What is the treatment for a patient with suspected Fournier's gangrene?

Treatment of Fournier's Gangrene

Immediate surgical intervention is the cornerstone of treatment and must be performed as soon as possible—do not delay surgery for imaging in patients with clinical suspicion or hemodynamic instability. 1

Surgical Management: The Primary Treatment

Timing of Initial Surgery

• Operate emergently upon clinical suspicion of Fournier's gangrene, as delayed treatment significantly increases mortality 1
• In hemodynamically unstable patients after proper resuscitation, proceed directly to the operating room without CT imaging 1
• In stable patients, CT scan may be obtained to assess extent but should never delay surgical intervention 1

Surgical Technique

• Complete removal of all necrotic tissue is essential—debride radially until healthy, bleeding tissue is encountered 1
• Drainage of fluid collections and complete debridement of necrotic tissue must be performed at the index operation 1
• Early and aggressive surgical debridement improves survival and reduces the total number of surgical revisions required 1

Repeat Surgical Revisions

• Plan serial debridements every 12-24 hours based on patient condition until completely free of necrotic tissue 1
• Continue surgical revisions until no necrotic tissue remains—this is non-negotiable for survival 1

Extent of Surgery and Multidisciplinary Approach

• Involve general/emergency surgeons, urologists, intensivists, and plastic surgeons early in the course 1
• Preserve genital structures when possible—perform orchiectomy or other genital surgery only if strictly necessary, ideally with urologic consultation 1

Fecal Diversion Considerations

• Consider colostomy for: anal sphincter involvement, fecal incontinence, or continued fecal contamination of the wound 1
• Delay the decision on stoma creation for 48 hours after initial surgery when possible, allowing acute inflammation and edema to regress for proper evaluation of sphincters and perianal tissues 1
• Temporary fecal management systems can be used as an alternative but only for short periods to avoid intra-rectal device-related damage 1

Urinary Diversion Considerations

• Indications for suprapubic cystostomy include: extensive penile and perineal debridement, urethral involvement, and periurethral abscesses 1
• Most cases can be managed with urinary catheterization alone 1

Antimicrobial Therapy: Start Immediately

Empiric Antibiotic Regimen

• Start broad-spectrum empiric antimicrobial therapy immediately upon suspicion of Fournier's gangrene, before surgical intervention 1, 2
• Coverage must include: gram-positive organisms (including MRSA), gram-negative organisms, and anaerobic bacteria 1, 2
• Recommended regimens: vancomycin PLUS either piperacillin-tazobactam, ampicillin-sulbactam, or a carbapenem 3

Microbiological Sampling and De-escalation

• Obtain intraoperative cultures during the index debridement to guide targeted therapy 1, 2
• De-escalate antimicrobials based on: clinical improvement, cultured pathogens, and rapid diagnostic test results when available 1, 2

Supportive Care

Hemodynamic Management

• Provide aggressive hemodynamic resuscitation alongside surgical and antimicrobial therapy 1, 2

Adjunctive Therapies

• Negative pressure wound therapy (NPWT) can be applied after complete removal of necrotic tissue to facilitate wound healing 3, 2, 4
• Hyperbaric oxygen therapy is NOT recommended as it has not been proven beneficial and may delay critical resuscitation and surgical debridement 3

Prognostic Assessment

• Use the Fournier's Gangrene Severity Index (FGSI) for prognosis and risk stratification—scores above 9 are associated with higher mortality 1, 2
• Use the Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score for early diagnosis 1

Critical Pitfalls to Avoid

The following errors significantly increase mortality:

• Delaying surgery while waiting for imaging studies—this is the most common preventable cause of death 1, 3, 2
• Inadequate initial debridement—failure to remove all necrotic tissue leads to continued infection spread 3, 2
• Not planning for repeat surgical revisions—single debridement is almost never sufficient 1, 3, 2
• Failing to obtain intraoperative cultures, which are essential for targeted antibiotic therapy 1, 2
• Underestimating the extent of infection—debridement must continue into healthy-appearing tissue 2