Fournier's Gangrene Research Articles

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.

Penile and scrotal defects post-Fournier gangrene: reconstructive options and challenges in resource limited settings

Introduction: Penile and scrotal defects following necrotizing fasciitis (Fournier gangrene) of the perineum in males can be a source of great morbidity and psychological concern to the patients inflicted with such a problem. In severe cases, it can result in mortality. Reconstruction of extensive defects/ulcers can be challenging in resource limited settings due to limited availability of tools such as doppler ultrasound/stethoscope, loupes, and operating microscopes for microsurgical procedures. Fournier gangrene is usually managed by the urologists in most centers in collaboration with the plastic surgeons for reconstruction of more extensive defects. Objective: The aim of the study was to review the penile and reconstructive options deployed for post-Fournier gangrene patients over a 3-year period (April 2017 to March 2020) in a tertiary hospital setting highlighting options utilized, indications for the respective options, and challenges encountered. Methodology: Case notes of Fournier gangrene patients offered penoscrotal reconstruction by the urology and plastic surgical teams within the period were retrieved, reviewed, and relevant data useful in achieving the above objectives extracted for analysis. Clinical photographs of some of the patients were included for illustration. Results: Twenty patients (20) that met the inclusion criteria were reviewed. Fourteen (70%) had defects involving both the scrotum and the penis, five (25%) involved the scrotum alone, while one (5%) had defect on the penis alone. Four (20%) had diabetes mellitus, three (15%) had HIV infection, and two (10%) had hypertension. Seventy percent (14) of the patients had secondary wound repair by direct closure, 5% (one) had split skin grafting alone, 5% (one) had a combination of split skin grafting and local advancement flap, and 20% (four) required the use of available locoregional flap [three being bilateral scrotal advancement flaps and one being bilateral pudendal thigh (Singapore) flap]. Healing was satisfactory in all the patients although two of them (10%) had surgical site infection whereas one (5%) had mild wound dehiscence, but all healed within 2 weeks. Conclusion: Post-Fournier gangrene defects can be reconstructed using several options, the choice of which is dependent on the size of the defect, elasticity of residual scrotal skin, status of defined locoregional pedicles, availability of modern diagnostic and operating equipment, and expertise of the surgeon. Collaboration between the urologists and the plastic surgeons is recommended for optimal outcome.

848 - Hypocalcemia may be associated with extensive Fournier’s gangrene and mortality

848 - Hypocalcemia may be associated with extensive Fournier’s gangrene and mortality

1005 - Factors affecting length of stay and mortality in Fournier gangrene: A retrospective analysis of 10 years data

1005 - Factors affecting length of stay and mortality in Fournier gangrene: A retrospective analysis of 10 years data

Microorganisms and Antibiogram Patterns in Fournier's Gangrene: Contemporary Experience from a Single Tertiary Care Center.

We evaluate the prevalent microorganisms, antibiotic sensitivity patterns and associated outcomes in patients with Fournier's gangrene. A retrospective chart review of patients with Fournier's gangrene was conducted between October 2011 and April 2018 at our institution. Univariate analysis was performed using the independent t-test or Kruskal-Wallis H test for continuous variables and exact test for categorical variables. Of the 143 patients included in this study, wound culture was available in 131 (92%) patients with a median number of 3 microorganisms per wound. The most commonly grown pathogens were Staphylococcus species (66, 46%), Streptococcus species (53, 37%), Bacteroides species (34, 24%), Candida species (31, 22%), Escherichia coli (28, 20%) and Prevotella species (26, 18%). Most bacteria were sensitive to ampicillin-sulbactam, ceftriaxone, piperacillin-tazobactam, amikacin and cefepime, and resistant to ampicillin, trimethoprim-sulfamethoxazole, levofloxacin and clindamycin. Enterococcus faecalis and Streptococcus anginosus were resistant to vancomycin. The overall Fournier's gangrene mortality count was 14 (10%) patients. No association was noted between the type of infection and Fournier's gangrene severity index, length of hospital stay or mortality. At our institution Candida is a prevalent pathogen in the wound culture of patients with Fournier's gangrene. The resistance patterns for clindamycin and vancomycin are concerning. Addition of an antifungal agent to the empiric treatment should be considered based on clinical presentation.

