSOFA scoring system has a high prognostic value and can be used to determine prognosis of Fournier's gangrene patients.

[Outcome, quality of life and functional assessment after perineal and external genitalia gangrene]

INTRODUCTION

External genitalia gangrene is a well-known uncommon disease; however, mortality remains important. Recent literature focuses on early management. The object of this study was to assess quality of life and disease-specific function, in the medium- and long-term.

METHOD

We evaluated retrospectively adult inpatients with external genitalia gangrene who had a surgical debridement between 2010 and 2020 at CHU de Poitiers. Preoperatory FGSI Score was calculated for patients included. In a second phase, surviving patients at 2020 who had agreed to take part in the follow-up were assessed by clinical examination, and asked to complete Short-Form 36 test and two additional disease-specific questionnaire (USP, IIEF5).

RESULTS

The patients consisted of 33 men. Mean age was 61.18. Eleven patients (33%) died primarily from external genitalia gangrene. Median FGSI score was 6 (1-13). We were able to reach 11 patients (33%) for secondary clinical revaluation. Time before revaluation was 3months to 8years. All parts of SF-36 were significantly low. Mean USP score was 1.27±2.68/4.54±4.43/0.72±1.84. Nine patients (81%) suffered erectile dysfunction without any sexual intercourse possible.

CONCLUSION

Patients with external genitalia gangrene experience severe deterioration of their quality of life. Multidisciplinary healthcare process should systematically be carried out, as so as early screening of vulnerability risks factors, to improve functional outcomes and quality of life.

Bibliometric insights in fournier's gangrene: Research landscapes, turning points, and global trends

Study Design

Bibliometric and visualization analysis.

Objective

To analyze the research landscapes and hotspots of Fournier's gangrene, and reveal the dynamic changes and development trend of research hotspots for the purpose of providing ideas and a basis for clinical and basic research in this field.

Methods

Research datasets were acquired from the Web of Science. The publication years were limited from January 1, 1900 to August 5, 2022. The bibliometric tools CiteSpace (v5.8) and VOSviewer (v1.6) were used to analyze the data and generate visualization knowledge maps. Trends in annual publications, distribution, H-index status, coauthorships status and research hotspots were analyzed.

Results

According to the search strategy, we identified and enrolled 688 publications regarding to Fournier's gangrene. The number of published papers showed an overall upwards trend. The USA was the largest contributor, ranking first in total publications, citations and the H-index. The top 10 most productive institutions were all from the USA. De Simone B and Sartelli M were the most productive authors. There was close cooperation among countries, but the cooperation among institutions and authors had little contact and poor interactivity. The research hotspots included the pathogenesis factors and treatment. All the identified keywords were divided into 14 clusters, and the label of the latest cluster was "empagliflozin". Prognosis and risk factors, emerging treatment methods, and pathogenesis were at the forefront of the Fournier's gangrene field and were predicted to be the next hot topics.

Conclusion

The research of Fournier's gangrene has made some achievements, but the overall research level is still in the primary stage. The academic cooperation between different institutions and authors needs to be strengthened. At the early stage, the mainstream of research was the infected tissue and site, pathogenesis, and diagnosis of disease, while research on newly discovered sodium-glucose cotransporter 2 inhibitor, adjuvant therapy and prognostic factors may be the main directions in the future.

Factors for In-Hospital Mortality in 145 Male Patients with Fournier's Gangrene: A 10-Year Observational Study from a Single Tertiary Referral Center in Indonesia

BACKGROUND Fournier's gangrene (FG) is a potentially fatal necrotizing infection. Due to the rapid progression of the disease, the fatality rate remains high despite advances in therapy. This 10-year observational study from a single tertiary referral center in Indonesia aimed to identify the risk factors for in-hospital mortality from 145 male patients diagnosed with FG. MATERIAL AND METHODS This retrospective cohort study was conducted at one of Indonesia's largest tertiary referral hospitals. The risk factors of in-hospital mortality were analysed using data collected through hospital medical records. All patients diagnosed with FG from January 2012 until December 2021 were included. Outcome measured was sociodemographic factors, comorbidities, laboratory findings, length of stay, culture results, and disease outcome. The microbiological culture was performed on FG lesions isolates. The statistical analysis was conducted using SPSS version 26.0. RESULTS The analysis included 145 male patients with a median age of 52 (IQR, 43-61) years. Of them, 38 (26.20%) patients died. There were more patients with diabetes mellitus (DM) in non-survivor groups compared to survivor groups (76.3% vs 57%, p=0.035). On multivariate analysis, DM and Clostridium perfringens infection were found to be independent factors of in-hospital mortality [adjusted odds ratio (aOR)2.583, 95% confidence interval (CI)=1.061-6.289, aOR 5.982,95% CI=1.241-28.828, respectively]. CONCLUSIONS The mortality rate for FG was considerably high. DM and Clostridium perfringens infection were shown to be independent risk factors for mortality among men.

