Fournier's Gangrene Cases Research Articles

Revisiting Fournier Gangrene: A Contemporary Epidemiological Perspective vs Perineal Cellulitis.

We conducted a population-based analysis of Fournier gangrene (FG) to compare risk factors and mortality with those of perineal cellulitis. We analyzed National Inpatient Sample data (2016-2020) to identify FG and perineal cellulitis cases. Demographic, comorbidity, and procedural data were extracted. Logistic models assessed risk factors of FG diagnosis and mortality. A total of 73,472 cellulitis and 9326 FG cases were identified corresponding to 74,905 (range, 63,050-79,165) and 9115 (range, 7925-11,080) median yearly weighted cases, respectively. FG diagnosis vs cellulitis was positively associated with Native American race (odds ratio [OR], 1.46; 95% CI, 1.19-1.79), weekend (OR, 1.12; 95% CI, 1.06-1.18) or December (OR, 1.33, 95% CI, 1.22-1.44) admissions, diabetes mellitus (OR, 2.51; 95% CI, 2.38-2.64), and malignancy (OR, 2.29; 95% CI, 2.07-2.54). Conversely, Hispanic (OR, 0.79; 95% CI, 0.74-0.85) and Asian/Pacific Islander races (OR, 0.83; 95% CI, 0.69-0.99) and the highest household income quartile (OR, 0.84; 95% CI, 0.78-0.90) were linked to a reduced likelihood of FG diagnosis. Elevated mortality risks were observed with female sex (OR, 1.33; 95% CI, 1.08-1.63), Native American ethnicity (OR, 2.29; 95% CI, 1.14-4.57), and procedural frequency (OR, 1.27; 95% CI, 1.24-1.3) among FG cases. Various patient and clinical factors are linked to the development and mortality of FG compared with perineal cellulitis. Improved access to care and understanding of FG can enhance patient outcomes.

Fournier's Gangrene Surgical Reconstruction: A Systematic Review.

Fournier's gangrene (FG) is a rare form of necrotizing fasciitis of the perineal, genital, or perianal region. It is characterized by an aggressive course and high mortality rate, over 20%. FG demands immediate treatment including resuscitation maneuvers, intravenous antibiotic therapy and early surgical debridement. Background/Objectives: The gold-standard treatment for FG is surgical reconstruction. However, up to date, no precise guidelines exist. Thus, we decided to systematically review the literature, focusing on FG contemporary approaches to reconstructive surgery, aiming to analyze the various reconstructive strategies and their specific indications. Methods: A systematic review was carried out according to the PRISMA statement by searching various databases from April 2014 to April 2024, using the terms ''Fournier Gangrene OR Fournier Gangrene Reconstruction OR Fournier Gangrene Treatment OR Fournier Gangrene Plastic Surgery OR Necrotizing Fasciitis OR Necrotizing Fasciitis AND Reconstruction". The eligibility criteria included original studies aimed at discussing FG reconstruction with at least three clinical cases. Results: The final synthesis included 38 articles, and 576 reconstructions were described. Of these, 77.6% were minimally invasive strategies (direct closure, secondary healing, grafts, and local random flaps), while more invasive reconstructions (loco-regional flaps based on known vascular anatomy) were adopted in 22.4%. No free flaps were reported. Conclusions: FG requires immediate medical interventions including broad-spectrum antibiotic therapy, surgical debridement, adjuvant therapies, and reconstructive surgeries. Taking into account the anatomical characteristics of the inguinal-crural region, skin grafts and local random flaps could offer versatile and effective reconstructions for most FG cases, while the more invasive strategies should be reserved for very few cases. Future research is warranted to define an FG dedicated reconstruction protocol.

Re: Wirjopranoto S. Comparison between neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio as predictors of mortality on Fournier's gangrene cases. Indian J Urol 2023;39:121-5.

Re: Wirjopranoto S. Comparison between neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio as predictors of mortality on Fournier's gangrene cases. Indian J Urol 2023;39:121-5.

Author Reply Re: Wirjopranoto S. Comparison between neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio as predictors of mortality on Fournier's gangrene cases. Indian J Urol 2023;39:121-5.

