From the Guidelines
Fournier gangrene is diagnosed through clinical examination and imaging studies like CT scans, and treatment requires immediate surgical debridement and broad-spectrum antibiotics, with a multidisciplinary approach to manage the condition and prevent mortality. The diagnosis of Fournier gangrene is mainly clinical, with signs and symptoms including painful, swollen genitalia with crepitus, foul-smelling discharge, and necrotic tissue, supported by laboratory findings of leukocytosis, elevated C-reactive protein, and abnormal renal function 1. Imaging studies like CT scans help determine the extent of infection, with a sensitivity approaching 90% for the diagnosis of necrotizing soft tissue infections 1.
The treatment of Fournier gangrene includes prompt appropriate antibiotic therapy, hemodynamic support, and early debridement, with early and extensive initial surgical debridement improving survival 1. Broad-spectrum antibiotics should be started empirically, typically including a combination of a carbapenem, vancomycin, and either metronidazole or clindamycin to cover gram-positive, gram-negative, and anaerobic organisms 1. Supportive care includes fluid resuscitation, pain management, nutritional support, and tetanus prophylaxis if needed.
In terms of 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. Negative pressure wound therapy (NPWT) plays an important role in managing soft tissue infections, with multiple advantages when compared to traditional dressings, including increasing blood supply and encouraging migration of inflammatory cells into the wound region 1.
The Fournier’s Gangrene Severity Index (FGSI) is a standard score for predicting outcome in patients with FG, obtained from a combination of physiological parameters at admission, including temperature, heart rate, respiration rate, sodium, potassium, creatinine, leukocytes, hematocrit, and bicarbonate, with a FGSI score above 9 having been demonstrated to be sensitive and specific as a mortality predictor in patients with Fournier’s gangrene 1.
Overall, the aggressive approach to Fournier gangrene is justified by the condition's rapid progression and high mortality rate of 20-40% if not promptly treated, with a multidisciplinary approach to manage the condition and prevent mortality 1.
Some key points to consider in the management of Fournier gangrene include:
- Prompt recognition and treatment are of utmost importance
- Imaging studies like CT scans help determine the extent of infection
- Broad-spectrum antibiotics should be started empirically
- Supportive care includes fluid resuscitation, pain management, nutritional support, and tetanus prophylaxis if needed
- A multidisciplinary approach is needed to manage the condition and prevent mortality
- Negative pressure wound therapy (NPWT) plays an important role in managing soft tissue infections
- The Fournier’s Gangrene Severity Index (FGSI) is a standard score for predicting outcome in patients with FG.
From the Research
Diagnostic Findings
- Fournier gangrene is a clinical diagnosis, but laboratory and radiography investigations can serve as useful adjuncts to expedite surgical management, hemodynamic resuscitation, and antibiotic administration 2.
- Computed tomography (CT) can confirm the diagnosis in equivocal cases, determine the source of infection, and evaluate the disease extent 3, 4.
- CT findings include:
- Asymmetrical fascial thickening
- Soft tissue stranding
- Soft tissue gas
- Collection
- Abscess formation
- Subcutaneous emphysema is the hallmark of Fournier gangrene but is not seen in all cases 4.
Treatment Options
- Emergent surgical debridement of all necrotic tissue is essential for successful treatment 2, 5, 6.
- Broad-spectrum antibiotics are necessary to treat the polymicrobial infection 2, 5, 6.
- Resuscitation with intravenous fluids and vasoactive medications is crucial to manage hemodynamic instability 2.
- Adjunctive therapies such as hyperbaric oxygen and vacuum-assisted closure may be considered in some cases, but their use is limited by the lack of randomized controlled studies 6.
- Unprocessed honey has been suggested as a topical antimicrobial agent for small lesions in uncomplicated patients 6.