How likely is septic shock to develop in a patient with Fournier's gangrene? A risk prediction model based on a 7-year retrospective study

Background

Fournier's gangrene (FG) is a rare life-threatening form of necrotizing fasciitis. The risk factors for septic shock in patients with FG are unclear. This study aimed to identify potential risk factors and develop a prediction model for septic shock in patients with FG.

Methods

This retrospective cohort study included patients who were treated for FG between May 2013 and May 2020 at the Sixth Affiliated Hospital, Sun Yat-sen University (Guangzhou, China). The patients were divided into a septic shock group and a non-septic shock group. An L1-penalized logistic regression model was used to detect the main effect of important factors and a penalized Quadratic Discriminant Analysis method was used to identify possible interaction effects between different factors. The selected main factors and interactions were used to obtain a logistic regression model based on the Bayesian information criterion.

Results

A total of 113 patients with FG were enrolled and allocated to the septic shock group (n = 24) or non-septic shock group (n = 89). The best model selected identified by backward logistic regression based on Bayesian information criterion selected temperature, platelets, total bilirubin (TBIL) level, and pneumatosis on pelvic computed tomography/magnetic resonance images as the main linear effect and Na⁺ × TBIL as the interaction effect. The area under the ROC curve of the probability of FG with septic shock by our model was 0.84 (95% confidence interval, 0.78-0.95). The Harrell's concordance index for the nomogram was 0.864 (95% confidence interval, 0.78-0.95).

Conclusion

We have developed a prediction model for evaluation of the risk of septic shock in patients with FG that could assist clinicians in identifying critically ill patients with FG and prevent them from reaching a crisis state.

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.

First Reported Australian case of Fatal Streptococcal Group B Pneumonia (serotype 21) Necrotising fasciitis complicated by Toxic Shock Like Syndrome – A Case report and review

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Group B Streptococcus Pneumonia Necrotising fasciitis (GBSPn NF) is uncommon.

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Only 5 reported cases have been published between 2011 and 2020.

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GBSPn NF has a high mortality.

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GBSPn NF is associated with Toxic like Shock Syndrome.

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Reliance on severity scoring systems could have a deleterious outcome on patients.

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Clinical suspicion and early debridement remain the mainstay of therapy.

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Empirical antibiotics are essential according to local therapeutic guidelines.

Introduction

NF is a life-threatening infection and progressive disease resulting in widespread fulminant tissue destruction. It is rarely caused by Group B Streptococcus pneumonia. Early management with surgical removal of devitalized tissue and urgent antibiotic administration are key therapies.

Aim

The aim of this report is to highlight the importance of atypical microorganisms seen in NF.

Method

A case presentation and cohort summary of reported NF cases secondary to SPN from the year 2011 to 2020.

Results

We report the case of a 67-year-old male, not on immune-suppressive medications, admitted to our intensive care unit with septic shock and multiorgan failure secondary to left leg NF following a 3-week history of cactus prick with an SPN bacteraemia and LRINEC score of 5 on admission. He required multiple surgical debridements and was commenced on appropriate antibiotics. Despite continuous vasopressor supportive therapy, high flux CRRT, and IVIG, our patient died after an 8-day inpatient stay. A 10-year review showed only 5 reported GBSPn NF cases with an associated mortality rate of 40%.

Conclusion

A high clinical suspicion of SPN infections in NF is required to avoid high mortality with early diagnosis and targeted anti-microbial therapy. Severity scores may not align with clinical severity.

Fournier's Gangrene: validation of the severity index

INTRODUCTION

Fournier's gangrene is a serious infection and is considered a major emergency. A complete assessment of the severity factors using a severity score is essential and makes it possible to adapt the therapeutic management.