Author Reply Re: Wirjopranoto S. Comparison between neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio as predictors of mortality on Fournier's gangrene cases. Indian J Urol 2023;39:121-5.

Comparison between neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio as predictors of mortality on Fournier's gangrene cases.

Fournier's gangrene (FG) is an infection of the subcutaneous tissue and fascia that progresses quickly and leads to necrosis. It is more prevalent in male patients and immunocompromised individuals, such as those suffering from uncontrolled diabetes. It has a high mortality rate, which makes its early identification and clinical suspicion critical. This study aimed to compare two laboratory parameters, neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR), and to predict the mortality of FG in a tertiary care hospital. In a retrospective study, data was retrieved from medical records for the period from January 2014 to December 2020, of patients diagnosed with FG. Recorded data that is age, sex, comorbidities, mortality, and laboratory results (PLR and NLR) were used to assess determinants of survival. There were 23 (17.04%) nonsurvivors among the 135 subjects studied. The mean age was 50.9 ± 14.9 years and men were 103 (83%) patients. Among the participants, diabetes mellitus was the most frequent comorbidity at 74 (54.81%) patients. NLR ≥8 was statistically significant (P = 0.013) for identifying mortality, while PLR >140 was not. In multivariate analysis, NLR ≥8 was found to be a reliable predictor of the FG mortality rate (adjusted odds ratio 12.062, confidence interval 95% 2.115-68.778, P = 0.005). NLR had prognosis predictive value for FG, whereas PLR did not.

Fournier’s gangrene reconstruction: A 10-year retrospective analysis of practice at Guys and St Thomas’s NHS Foundation Trust

Fournier's gangrene is a rare and potentially fatal condition that affects the external genitalia and perineum as a necrotizing soft-tissue infection. It is equally prevalent in men and women and although there are many ways to manage the condition, it must be done so effectively because there is a chance that life-threatening complications could develop. This retrospective study set out to fill any knowledge gaps, compare reconstructive options to those described in the literature, and promote reflection on current management. Between January 2010 and January 2020, all perineal debridement operation notes were examined. The primary conclusions were that a large majority of defects could be repaired using split skin grafts to reduce surgical time and donor site morbidity. To avoid secondary contracture and the need for revision surgery, full-thickness skin grafts should be used whenever possible to treat penile defects.

Genital gangrene in a patient with type II diabetes mellitus, treated with dapagliflozin: a case report

Fournier gangrene (FG) is a necrotizing soft tissue infection initiated from the genital area or perineum, irrespective of the sex of the patient. A patient presented in the hospital with the chief complaints of inflammation in the scrotum from the past three days, which finally led to a rise in the body temperature. He also observed the discharge from the scrotum for two days. Six days back, he got mildly injured on the left side of his scrotum after falling off from his two vehicle and did not take any treatment. Local examination revealed that the size of the scrotum is slightly enlarged, tender, and oedematous, along with palpable crepitations. There were very observable patches of gangrene all over the scrotum, with no past of Diabetes Mellitus (DM). After the investigation, broad-spectrum antibiotics cefoperazone with sulbactam along with metronidazole were prescribed. After that, the patient was prepared for surgery immediately. After the surgery, the patient was prescribed appropriate antibiotics, followed by a wet dressing. The antibiogram results interpretation confirms that the combined form sulbactam and cefoperazone cause sensitivity towards Staphylococcus Aureusand Escherichia coli. His response was positive towards the treatment. The morbidity and mortality of this medical condition have declined over time due to improvements in diagnostic methods, surgical procedures, powerful antibacterial, and intensive care. This is advised to use an advanced approach while handling FG cases to reduce morbidity and mortality, mainly when concomitant conditions like diabetes and multiple organ failure are present.

