Antibiotic management of Fournier's gangrene (FG) is without evidence-based guidelines and is based on expert opinion. The effect of duration of antibiotic therapy on outcomes in FG is unknown.
A ...retrospective review was performed of FG patients from 2012 to 2015 at a single institution. Patients were managed by our institutional practice of complete primary wound closure as possible, with antibiotic duration according to physician judgment. Patients were stratified into multiple durations of antibiotic administration.
Overall, 168 patients with FG were included. When examining multiple stratifications of antibiotic therapy of 7 days or less, 8 days to 10 days, 11 days to 14 days, or 15 days or more of antibiotics, there was no significant difference in mortality (p = 0.11), primary closure (p = 0.75), surgical site infection (SSI) (p = 0.52), or Clostridium difficile infection (p = 0.63). There were no cases of recurrent FG in any antibiotic stratification. Mortality was not increased (p = 1.00) and ability to achieve primary closure was not decreased (p = 0.08) with initial antibiotic therapy exclusive of cultured organisms.
Shorter antibiotic courses for patients in whom source control is obtained and initial antibiotic selection exclusive of many resistant organisms were not associated with worse outcomes in FG.
Therapeutic, level IV.
Background
Fournier's gangrene is a form of necrotising fasciitis involving perineo‐scrotal skin. It is treated with radical debridement, infection control and often leaves a large anatomical defect ...that is challenging to reconstruct. The anatomical location of the defect leads to faecal contamination, difficulties when mobilizing, and negative psychological impact. Traditional approaches for managing such defects have relied on either healing by secondary intention or skin grafting. There are few reported cases in the literature to cover such defects with a flap.
Methods
Pedicled Superficial Circumflex Iliac Artery Perforator (SCIP) flap reconstruction was performed in three patients who had perineo‐scrotal defects following debridement for Fournier's gangrene.
Results
All flaps survived with no significant postoperative complications and good functional and aesthetic outcomes were achieved. The mean age of patient was 52 years and the largest defect measured 22 × 10 cm.
Conclusion
The reconstruction of perineo‐scrotal defects is difficult despite a range of reconstructive options. The pedicled SCIP flap offers many advantages over standard techniques. This flap is thin, pliable, and has a consistent anatomy. With continued experience, we feel that this flap could be considered the gold standard of treatment for such defects.
Perineoscrotal defects are difficult to reconstruct. SCIP flap is an easy and a reliable option for reconstructing scrotal defects following Fournier's gangrene. The flap is naturally thin flap and provides good aesthetic and functional coverage. With continued experience SCIP could be considered the gold standard treatment of perineoscrotal defects.
Objectives
To validate the predictive value of Fournier's Gangrene Severity Index in patients with Fournier gangrene and to facilitate patient mortality risk‐stratification by simplifying the ...Fournier's Gangrene Severity Index.
Methods
From January 1989 to December 2011, 85 male patients with clinically‐documented Fournier's gangrene undergoing intensive treatment and with complete medical records were recruited. The demographic information and nine parameters of Fournier's Gangrene Severity Index were compared between survivors and non‐survivors. The parameters that showed a significant difference between the two groups were selected to generate a simplified scoring index.
Results
Of the 85 patients recruited, 16 patients died of the disease with mortality rate of 18.8%. The Fournier's Gangrene Severity Index score at initial diagnosis was significantly higher in non‐survivors than in survivors. Of the nine parameters of Fournier's Gangrene Severity Index, the scores of serum creatinine level, hematocrit level and serum potassium level were significantly different between the two groups. However, the mean body temperatures, heart rate, respiration rate, white blood cell count, serum sodium and bicarbonate levels were non‐significantly different. Of the 12 patients with chronic kidney disease or end‐stage renal disease, 10 died of severe sepsis. A simplified scoring index including parameters of creatinine, hematocrit and potassium was generated, which provided sensitivity and specificity of 87% and 77% in predicting patient mortality, respectively. The predictive values of this simplified Fournier's Gangrene Severity Index were shown to be non‐inferior to Fournier's Gangrene Severity Index in our patients.
Conclusions
The simplified Fournier's Gangrene Severity Index is easy to use at initial diagnosis, and offers a way to compare outcomes in different clinical populations.
Objectives
To explore the trends in Fournier's gangrene (FG) incidence and mortality rate in Taiwan and to investigate the contributing factors to such changes.