AIM

Validate Fournier's Gangrene Severity Index and evaluate its benefits in the initial assessment of disease severity.

METHODS

This is a retrospective, monocentric study which gathered all the cases of perineal gangrene that were managed in General Surgery Department of Habib Bougatfa Hospital in Bizerte over a period of 8 years. The primary endpoint in our study was mortality.

RESULTS

Thirty-five cases of Fournier's gangrene were collected. The average age of our patients was 46 years. Mortality rate was 23%. We calculated the Fournier's Gangrene Severity Index for 22 patients. There was a significant difference in the average Fournier's Gangrene Severity Index score between the group of surviving patients (3.75) and the group of deceased patients (12.63) (p 9.5 (sensitivity 87.5%, specificity 100%), we noted that the mortality rate was significantly higher in the group with a score> 10 (100%) than in the group with a score ≤ 9 (6%) (p.

Are there factors in the disease of peroneal necrotizing fasciitis which should be used when choosing the anesthetic technique?: Descriptive analysis of a cohort from two centers

BACKGROUND

This study aims to examine the factors affecting the selection of anaesthesia method in Fournier's gangrene.

METHODS

A retrospective evaluation was made of 113 patients operated on because of Fournier's gangrene between January-May 2019. The operations were performed under spinal anaesthesia in 78 cases (Group S) and under general anaesthesia in 35 cases (Group G). The patients were evaluated regarding age, gender, the anaesthesia method used (spinal, general) anaesthetic agent applied, presence of sepsis, and biochemical, hematological and inflammatory parameters.

RESULTS

When the patients were evaluated regarding the Fournier Gangrene Severity Index (FGSI), patients in Group S had lower scores (p=0.001). Examination of the tomography images revealed that in 13 (37.1%) patients, air values were seen in the right or left gluteal area, or both, extending to the subcutaneous tissue. In the evaluation of the factors affecting the selection of general anaesthesia, a positive correlation was determined between an increase in FGSI (r=0.482, p=0.001) and the presence of sepsis (r=0.485, p=0.001) and gluteal region involvement (r=0.628, p<0.001).

CONCLUSION

The selection of anaesthesia method in Fournier gangrene patients is a complex process affected by factors, such as the patients' general condition, sepsis, and whether or not there is bleeding diathesis. The risk -benefit balance in the selection of anaesthesia method should be evaluated individually for patients.

Sodium-Glucose Cotransporter 2 Inhibitor Use Associated With Fournier's Gangrene: A Review of Case Reports and Spontaneous Post-Marketing Cases

BACKGROUND

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are effective for glycemic control and have demonstrated cardiorenal benefits. The U.S. Food and Drug Administration (FDA) released a boxed warning in 2018 regarding the potential development of Fournier's gangrene (FG) with the use of SGLT2 inhibitors. FG is a serious perineal infection with a mortality rate of up to 88% in some cases.

OBJECTIVES

To report spontaneous post-marketing cases from the FDA Adverse Event Reporting System (FAERS) database and case reports from the literature of FG associated with the use of SGLT2 inhibitors and to determine whether correlations exist with specific agents.

METHODS

A search of the FAERS database was conducted to identify reported cases of FG associated with the use of any FDA-approved SGLT2 inhibitor between 1 March 2013 and 30 June 2020. Additionally, a literature search was conducted of PubMed, Embase, and the Cochrane library using PRISMA guidelines to identify case reports of FG with the use of SGLT2 inhibitors up to 9 October 2020.

RESULTS

A total of 491 cases from the FAERS database were included for review. Descriptive analysis depicted more cases in the empagliflozin, canagliflozin, and dapagliflozin groups than in the ertugliflozin group. Nine case reports were included from the literature review; four attributed to dapagliflozin, three to empagliflozin, and two to canagliflozin. The median ages from cases reported in the FAERS database and from the literature review were 54 and 52 years, respectively. In both datasets, males had a higher incidence of FG than females. Additional data reported include clinical outcomes and concomitant antihyperglycemic medications.

CONCLUSION

Consistent findings are noted in this systematic review and warrant further investigation to elucidate the association between SGLT2 inhibitor use and the development of FG. These results may drive enhanced prescribing patterns to consider patient-specific risk factors and timely monitoring, especially as more indications are approved related to these medications' cardiorenal protective properties.