Comparison of Conventional Wet Dressing and Vacuum Assisted Closure with Hypochlorous Acid Application in Fournier Gangrene Treatment

Background: Bacterial toxins cause local tissue damage and necrosis. This can continue until a significant amount of tissue becomes necrotic. Neutralization of bacterial toxins improves results. Low concentrations of Hypochlorous Acid can be antimicrobial without causing cytotoxicity in normal cells in the wound and surrounding tissues. In this study, we aimed to compare the results of patients treated with hypochlorous acid (0.01% w/v) through Vacuum Assisted Closure and with traditional wet dressing after surgical debridement due to Fournier Gangrene in our clinic. Materials and Methods: 73 patients treated for Fournier Gangrene between 2009-2019 in our clinic were evaluated retrospectively. The patients were divided into two groups: those who received Hypochlorous Acid with Vacuum Assisted Closure (Group A, n = 30) and those who received traditional wet dressing (Group B, n = 42) after the first debridement. Hypochlorous Acid (0.01% w/v), known to destroy bacteria and bacterial toxins, was administered to 30 patients with Fournier Gangrene in saline with a pH of 4-5, 5-6 times a day. Using Vacuum Assisted Closure, 5-10 ml of 0.01% Hypochlorous Acid was applied to the wound and aspirated. For wet dressing application, the wound was closed by applying mupirocin calcium and rifamycin to an appropriate number of wet sponges suitable for the wound surface and depth after cleansing the wound with sponges moistened with isotonic 3 times a day. The collected data were compared. P values smaller than 0.05 were considered significant. Results: The hospitalization time and wound healing time of 30 patients who received Hypochlorous Acid with Vacuum Assisted Closure were shorter (p <0.05), and the number of patients requiring secondary debridement was also lower (p <0.05). Conclusion: Hypochlorous Acid application with Vacuum Assisted Closure is an effective, successful and important postoperative treatment and wound care method that provides shorter hospital stay and faster recovery time. Toxicity and immune dysfunction due to bacterial toxins and toxins released from damaged cells can be alleviated with 0.01 Hypochlorous Acid application via Vacuum Assisted Closure. We recommend this method, which is easy to apply and inexpensive in certain Fournier Gangrene cases.

Coexistence of human immuno deficiency virus, diabetes mellitus, epididymal cysts, and Fournier's gangrene: A case report

Fournier's gangrene (FG) is a form of necrotizing fasciitis that is localized in the external genital organs and perianal region and causes skin and subcutaneous tissue gangrene. The clinical picture may vary depending on the patient's comorbidities and the extent of infection; Many predisposing conditions such as immunodeficiency, diabetes, alcoholism encourage the spread of the infection. In this case report, we highlighted the importance of emergency debridement in patients with multiple comorbidities by presenting the Fournier's Gangrene case in a 57-year-old immunosuppressive male patient with cystic lesions in the epididymis, with a history of hypertension, coronary artery disease, diabetes, HIV (human immunodeficiency virus) and a history of bipolar disorder. The patient, who was operated on for debridement by the urology, was given 1x500mg daptomycin, 3x1g meropenem, 3x450mg clindamycin IV treatment. The patient was discharged with full recovery after 17 days of hospitalization. Clinical suspicion in Fournier's gangrene cases, early surgical debridement, and extended-spectrum anti biotherapy are important. with rapid diagnosis and treatment in patients with improvement can also be seen in patients with comorbidities.

Fournier Gangrene Associated with Sodium-Glucose Cotransporter-2 Inhibitors: A Pharmacovigilance Study with Data from the U.S. FDA Adverse Event Reporting System.