Methods
Between 2002 and 2016, ...hospitalized FG patients who underwent subsequent surgical intervention were included in this retrospective study. Incidence, outcomes, age‐adjusted Charlson Comorbidity Index (ACCI), hospitalization cost, surgical timing, and the number of multidisciplinary specialists involved in the first‐line management of FG in each year were collected. Simple linear regression and Pearson correlation coefficient (r) were used for the subsequent analysis.
Results
The national cohort enrolled 2183 FG patients from 2002 to 2016 in Taiwan. The age‐standardized incidence rate of FG was between 0.4 and 0.8 per 100 000 population, and overall mortality was 7.8% in these 15 years. We illustrated the downward trendline of FG mortality with a 0.62 coefficient of determination. The mortality of FG patients who underwent surgery within 24 h and after 24 h were found to be 8.3 ± 3.9% and 14.6 ± 25.2%, respectively (p = 0.02). The numbers of urologists, anesthesiologists, emergency doctors, and physicians per 100 000 population had a strong negative linear correlation with FG mortality (r = 0.8, p < 0.001). ACCI score had a moderate linear relationship with FG mortality (r = 0.57, p = 0.027). The hospitalization cost showed a weak linear correlation with FG mortality (r = −0.03, p = 0.92).
Conclusions
We demonstrated the downward trend of the FG mortality rate in Taiwan from 2002 to 2016. Besides underlying comorbidities and surgical timing, sufficient multidisciplinary specialists are essential for the survival benefit of FG patients in Taiwan experience.
Necrotizing skin and soft tissue infections are severe bacterial infections resulting in rapid and life-threatening soft tissue destruction and necrosis along soft tissue planes.
Skin-sparing debridement (SSd) was introduced as an alternative to en bloc debridement (EBd) to decrease morbidity caused by scars in patients surviving Necrotizing soft-tissue infections (NSTI). An ...overview of potential advantages and disadvantages is needed. The aim of this review was to assess (1) whether SSd is noninferior to EBd regarding general outcomes, that is, mortality, length of stay (LOS), complications, and (2) if SSd does indeed result in decreased skin defects.
A systematic literature search was performed according to the PRISMA guidelines. All human studies describing patients treated with SSd were included, when at least of evidence level consecutive case series. Studies describing up to 20 patients were pooled to improve readability and prevent overemphasis of findings from single small studies.
Ten studies, one cohort study and nine case series, all classified as poor based on Chambers criteria for case series, were included. Compared to patients treated with EBd, patients treated with SSd had no increased mortality rate, LOS or complication rate. SSd-treated patients had a high rate (75%) of total delayed primary closure (DPC) in the pooled case series.
The current available evidence is of insufficient quality to conclude whether SSd is noninferior to EBd for all assessed outcomes. There are suggestions that SSd may result in a decreased need for skin transplants, which could potentially improve the (health related) quality of life in survivors. Experienced surgical teams could cautiously implement SSd under close monitoring, ideally with uniform outcome registry.
To determine predisposing or prognostic factors and mortality rates of patients with Fournier's gangrene compared to other necrotizing soft tissue infections (NSTI).
Data of 55 intensive care ...patients (1981-2010) with NSTI were evaluated. Data were collected prospectively.
43.4% of the patients were in septic condition and 27.3% were hemodynamically unstable. Half of the patients showed predisposing factors (52.7%). The lower extremity (63.2%), abdomen (30.9%), and perineum (14.5%) were most affected. Polymicrobial infections were frequent (65.5%, mean 2.8, range: 1-4). The mortality rate was 16.4% (n = 9). An increase was shown for diabetes mellitus (20%), cardiac insufficiency (22.3%), septic condition at presentation (33.3%), abdominal affection (47.1%), and hemodynamic instability (46.7%). Comparing survivors and nonsurvivors, statistical significance was seen with age (p < 0.001), septic condition at admission (p < 0.001), hemodynamic instability (p < 0.001), low blood pressure (p < 0.001), and abdominal affection (p < 0.001). In laboratory findings, an increase of creatine kinase (p < 0.001) and lactate (p < 0.001) and a decrease of antithrombin III (p < 0.007) and the Quick value (p < 0.01) proved to be significant.
Patients with Fournier's gangrene do not differ in all aspects from those with other NSTI. Successful treatment consists of immediate surgical debridement, broad-spectrum antibiotic treatment, and critical care management. Supportive hyperbaric oxygen therapy should be considered.
To evaluate effective factors in the survival of patients with Fournier’s gangrene (FG) and to determine the validity of the Fournier’s Gangrene Severity Index (FGSI), which was designed for ...determining disease severity in these patients.