Necrotizing fasciitis of cryptoglandular infection treated with multiple incisions and thread-dragging therapy: A case report

BACKGROUND

Necrotizing fasciitis is a fulminant necrotizing soft tissue disease with a high fatality rate. It always starts with impact on the deep fascia rapidly and might result in secondary necrosis of the subcutaneous tissue, fascia, and muscle. Thus, timely and multiple surgical operations are needed for the treatment. Meanwhile, the damage of skin and soft tissue caused by multiple surgical operations may require dermatoplasty and other treatments as a consequence.

CASE SUMMARY

Here, we report a case of 50-year-old male patient who was admitted to our hospital with symptoms of necrotizing fasciitis caused by cryptoglandular infection in the perianal and perineal region. The symptoms of necrotizing fasciitis, also known as the cardinal features, include hyperpyrexia, excruciatingly painful lesions, demonstration gas in the tissue, an obnoxious foul odor and uroschesis. The results of postoperative pathology met the diagnosis. Based on the premise of complete debridement, multiple incisions combined with thread-dragging therapy (a traditional Chinese medicine therapy) and intensive supportive therapies including comprising antibiotics, nutrition and fluids were given. The outcome of the treatment was satisfactory. The patient recovered quickly and achieved ideal anal function and morphology.

CONCLUSION

Timely and effective debridement and multiple incisions combined with thread-dragging therapy are an integrated treatment for necrotizing fasciitis.

Fournier's Gangrene in Patients with Oncohematological Diseases: A Systematic Review of Published Cases

Patients suffering from hematological malignancies are at increased risk of Fournier's gangrene (FG) due to immunosuppression caused by the disease itself or by disease-related treatments. A systematic review of PubMed, ISI Web of Knowledge, and Scopus databases was performed in June 2021. We included full papers that met the following criteria: original research, human studies, and describing clinical presentation, treatment, and outcomes of FG in patients with oncohematological diseases. We identified 35 papers published from 1983 to 2021 involving 44 patients (34 males, 8 females) aged between 4 days and 83 years. The most common malignant hematological disorders were acute myeloid leukemia (n = 21) and acute lymphocytic leukemia (n = 9). In 10 patients FG represented the first presentation of hematological malignancy. Scrotum (n= 27) and perineum (n = 11) were the sites most commonly involved. Pseudomonas aeruginosa (n = 21) and Escherichia coli (n = 6) were the most commonly isolated microorganisms. Surgery was performed in 39 patients. Vacuum-assisted closure and hyperbaric oxygen therapy were adopted in 4 and in 3 patients, respectively. Recovery was achieved in 30 patients. FG-related mortality was observed in 11 patients. FG should be carefully considered in patients with oncohematological diseases.

Prognostic factors for mortality in 123 severe cases of necrotizing fasciitis in 5 hospitals in the Netherlands between 2003 and 2017

Purpose

Necrotizing fasciitis (NF) is a severe soft tissue infection with a high morbidity and mortality. With early diagnosis and treatment this could be reduced. Unfortunately, the diagnosis of necrotizing fasciitis can be very difficult. In recent years many risk factors have been identified. In 2004, the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was developed. A tool that could help diagnosing NF. In this study, we search for prognostic factors for mortality in necrotizing fasciitis.

Methods

All adult patients with histopathological or surgical confirmed NF needed to be admitted to the intensive care unit for at least 24 h between January 2003 and December 2017 in five hospitals from the Nijmegen teaching region were included. We excluded patients with other forms of soft tissue infections or patients with an intensive care unit (ICU) stay of < 24 h because we exclusively wanted to include patients with a fulminant course of necrotizing fasciitis.

Results

We have included 123 cases. The overall mortality was 31.7% (N = 39). The overall mean LRINEC score was 7.4 ± 2.7. Patients who died as the result of NF had a significantly higher median LRINEC score (8 vs. 7, p = 0.034). Other parameters found to be associated with mortality are age ≥ 60 years, cardiovascular disease in the medical history, ≥ 2 comorbidities, and lactate level greater than 1.7 mmol/L.

Conclusion

LRINEC score should be calculated in all patients presenting with NF to provide an additional source for clinical outcome. A high LRINEC score could implicate a higher risk of mortality. Especially in elderly patients, with a cardiac history, more than two comorbidities or a lactate level greater than 1.7 mmol/L.