Background The U.S. Food and Drug Administration (FDA) released a safety warning of Fournier gangrene (FG), a rare but serious adverse effect of sodium-glucose cotransporter-2 (SGLT2) inhibitors in August 2018. However, existing studies have focused mainly on individual FG case reports. Although several previous studies conducted reviews of cases, objective scientific analysis was not applied, and the prognosis data were inadequate. Objective This study is aimed at presenting data supplementary to existing studies by analysing postmarketing adverse event reports in the FDA Adverse Events Reporting System (FAERS) database. Multiple statistical analysis methods were applied to evaluate the potential association between SGLT2 inhibitors and FG, thus providing reliable and professionalized medication usage recommendations for SGLT2 inhibitors in clinical practice. Methods Disproportionality analysis and Bayesian analysis were applied for data mining among the suspected adverse event reports of FG associated with SGLT2 inhibitors recorded in the FAERS database during the period from January 2004 to September 2019. Results There were 542 FG cases identified in the FAERS database in patients receiving SGLT2 inhibitors. Among all SGLT2 inhibitor therapies, empagliflozin was associated with the highest number of FG reports (232 in total), while empagliflozin plus metformin had the strongest association with FG occurrence with the reporting odds ratio (ROR 54.79, 95% two-sided CI 31.56 to 95.12) and proportional reporting ratio (PRR 53.36, χ2 666.70). There were 391 patients who underwent initial or prolonged hospitalization (72.14%), and 26 patients died (4.81%). Three new FG cases caused by ertugliflozin were found in 2019. Conclusion The analysis of SGLT2 inhibitor-associated FG reports in the FAERS database identified signals between the drug and adverse events of interest. It also provides comprehensive information on the characteristics of FG onset and prognosis. Clinicians should pay more attention to this rare but severe adverse event when prescribing SGLT2 inhibitors in clinical practice.

Fournier Gangrene Associated With Sodium-Glucose Cotransporter-2 Inhibitors: A Review of Spontaneous Postmarketing Cases.

Use of sodium-glucose cotransporter-2 (SGLT2) inhibitors has been associated with Fournier gangrene (FG), a rare urologic emergency characterized by necrotizing infection of the external genitalia, perineum, and perianal region. To describe and compare reported cases of FG in diabetic adults receiving treatment with SGLT2 inhibitors or other antiglycemic agents. Descriptive case series. U.S. Food and Drug Administration (FDA) Adverse Event Reporting System and published case reports. Adults receiving SGLT2 inhibitors or other antiglycemic agents. Clinical and laboratory data. The FDA identified 55 unique cases of FG in patients receiving SGLT2 inhibitors between 1 March 2013 and 31 January 2019. The patients ranged in age from 33 to 87 years; 39 were men, and 16 were women. Time to onset after initiation of SGLT2-inhibitor therapy ranged from 5 days to 49 months. All patients had surgical debridement and were severely ill. Reported complications included diabetic ketoacidosis (n= 8), sepsis or septic shock (n= 9), and acute kidney injury (n= 4). Eight patients had fecal diversion surgery, 2 patients developed necrotizing fasciitis of a lower extremity that required amputation, and 1 patient required a lower-extremity bypass procedure because of gangrenous toes. Three patients died. For comparison, the FDA identified 19 FG cases associated with other antiglycemic agents between 1984 and 31 January 2019: metformin (n= 8), insulin glargine (n= 6), short-acting insulin (n= 2), sitagliptin plus metformin (n= 2), and dulaglutide (n= 1). These patients ranged in age from 42 to 79 years; 12 were men, and 7 were women. Two patients died. Inability to establish causality or incidence, variable quality of reports, possible underreporting, and confounding by indication. FG is a newly identified safety concern in patients receiving SGLT2 inhibitors. Physicians prescribing these agents should be aware of this possible complication and have a high index of suspicion to recognize it in its early stages. None.

Recognizing Fournier's Gangrene in the Emergency Department.

Fournier's gangrene is a rare disease with a significant mortality rate. The potentially fatal disease stems from both aerobic and anaerobic bacteria and primarily occurs in men. The majority of Fournier's gangrene cases are idiopathic or derived from perineal and genital skin infections. Comorbid risk factors include diabetes mellitus, alcohol misuse, and immunosuppression (). The infection initially presents as a cellulitis in the perineum or perianal area. As Fournier's gangrene progresses, the infected tissue becomes swollen, significantly painful, and necrotic. The progression of infection can lead to systemic symptoms, sepsis, and death. Early intervention is a key component in the treatment plan for Fournier's gangrene. The primary intervention is surgical debridement of the necrotic tissue. If an abscess is present, incision and drainage are indicated. In addition to surgical debridement, the administration of broad-spectrum antibiotics and hemodynamic stabilization are required (). Complications after treatment include chronic pain, sexual dysfunction, decreased sensation of the penile skin, and scarring ().

Fournier's gangrene: Review of 36 cases.

