From the Guidelines
Fournier gangrene requires immediate surgical debridement and broad-spectrum antibiotics, with a recommended empiric antimicrobial therapy including cover for gram-positive, gram-negative, aerobic and anaerobic bacteria, and an anti-MRSA agent, as suggested by the most recent guidelines 1. The treatment of Fournier’s gangrene involves prompt appropriate antibiotic therapy, hemodynamic support, and early debridement, with early and extensive initial surgical debridement improving survival 1.
Key Considerations
- The infection typically results from a polymicrobial synergy of aerobic and anaerobic bacteria entering through breaks in the skin or mucosa, causing rapid tissue destruction through the release of enzymes and toxins.
- Risk factors include diabetes, immunosuppression, obesity, alcohol abuse, and poor hygiene.
- Early recognition and intervention are critical, as mortality rates range from 20-40% despite appropriate treatment.
- Following initial management, patients often require reconstructive surgery and ongoing wound care.
Surgical Approach
- Radical surgery, with complete removal of all visible necrotic tissue, may be sufficient to treat the infection, with a multidisciplinary and tailored approach based upon the extent of perineal involvement, the degree of fecal contamination, and the possible presence of sphincter or urethral damage 1.
- Fecal diversion via colostomy may be considered in severe cases, but its use should be limited to short periods of time to avoid intra-rectal damage due to the device itself.
Antibiotic Regimen
- A typical antibiotic regimen includes a combination of piperacillin-tazobactam 4.5g IV every 6 hours, plus vancomycin 15-20mg/kg IV every 12 hours, and either metronidazole 500mg IV every 8 hours or clindamycin 600-900mg IV every 8 hours to cover aerobic and anaerobic organisms, with adjustments based on culture results 1.
Adjunctive Therapy
- Aggressive fluid resuscitation, pain management, and nutritional support are essential adjuncts to therapy.
- Hyperbaric oxygen therapy may be beneficial in some cases.
- Negative pressure wound therapy (NPWT) plays an important role in managing soft tissue infections, with multiple advantages when compared to traditional dressings, including increased blood supply and removal of exudate, bacteria, and their products 1.
From the Research
Definition and Characteristics of Fournier Gangrene
- Fournier gangrene (FG) is a rare form of necrotizing fasciitis of the perineal, genital, or perianal region 2
- It is characterized by an aggressive course and high mortality rate, over 20% 2
- FG is a synergistic necrotic fasciitis or myositis of genitalia, perineum, and abdominal wall 3
- The infection is often fulminant and can rapidly cause multiple organ failure and death 4
Causes and Risk Factors
- Several etiologic factors have been reported, including microorganisms isolated and co-morbidity factors identified 3
- FG has a strong association with male patients with advanced age and comorbidities affecting microvascular circulation and immune system function, most commonly those with diabetes or alcohol use disorder 4
- Comorbid risk factors include diabetes mellitus, alcohol misuse, and immunosuppression 5
Diagnosis and Treatment
- Immediate and accurate diagnosis decreases mortality rate, which ranges from 3-67% 3
- Aggressive resuscitation and surgical debridement consist of the appropriate treatment 3
- Treatment includes emergent surgical debridement of all necrotic tissue, broad-spectrum antibiotics, and resuscitation with intravenous fluids and vasoactive medications 4
- Early extensive surgical debridement can help reduce the need for further intervention and shorten the hospital stay 6
- Skin grafts and local random flaps could offer versatile and effective reconstructions for most FG cases, while more invasive strategies should be reserved for very few cases 2
Complications and Outcomes
- Complications after treatment include chronic pain, sexual dysfunction, decreased sensation of the penile skin, and scarring 5
- Fournier's gangrene has high mortality rates, with 32.1% complications recorded according to the Clavien Dindo classification, and 6 patients died in the perioperative period 6
- The average duration of antibiotic therapy was 22.0±9.1 days, and the average length of stay was 17.6±11.8 days 6