Necrotizing Soft Tissue Infection: A Single-Center Retrospective Study of Treatment and Outcomes

Introduction

Necrotizing fasciitis is a severe inflammatory disease of the body's soft tissue characterized by spreading rapidly and high mortality. Rapid surgical intervention along with other supportive measures of treatment have a great impact on the outcome of treatment.

Material and methods

This study was conducted by a retrospective medical record review of all patients with a microbiologically and clinically confirmed diagnosis of necrotizing fasciitis who were admitted to the general surgery department at the General Hospital Novi Pazar, Serbia, during the period between 2017 and 2020. Demographic, clinical, laboratory, and microbiology data were analyzed.

Results

A total of 13 cases were identified, which represents 0.21% of the total number of patients treated at the surgical department during the period January 2017 to November 2020. The mean age of patients was 55 years, with a male/female ratio of 1:1.6. All of them had at least one comorbidity and more than half had three or more. Diabetes, cardiovascular diseases, and obesity were the most common comorbidities. The most common causes of infection were Klebsiella spp, Pseudomonas aeruginosa, S. pyogenes, and S. aureus. All patients received multiple surgical interventions (mean 2.3).

Conclusion

Treating necrotizing fasciitis requires a multidisciplinary approach. Early diagnosis and rapid clinical response allow for better disease outcomes. Getting to know more about necrotizing fasciitis will help doctors make better decisions when treating it.

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.

Fournier gangrene: pictorial review

Fournier gangrene is an emergency condition that is associated with a high mortality rate. It is defined as a rapidly progressing infective necrotizing fasciitis of the perineal, perianal, and genital regions. Early diagnosis, broad-spectrum antibiotic coverage, and adequate surgical debridement are crucial and lead to better prognosis and patient survival. There is increasing utilization of computed tomography (CT) in the initial evaluation of Fournier gangrene. CT can confirm the diagnosis in equivocal cases, determine the source of infection, and evaluate the disease extent. In this pictorial review, we discuss the pathogenesis of Fournier gangrene and display the imaging spectrum with an emphasis on CT findings, including asymmetrical fascial thickening, soft tissue stranding, soft tissue gas, collection, and abscess formation. The infection originating from colorectal pathology, the affected anatomy, and the involvement of the abdominal wall are important predictors of mortality. The familiarity of the varied imaging appearance of Fournier gangrene is necessary to provide an accurate diagnosis, and evaluation of disease extent is crucial for optimal surgical debridement.

Fournier's gangrene - challenge for surgeon

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSIONS

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

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

INTRODUCTION

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Obesity Is Not an Independent Predictor of Necrotizing Soft Tissue Infection Outcomes

Background: Necrotizing soft tissue infections (NSTIs) are a group of rapidly progressive infections of the skin and its underlying tissue. These infections result in substantial morbidity and mortality. The focus of this study was to determine if obesity is associated with a worsened clinical outcome or prolonged hospital course for patients with NSTIs. Patients and Methods: We conducted a retrospective chart review of patients with NSTI presenting to a single tertiary hospital. Fat content, measured with body mass index (BMI) and abdominal fat thicknesses, including subcutaneous and visceral fat, were compared against primary and secondary outcomes of NSTIs. Results: We found that women had a higher mortality rate compared with men (27% vs. 15% mortality). Women also had an increased subcutaneous abdominal fat thickness (55.7 vs. 36.9 mm, p = 0.028). However, no measurements of fat, BMI, subcutaneous fat, or visceral fat differed between survivors and mortalities of NSTIs. In fact, with the exception of a higher BMI in those who developed acute kidney injury (AKI, p = 0.034), we found no correlation between increases in fat measurement and secondary outcome, including propensity to develop sepsis during hospitalization, length of hospital stay, length of intensive care stay, or antibiotic usage. Multivariable logistic regression analysis was conducted, and we found no statistically significant differences in primary or secondary outcomes. Conclusion: Women appear to have a higher mortality in NSTI, although the reasons for this are unclear. Obesity, as measured by BMI, subcutaneous, and visceral fat thicknesses, does not appear to be an independent risk factor.

Fournier's gangrene mortality: A 17-year systematic review and meta-analysis

BACKGROUND

To provide better management of Fournier's gangrene, mortality-associated comorbidities and common etiologies were identified.

