From the Guidelines
Fournier gangrene requires immediate surgical debridement as soon as possible, combined with broad-spectrum antibiotics, to improve survival and reduce morbidity. The treatment of Fournier’s gangrene involves prompt appropriate antibiotic therapy, hemodynamic support, and early debridement 1. A typical antibiotic regimen includes a combination of piperacillin-tazobactam, vancomycin, and either metronidazole or clindamycin to cover aerobic and anaerobic organisms 1.
Key Considerations
- Early and aggressive surgical debridement is crucial to halt the progression of infection and improve survival 1.
- Repeated debridements every 24-48 hours may be necessary until healthy tissue is established 1.
- Hemodynamic support with IV fluids and vasopressors may be necessary for patients with septic shock.
- The infection typically results from a polymicrobial synergy between aerobic and anaerobic bacteria that enter through breaks in the skin or mucosa, causing rapid tissue destruction through the release of enzymes and toxins.
Management
- Surgical intervention should be performed as soon as possible in the presence of high suspicion for Fournier’s gangrene 1.
- Subsequent surgical revisions should be planned based on the patient conditions, ideally every 12–24 h 1.
- Surgical revisions should be continued until the patient is free of necrotic tissue 1.
- Fecal diversion, such as colostomy or fecal diversion tubes, may be considered in cases of Fournier’s gangrene with fecal contamination 1.
Antibiotic Regimen
- Empiric antimicrobial therapy should include cover for gram-positive, gram-negative, aerobic and anaerobic bacteria, and an anti-MRSA agent 1.
- Microbiological samples should be obtained at the index operation to guide antimicrobial therapy 1.
- Antimicrobial de-escalation should be based on clinical improvement, cultured pathogens, and results of rapid diagnostic tests where available 1.
From the Research
Definition and Overview of Fournier Gangrene
- Fournier gangrene (FG) is a rare, life-threatening infection that can result in significant morbidity and mortality 2.
- It is a mixed infection of aerobic and anaerobic bacterial flora, often affecting the genitourinary tract, gastrointestinal tract, or perineum 2.
- FG is characterized by a fulminant development and progression of gangrene, which can rapidly cause multiple organ failure and death 2.
Risk Factors and Demographics
- FG has a strong association with male patients, particularly those with advanced age and comorbidities affecting microvascular circulation and immune system function 2.
- Common risk factors include diabetes, alcohol use disorder, and other immune-compromised states 2, 3, 4.
- Despite these risk factors, FG can also affect patients without underlying conditions 2.
Clinical Presentation and Diagnosis
- Initial symptoms of FG can be indistinct and may rapidly progress to overwhelming infections 5.
- Common clinical presentations include scrotal and labial pain, fever, abscesses, crepitus, erythema, and cellulitis 5.
- Diagnosis is made from clinical findings in conjunction with imaging, such as point-of-care ultrasound, conventional radiography, and computed tomography 2, 5.
Treatment and Management
- The gold standard treatment for FG is a combination of surgical debridement, broad-spectrum antibiotics, and the administration of intravenous fluids 2, 6, 5.
- Early extensive surgical debridement is crucial to reduce the need for further intervention and shorten hospital stay 6.
- 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 high-quality evidence 3.
- Patient survival is directly related to the time from diagnosis to treatment, highlighting the importance of early identification and prompt treatment 5.