Management of Gangrene
The management of gangrene requires immediate surgical debridement to remove all necrotic tissue, along with appropriate antibiotic therapy and supportive care. 1
Types of Gangrene and Initial Assessment
- Gangrene can be classified as dry gangrene, wet gangrene (including Fournier's gangrene), or gas gangrene, with each requiring specific management approaches 2
- Diagnosis is based on clinical signs including cutaneous manifestations, erythema, subcutaneous crepitations, patches of necrosis, foul smell, purulence, and tenderness 1
- Imaging (CT, MRI, ultrasound) may help identify extent of soft-tissue involvement but should never delay surgical intervention when clinical suspicion is high 2
- In hemodynamically unstable patients, proceed directly to surgical intervention without waiting for imaging 2
Surgical Management
- Early and aggressive surgical debridement is the cornerstone of treatment and must be performed as soon as possible to halt progression of infection 1, 2
- Complete removal of all necrotic tissue is essential, continuing debridement into healthy-looking tissue 1
- Plan for repeat surgical revisions every 12-24 hours until the patient is completely free of necrotic tissue 2
- For Fournier's gangrene (perineal/genital gangrene), radical surgical debridement of the entire affected area improves survival 1
- A multidisciplinary approach is recommended based on extent of tissue involvement and presence of damage to surrounding structures 2
Antimicrobial Therapy
- Start empiric broad-spectrum antimicrobial therapy as soon as gangrene is suspected 2
- Empiric therapy should cover gram-positive, gram-negative, aerobic and anaerobic bacteria, including MRSA 2
- Obtain microbiological samples during the initial debridement to guide targeted antibiotic therapy 1, 2
- In the absence of a definitive etiologic diagnosis, use broad-spectrum treatment with vancomycin plus either piperacillin-tazobactam, ampicillin-sulbactam, or a carbapenem 2
- De-escalate antimicrobial therapy based on clinical improvement, cultured pathogens, and results of diagnostic tests 2
Adjunctive Measures
- For Fournier's gangrene with fecal contamination, consider fecal diversion through colostomy or fecal tube systems 1
- Negative pressure wound therapy (NPWT) can be considered for wound care after complete removal of necrosis 1, 3
- Fecal diversion tubes can be used in combination with NPWT for effective isolation of wounds from fecal contamination 1
- Provide appropriate hemodynamic resuscitation alongside surgical and antimicrobial therapy 2
- The evidence for hyperbaric oxygen therapy is mixed and should not delay resuscitation or surgical debridement 2, 4, 5
Monitoring and Follow-up
- Use the Fournier's Gangrene Severity Index (FGSI) to predict outcomes in patients with Fournier's gangrene; a score above 9 is associated with higher mortality 1
- Monitor for clinical improvement including reduction in erythema, drainage, and pain 6
- Follow inflammatory markers such as procalcitonin to assess treatment response 1, 6
- Continue antibiotics until further debridement is no longer necessary and the patient is afebrile for 48-72 hours 6
Common Pitfalls to Avoid
- Delaying surgical intervention while waiting for imaging studies 2
- Inadequate debridement of necrotic tissue, which can lead to continued infection and spread 2
- Failure to plan for repeat surgical revisions until all necrotic tissue is removed 2
- Underestimating the extent of infection; debridement should continue into healthy-looking tissue 1, 2
- Neglecting to obtain cultures during initial debridement, which are essential for targeted antibiotic therapy 1