METHODS

A systematic search was conducted using 12 databases, followed by meticulous screening to select relevant articles. Meta-analysis and meta-regression (for possible cofounders) were both done for all possible outcomes.

RESULTS

Out of 1186 reports screened, 38 studies were finally included in the systematic review and meta-analysis. A higher risk of mortality was detected in patients with diabetes, heart disease, renal failure, and kidney disease, with risk ratios (RR) and 95% confidence intervals (95% CI) of 0.72 (0.59-0.89), 0.39 (0.24-0.62), 0.41 (0.27-0.63), and 0.34 (95% CI 0.16-0.73), respectively. However, there was no association between mortality rates and comorbid hypertension, lung disease, liver disease, or malignant disease (p > 0.05). The highest mortality rates were due to sepsis (76%) and multiple organ failure (66%), followed by respiratory (19.4%), renal (18%), cardiovascular (15.7%), and hepatic (5%) mortality.

CONCLUSIONS

Modifications to the Fournier's Gangrene Severity Index (FGSI) are recommended, in order to include comorbidities as an important prognostic tool for FG mortality. Close monitoring of the patients, with special interest given to the main causes of mortality, is an essential element of the management process.

Japan Gastroenterological Endoscopy Society guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection

Suitable lesions for endoscopic treatment include not only early colorectal carcinomas but also several types of precarcinomatous adenomas. It is important to establish practical guidelines wherein preoperative diagnosis of colorectal neoplasia and selection of endoscopic treatment procedures are appropriately outlined and to ensure that actual endoscopic treatment is useful and safe in general hospitals when carried out in accordance with guidelines. In cooperation with the Japanese Society for Cancer of the Colon and Rectum, the Japanese Society of Coloproctology, and the Japanese Society of Gastroenterology, the Japan Gastroenterological Endoscopy Society compiled colorectal endoscopic submucosal dissection/endoscopic mucosal resection guidelines by using evidence-based methods in 2014. The first edition of these guidelines was published 5 years ago. Accordingly, we have published the second edition of these guidelines based on recent new knowledge and evidence.

Fournier's Gangrene and Intravenous Drug Abuse: an Unusual Case Report and Review of The Literature

Fournier's gangrene is a potentially fatal emergency condition characterized by necrotizing fasciitis and supported by an infection of the external genital, perineal and perianal region, with a rapid and progressive spread from subcutaneous fat tissue to fascial planes. In this case report, a 52-year-old man, with a history of hepatitis C-virus (HCV)-related chronic liver disease and cocaine use disorder for which he was receiving methadone maintenance therapy, was admitted to the Emergency Department with necrotic tissue involving the external genitalia. Fournier's gangrene is usually due to compromised host immunity, without a precise cause of bacterial infection; here it is linked to a loco-regional intravenous injection of cocaine. A multimodal approach, including a wide surgical debridement and a postponed skin graft, was needed. Here we report this case, with a narrative review of the literature.

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.

Scrotal Ultrasound

Ultrasound is the imaging modality of choice to evaluate the scrotum because of its high resolution, Doppler capabilities, availability, and lack of ionizing radiation. Acute urologic emergencies diagnosed with ultrasound include testicular torsion, testicular rupture, and Fournier gangrene. The radiologist's knowledge of sonographic features of vascular, infectious, traumatic, and benign and malignant processes that occur in the scrotum coupled with the patient's presenting symptoms, age, and physical examination allows for the correct diagnosis of a wide spectrum of scrotal pathology.

Recognizing Fournier's Gangrene in the Emergency Department

Fournier's gangrene is a rare disease with a significant mortality rate. The potentially fatal disease stems from both aerobic and anaerobic bacteria and primarily occurs in men. The majority of Fournier's gangrene cases are idiopathic or derived from perineal and genital skin infections. Comorbid risk factors include diabetes mellitus, alcohol misuse, and immunosuppression (). The infection initially presents as a cellulitis in the perineum or perianal area. As Fournier's gangrene progresses, the infected tissue becomes swollen, significantly painful, and necrotic. The progression of infection can lead to systemic symptoms, sepsis, and death. Early intervention is a key component in the treatment plan for Fournier's gangrene. The primary intervention is surgical debridement of the necrotic tissue. If an abscess is present, incision and drainage are indicated. In addition to surgical debridement, the administration of broad-spectrum antibiotics and hemodynamic stabilization are required (). Complications after treatment include chronic pain, sexual dysfunction, decreased sensation of the penile skin, and scarring ().