Fournier's gangrene (FG) is a very rare disease in daily urological practice. Despite medical improvements, mortality in FG is still high. Early diagnosis is very important to reduce additional instrumentations and mortality. In this study, we aimed to present the characteristics of the patients with Fournier's gangrene followed in two centers during ten years period. The medical records of patients with FG were reviewed retrospectively. The patient characteristics, causative pathogens, laboratory findings and treatment modalities were evaluated. A total of 36 FG cases admitted between January 2008 and February 2018 were included in this study, consisting of 35 male patients, and one female patient with a mean age of 59.27±12.91 years. The mean duration of hospital stay was 19±10.44 days. The most common predisposing factor was diabetes mellitus, which was found in 28 patients. Malignancy was detected in three patients; prostate cancer in two patients and chronic lymphoblastic leukemia in one patient. Two patients had liver cirrhosis, and one patient had Behcet's disease and psoriasis. The microbiological agent was isolated from a wound culture in nine patients. After urgent surgical debridement, daily dressing with nitrofurazone (Furacin) was done. Additional debridement was conducted when necessary. Orchiectomy was performed in 10 patients; two of them underwent bilateral orchiectomy. One patient died because of sepsis on the seventh day of hospital admission. FG is a life-threatening urological emergency with a high mortality rate. Treatment with broad-spectrum antibiotics and urgent surgery is pivotal for the prevention of mortality.

Fournier's Gangrene: A Review and Outcome Comparison from 2009 to 2016.

Objective: The outcome of Fournier's gangrene (FG) may be affected by comorbidities, demographics, and choice of treatment modality. We sought to evaluate our institution's management protocol of FG measured by mortality rate (MR) and length of hospital stay (LHS) in a retrospective cohort study. Approach: A database of 20 FG cases at our institution throughout the 2009-2016 study period was assembled by a retrospective review of medical records. A Fournier's Gangrene Severity Index Score (FGSIS) was calculated for each case. Data were analyzed for statistical significance using logistic regression. Results: The most common presentation of FG at our institution was a hyperglycemic diabetic male in his fifth decade of life with a second risk factor such as recent surgery or active malignancy. The average FGSIS was 9 overall and 14 for the mortalities. An increased FGSIS was predictive of having an increased MR or hospital stay above the median (>25 days) (p = 0.0194). The average LHS was 32 days overall, 22 days for patients treated with hyperbaric oxygen therapy and 40 days for patients treated with tangential hydrosurgery. Overall MR was 15%. Innovation: This is the second known study to characterize usage of tangential hydrosurgery in the management of FG. Conclusion: Treatment outcomes at our institution are comparable to those reported in recent literature, a significant decline from the historical MR of 50-60%.

Reply

The commentator has provided insightful comments regarding the etiology and risk factors for Fournier's gangrene in our study. Cases of Fournier's gangrene caused by MRSA have only recently been reported and only in the form of patient case reports 1 Kalorin C.M. Tobin E.H. Community associated methicillin-resistant Staphylococcus aureus causing Fournier's gangrene and genital infections. J Urol. 2007; 177: 967-971 Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar , 2 Burton M.J. Shah P. Swiatlo E. Community-acquired methicillin-resistant Staphylococcus aureus as a cause of Fournier's gangrene. Am J Med Sci. 2008; 335: 327-328 Crossref PubMed Scopus (16) Google Scholar , 3 Vaidyanathan S. Soni B.M. Hughes P.L. et al. Localised necrosis of scrotum (Fournier's gangrene) in a spinal cord injury patient—a case report. BMC Fam Pract. 2002; 3: 20 Crossref PubMed Scopus (15) Google Scholar and the study by Fajdic et al, 4 Fajdic J. Gotovac N. Hrgovic Z. Fournier gangrene: our approach and patients. Urol Int. 2011; 87: 186-191 Crossref PubMed Scopus (14) Google Scholar which makes the incidence difficult to determine. Similarly, Candida sp was infrequently reported in previous studies (single patient case report 5 Johnin K. Nakatoh M. Kadowaki T. et al. Fournier's gangrene caused by Candida species as the primary organism. Urology. 2000; 56: 153 Abstract Full Text Full Text PDF PubMed Google Scholar ). A recent contemporary study demonstrated Candida sp in 12% of Fournier's gangrene cases, similar to our 7.3%. 6 Morua A.G. Lopez J.A. Garcia J.D. et al. Fournier's gangrene: our experience in 5 years, bibliographic review and assessment of the Fournier's gangrene severity index. Arch Esp Urol. 2009; 62: 532-540 PubMed Google Scholar Editorial CommentUrologyVol. 81Issue 4PreviewThe article presents an assessment of microbiologic findings in patients with Fournier's gangrene. Full-Text PDF