The study included 20 men with a median age of 63.5 yr treated for FG between July 2002 and June 2005. The data were evaluated about medical history, symptoms, physical examination findings, vital signs, admission and final laboratory tests, timing and extent of surgical debridement, and antibiotic treatment used. All the patients had radical surgical debridement. The FGSI, which was developed to assign a numerical score that describes the acuity of the disease, was used in our study. This index presents patients’ vital signs (temperature, heart and respiratory rates) and metabolic parameters (sodium, potassium, creatinine, and bicarbonate levels, hematocrit, white blood cell count) and computes a score relating to the severity of the disease at that time. The data were assessed according to whether the patient survived or died.
Of the evaluated 20 patients, 6 died (30%) and 14 survived (70%). The difference in age between survivors (median age, 60.0 yr) and those who died (median age, 64.5 yr) was not significant (p=0.321). The median extent of the body surface area involved in the necrotizing process in patients who survived and did not survive was 2.3% and 4.8%, respectively (p=0.001). Except for the albumin and alkaline phosphatase levels, no significant differences were found between survivors and who those died in the other admission laboratory parameters. The median admission FGSI scores for survivors and nonsurvivors were 2.0±2.2 and 4.0±3.7, respectively (p=0.331).
The FGSI score did not predict the disease severity and the patient’s survival. Metabolic parameters, predisposing factors, and extent of the disease seemed to be important risk factors for predicting FG severity and whether or not a patient survived.
The initial Fournier Gangrene Severity Score and admission metabolic parameters may not help to predict the disease severity and patients’ survival. Hence, metabolic parameters, predisposing factors, and the extent of the disease should be assessed together for predicting treatment outcome and patients’ survival.
We aimed to investigate the parameters that have an effect on the length of stay and mortality rates of patients with Fournier's gangrene.
A retrospective review was performed on 80 patients who ...presented to the emergency department and underwent emergency debridement with the diagnosis of Fournier's gangrene between 2008 and 2017. The demographic and clinical characteristics, length of stay, Fournier's Gangrene Severity Index score, cystostomy and colostomy requirement, additional treatment for wound healing and the mortality rates of the patients were evaluated.
Of the 80 patients included in the study, 65 (81.2 %) were male and 15 (18.7 %) female. The most common comorbidity was diabetes mellitus. The mean time between onset of complaints and admission to hospital was 4.6 ± 2.5 days. As a result of the statistical analyses, it was found that Fournier's Gangrene Severity Index score, hyperbaric oxygen therapy, negative pressure wound therapy and the presence of sepsis and colostomy were significantly positively correlated with length of stay. Also it was found that the Fournier's Gangrene Severity Index score, administration of negative pressure wound therapy and the presence of sepsis were correlated with mortality.
Fournier's gangrene is a mortal disease and an emergency condition. With the improvements in Fournier's gangrene disease management, mortality rates are decreasing, but long-term hospital stay has become a new problem. Knowing the values predicting length of stay and mortality rates can allow for patient-based treatment and may be useful in treatment choice.
To find out the outcomes of Fournier's gangrene (FG) patients using clinical data and prognostic biomarkers based on the current literature.
Descriptive study. Place and Duration of the Study: ...Department of General Surgery, University of Health Sciences, Gulhane Training and Research Hospital, Ankara, Turkey, from January 2018, to January 2022.
Patients who were diagnosed with and treated for FG were included in the study. Patients younger than 18 years of age, those with missing hospital records and postoperative follow-up data, those with benign diseases related to the perianal or anal region, and those with other malignant diseases were excluded from the study. Patients' demographic, clinical, and laboratory data, including the calculated systemic immune-inflammation index (SII) and pan-immune-inflammation values (PIV) were obtained retrospectively from the medical records. Variables were analysed using SPSS statistics software, version 25.0. The value of p <0.05 was considered statistically significant.
A total of twenty-four patients, 14 (58.3%) males and 10 (41.7%) females, were included in this study. No statistically significant correlations were found between the calculated indices and patients' clinical outcomes. The length of intensive care unit stay was strongly and positively correlated with age (r = 0.672 and p <0.001), and the length of hospital stay was moderately and inversely correlated with preoperative albumin levels (r = -0.584 and p = 0.003).
SII and PIV had no statistically significant interactions with FG.
Fournier's gangrene, Systemic immune-inflammation index, Pan-immune-inflammation value, Colostomy, Albumin.
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