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

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

Fournier Gangrene: Association of Mortality with the Complete Blood Count Parameters

BACKGROUND

The authors studied the alterations in mean platelet volume, neutrophil-to-lymphocyte ratio, and red blood cell distribution width values together with the platelet count in hospitalized patients diagnosed with Fournier gangrene to determine their association with disease prognosis.

METHODS

Records of patients diagnosed with Fournier gangrene were analyzed retrospectively.

RESULTS

Seventy-four patients (49 men and 25 women) with a mean age of 57.60 ± 15.34 years (range, 20 to 95 years) were included. Sixty-eight participants were discharged and six died during follow-up. In the discharged group, during hospitalization, there was a trend downward in neutrophil-to-lymphocyte ratio and mean platelet volume values, whereas platelet count increased significantly. In the nonsurvivor group, the neutrophil-to-lymphocyte ratio and mean platelet volume after first débridement and at the end of hospitalization were significantly higher; platelet counts at admission, after the first débridement, and at the end of hospitalization were significantly lower compared with the survivor group (p < 0.05). In correlation analysis, mortality rate was negatively correlated with platelet count at admission and after first débridement and positively correlated with the neutrophil-to-lymphocyte ratio and mean platelet volume after first débridement. Regarding the receiver operating characteristic curve analyses, a platelet count of 188,500/µl at admission and 196,000/µl after the first débridement, a neutrophil-to-lymphocyte ratio of 13.71, and a mean platelet volume of 9.25 fl after the first débridement were defined as the cutoff levels having the best sensitivities and specificities.

CONCLUSIONS

This study suggests that platelet count at admission and platelet count, mean platelet volume, and neutrophil-to-lymphocyte ratio after first débridement and during discharge may be included among the prognostic scores of Fournier gangrene. The authors defined some threshold values that can be used during patient follow-up. Larger prospective studies are warranted to determine the exact role of those parameters in the prognosis of Fournier gangrene.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Necrotizing Fasciitis: An Overview and 2 Illustrative Cases

Necrotizing fasciitis is the generic term for a series of progressive gangrenous infections of the skin and subcutaneous tissues. Typically, necrotizing fasciitis start with an, often small, infected lesion with atypical symptoms, which then quickly develops into a rapidly spreading, massive infection. The primary therapy is excision of all necrotic tissue in combination with treatment of systemic symptoms such as shock. The defects resulting from rigorous excision are often very large. Once they are clean, they require closure with an autograft. This article reviews the symptoms and treatment of necrotizing fasciitis. In addition, it illustrates, with 2 cases, how a hyaluronic-based extracellular matrix can be used to "fill in" with neodermis for the lost dermis and can create a wound bed most suitable for grafting.

Fournier's gangrene: prospective study of 34 patients in South Indian population and treatment strategies

Introduction

Fournier's gangrene (FG) is a fulminant necrotizing fasciitis of the perineum and genitalia. The objective of this study was to study the etiology and microbiology associated with FG and to study the debridement and reconstructive procedures required in these patients.

Methods

This was a prospective follow up study conducted from September 2011 to November 2012 at Coimbatore medical college hospital, Coimbatore, India. Patients presenting to the outpatient department and emergency department with the clinical diagnosis of FG were included in the study.

Results

A total of 34 patients were studied in the study period. The mean age of presentation in years was 50±11.13. The male to female ratio was 33:1. The source of the infection was most commonly anorectal. Diabetes mellitus was the most common co morbid factor associated. Most commonly the disease was polymicrobial with escherichia coli being the commonest grown organism. The average number of wound debridement required was 2.9±1.42. Primary closure of the scrotal skin defect was the most common reconstructive procedure performed. Mortality associated with the disease in our series was 11.8%.

Conclusion

Although FG is a relatively rare disease, it is still prevalent in Indian population. Incidence of FG in HIV patients is high, even though it is not the commonest of the co morbid condition. The mortality can be kept to minimal with aggressive medical and surgical management. Extensive raw area following the infection and wound debridement can be managed by simple reconstructive procedures with good outcome.