A three–year review of the management of Fournier’s gangrene presenting in a single Saudi Arabian institute

IntroductionFournier‘s gangrene (FG), is a rare life threatening urologic emergency that requires immediate admission of metabolic stabilization and surgical debridement. The mortality rate ranges from 16% to 40%. This study was conducted to investigate the reasons behind the excellent survival rate in our center.Materials and methodA retrospective analysis of the medical records of 20 FG cases from January 2010 to January 2013 was conducted. Data was collected on patients’ comorbidity, survivals, Fournier‘s severity index (FSI) at presentation, length of hospital stay (LOS), the number of intensive care unit (ICU) and operating room (OR) entries, the total phalli and testes removed, colostomies created, and cystostomies performed.ResultsAll 20 cases (100%) collected for the study survived. All patients were male. The median age of the patients was 55.95 years (39–78 year). Only one patient (5%) was admitted to ICU post–operatively. Penile amputation was carried out in three of the 20 cases (15%). The total number of OR entries was 34 (average of 1.7). A majority of 12 patients (60%) were diabetic. A total of six testes were extirpated from the study group. None of the patients required colostomy creation. Only one patient (5%) required a cystostomy tube insertion. FSI was 5.65 ranging from 0 to 14. The average length of hospital stay was 22.3 days.ConclusionIn contrast to what is published in the literature, FG is not rare in our center. Perfect survival rate owes to the moderate severity of the cases treated, but mostly to the urgent surgical intervention with extensive debridement.

Fournier's Gangrene: Management and Mortality Predictors in a Population Based Study

The Fournier's gangrene literature comes almost exclusively from tertiary referral centers. We used a population based database to evaluate variations in management and outcomes. Inpatients with Fournier's gangrene who underwent surgical débridement or died were identified from select states in the State Inpatient Databases. Multivariate logistic regression analysis was done to evaluate patient and hospital related predictors of mortality. We identified 1,641 males with Fournier's gangrene treated at a total of 593 hospitals. At teaching hospitals more Fournier's gangrene cases were treated per year, and more surgical procedures, débridements and supportive care were reported. Patients treated at teaching hospitals had longer length of stay, greater hospital charges and a higher case fatality rate. Patient related predictors of mortality were increasing age (adjusted OR 4.0 to 15.0), Charlson comorbidity index (adjusted OR 1.20 per additional comorbidity), preexisting conditions, ie congestive heart failure (adjusted OR 2.1), renal failure (adjusted OR 3.2) and coagulopathy (adjusted OR 3.4), and hospital admission via transfer (adjusted OR 1.9), after adjusting for hospital factors and Fournier's gangrene experience. Teaching hospitals had higher mortality due primarily to more acutely ill patients (adjusted OR 1.9). Hospitals where more than 1 Fournier's gangrene case per year were treated had 42% to 84% lower mortality after adjusting for patient age, race, Charlson comorbidity index and admission via transfer (p <0.0001). Teaching and nonteaching hospitals differ substantially in the populations, case definitions, and severity and management of Fournier's gangrene. Hospitals where more patients with Fournier's gangrene were treated had lower mortality rates, supporting the rationale for regionalized care for this rare disease.

Fournier's gangrene as a complication of varicella in a 15-month-old boy

An inguinal and perianal localization of Fournier's gangrene (FG) in a 15-month-old boy as a complication of the varicella infection is discussed. This is the first presentation of the disease as a complication of the varicella rashes. There were already 57 pediatric FG cases resulting from other causes that had been presented in the medical literature. J Pediatr Surg 37:1632-1633. Copyright 2002, Elsevier Science (USA). All rights reserved.