What is the best wound care approach for Fournier's gangrene after surgical debridement?

From the Guidelines

The best wound care approach for Fournier's gangrene after surgical debridement involves aggressive management with frequent dressing changes, antimicrobial therapy, and advanced wound care techniques, as recommended by the 2018 WSES/SIS-E consensus conference 1. After initial debridement, wounds should be cleaned with normal saline or antiseptic solutions like chlorhexidine and dressed with moist gauze or negative pressure wound therapy (NPWT) at -125 mmHg. Some key points to consider in wound care for Fournier's gangrene include:

• Frequent dressing changes, initially 2-3 times daily, then less frequently as healing progresses
• Use of broad-spectrum antibiotics for 7-14 days, such as piperacillin-tazobactam or meropenem, plus vancomycin
• Consideration of hyperbaric oxygen therapy to accelerate healing
• Nutritional support with high-protein supplements and adequate caloric intake
• Pain management with appropriate analgesics
• Serial debridements every 24-48 hours until healthy granulation tissue appears The 2018 WSES/SIS-E consensus conference also recommends early and extensive initial surgical debridement to improve survival, and consideration of fecal diversion in cases with fecal contamination 1. Additionally, the use of negative pressure wound therapy (NPWT) and rectal diversion devices can be effective in managing wound contamination and promoting healing 1. It is also important to note that the treatment of Fournier's gangrene should be tailored to the individual patient, taking into account the extent of the infection, the presence of any underlying medical conditions, and the patient's overall health status. The anorectal emergencies: WSES-AAST guidelines also suggest 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. However, the most recent and highest quality study, the 2018 WSES/SIS-E consensus conference, provides the most up-to-date and evidence-based recommendations for the management of Fournier's gangrene 1.

From the Research

Wound Care Approaches for Fournier's Gangrene

After surgical debridement, various wound care approaches can be employed for Fournier's gangrene. The following are some of the methods that have been studied:

• Vacuum-assisted closure (VAC) therapy: This method has been shown to be effective in improving wound healing and reducing hospital length of stay 2, 3, 4.
• Negative pressure wound therapy (NPWT): This approach has also been used successfully in the management of Fournier's gangrene, particularly in combination with loop colostomy 5.
• Conventional dressings: Daily antiseptic dressings have been compared to VAC therapy, with VAC therapy showing improved outcomes in terms of mortality and hospital length of stay 4.
• Hyperbaric oxygen therapy (HBOT): This treatment has been used as an adjunct to surgical debridement and antibiotic therapy, and has been shown to reduce systemic toxicity and prevent extension of necrosis 6.

Key Considerations

When choosing a wound care approach for Fournier's gangrene, the following factors should be considered:

• The size and extent of the wound: VAC therapy and NPWT may be more effective for larger wounds 2, 3, 4, 5.
• The patient's overall health status: Patients with severe sepsis or other comorbidities may require more intensive treatment, such as HBOT 6.
• The availability of resources: VAC therapy and NPWT may require specialized equipment and trained personnel, while conventional dressings and HBOT may be more readily available in some settings 2, 3, 4, 6, 5.