Fatal Acinetobacter baumanii Necrotizing Fasciitis following Open Reduction Internal Fixation in a Polytrauma Patient

Necrotizing fasciitis is an uncommon and potentially fatal infection that can affect the epidermis, dermis, and more commonly the subcutaneous, fascia, and muscle layers. NF is usually caused by toxin-producing bacteria with a relatively fast progression associated with severe surrounding tissue destruction. Early diagnosis and management are crucial factors for survival. Broad-spectrum antibiotics along with surgical debridement, sometimes multiple, are needed in order to stop or slow down the progression of NF. Despite optimal care, necrotizing fasciitis remains a highly morbid condition with a high mortality rate. We present a case of a 28-year-old male patient with rapidly developing fatal A. baumannii associated with necrotizing fasciitis, after open reduction and internal fixation (ORIF) of multiple fractures after polytrauma.

Profile of patients with Fournier's gangrene and their clinical evolution

OBJECTIVE

to analyze the profile of patients with Fournier's gangrene treated in a public tertiary hospital in western Paraná State.

METHODS

we conducted a cross-sectional, retrospective and descriptive study of patients with Fournier's gangrene treated between January 2012 and November 2016.

RESULTS

there were 40 patients with Fournier's gangrene treated in the period, 29 (72.5%) men and 11 (27.5%) women. The mean age was 51.7±16.3 years. The mean time of disease progression, from the initial symptom to hospitalization, was 10.5±1.2 days. All patients had clinical signs such as pain, bulging, erythema, among others, and 38 (95%) had associated comorbidities, the most common being type 2 diabetes mellitus and systemic arterial hypertension. The majority (30 patients - 75%) had perianal abscess as the probable etiology. All patients were submitted to antibiotic therapy and surgical treatment, with a mean of 1.8±1.1 surgeries per patient. Nine (22.5%) patients died. There was a strong correlation between the presence of sepsis on admission and mortality.

CONCLUSION

Fournier's gangrene patients in this series had a long disease duration and a high prevalence of comorbidities, with a high mortality rate.

Early Diagnosis and Surgical Treatment for Necrotizing Fasciitis: A Multicenter Study

Background

Necrotizing fasciitis (NF) is a group of relatively rare infections, usually caused by two or more pathogens. It affects the skin and subcutaneous tissues of lower and upper limbs, perineal area (Fournier’s gangrene), and the abdominal wall. Early diagnosis and aggressive surgical management are of high significance for the management of this potentially lethal disease.

Methods

We conducted a retrospective study in patients who presented, during the last decade, at four University Surgical Departments in the area of Athens, Greece, with an admission diagnosis of NF. Demographic, clinical, and laboratory data were gathered, and the preoperative and surgical treatment, as well as the postoperative treatment was analyzed for these patients.

Results

A total of 62 patients were included in the study. The mean age of patients was 63.7 (47 male patients). Advanced age (over 65 years) (P < 0.01) and female sex (P = 0.04) correlated significantly with mortality. Perineum was the mostly infected site (46.8%), followed by the lower limbs (35.5%), the upper limbs, and the axillary region (8.1%). Diabetes mellitus was the most common coexisting disease (40.3%), followed by hypertension (25.8%) and obesity (17.7%). The most common symptom was local pain and tenderness (90.3%). Septic shock occurred in eight patients (12.9%) and strongly correlated with mortality (P < 0.01). Laboratory data were used to calculate the LRINEC score of every patient retrospectively; 26 patients (41.9%) had LRINEC score under 6, 20 patients (32.3%) had LRINEC score 6–8, and 16 patients (25.8%) had LRINEC score >9. Surgical debridement was performed in all patients (mean number of repeated debridement 4.8), and in 16 cases (25.8%) the infected limb was amputated. The mean length of hospital stay was 19.7 days, and the overall mortality rate of our series was 17.7%.

Conclusion

Diagnosis of NF requires high suspect among clinicians, as its clinical image is non-specific. Laboratory tests can depict the severity of the disease; therefore, they must be carefully evaluated. Urgent surgical debridement is the mainstay of treatment in all patients; the need of repetitive surgical debridement is undisputed.

Fournier's gangrene associated with chronic kidney disease in a dog

A dog was diagnosed with Fournier's gangrene associated with chronic kidney disease. Clinical features included crepitant scrotal inflammation that spread to the penis; the lesion exhibited liquefactive necrosis or purulent moist gangrene. This is the first description of Fournier's gangrene associated with chronic kidney disease in a dog.