PROTETIVE COLOSTOMY IN FOURNIER’S GANGRENE

Fournier's Gangrene is a rapidly evolving polymicrobial necrotizing fasciitis of the perineal, perianal, and genital region, extending to the thigh root, abdominal wall and retroperitoneum, which rarely affects women and children, with an overall incidence rate of 1,6 cases per 100,000 men / year and a peak incidence after the age of 50. Incomplete hygiene, exacerbated skin folds, mechanical trauma, prolonged catheterization and invasive procedures, as well as comorbidities such as diabetes mellitus, smoking, obesity, chronic alcoholism, hypertension, immunosuppression, HIV, cancer patients, and chronic diseases are factors that predispose to the appearance of the lesion.The objective of the study is to report the case of a female patient, 43 years old, without comorbidities, with a picture of Fournier's gangrene in the perineal region and genitalia, accompanied by the General Surgery Service of the General Public Hospital of Palmas - TO, and submitted to colostomy in a descending loop as a protective measure of choice for the spread of the infection to the abdominal cavity, interrupting the progression of the disease.

The effectiveness of Dakin’s solution in wound care after debridement in Fournier’s gangrene

Background: Fournier's gangrene (FG) is a specific form of necrotizing fasciitis seen in the external genital organs and perianal region. The basic management of Fournier's gangrene is based on critical surgical debridement. Dakin's solution (sodium hypochlorite) was originally developed to treat war wounds. In this study, we aimed to show potentially efficient of Dakin’s solution on wound healing and reoperation rate.Methods: Thirty-three patients who were debrided due to Fournier Gangrene during 2012-2020 were included in the study. After debridement, wound care was done twice a day by dressing with a sponge moistened with Dakin's solution. Patients' age, concomitant disease, involvement site, re-debridement requirement, complications, and discharge times were recorded.Results: The mean age of 33 male patients who participated in the study was (51-74) 63.93±15.36. Although all patients had scrotal involvement, nine patients had perineal (27.2%), 12 patients had inguinal (36.3%), four patients had a penis and pubic spread (12.1%). The mortality rate was 6%. The average length of hospital stay was 13.1±4.2 days, and the average number of debridements was 1.Conclusions: Fournier gangrene is an important disease characterized by necrotizing infection of the genital, perineal, and perianal region and progresses with high mortality. Our mortality rate was lower than literature and we have linked our mortality rate to using Dakin's solution for wound care. Dressing with Dakin's solution is an effective and reliable method for wound care in FG patients.

Scoring Systems for the Prediction of Mortality in Patient with Fournier’s Gangrene: an Analysis of 60 Patients

The aim of this study was to evaluate demographic and clinical findings in Fournier’s gangrene and to assess feasibility of several scoring indexes for predicting morbidity and mortality. Patients who underwent surgery for Fournier’s gangrene between 2006 and 2020 were analyzed. Scores of Fournier Gangrene Severity Index, Uludag Fournier Gangrene Severity Index, Age-adjusted Charlson Comorbidity Index, and Sequential Organ Failure System for each patient were calculated. Mortality rate was regarded as the primary outcome. There were 60 patients with a mean age of 61.4 SD 16.0 years. There were 10 deaths with a mortality rate of 16.7%. There were significant differences between non-survivor (n = 10) and survivor patients (n = 50) with regard to hemoglobin, serum total protein, and serum bicarbonate levels (p < 0.05). In all patients who survived, the scores of all indexes were significantly higher than that of the patients who were non-survivors (p < 0.05). Although the diagnostic accuracy of Fournier Gangrene Severity Index and Uludag Fournier Gangrene Severity Index for mortality was moderate, diagnostic accuracies of Age-adjusted Charlson Comorbidity Index and Sequential Organ Failure System score for prediction of mortality were regarded as good. Fournier Gangrene Severity Index, Uludag Fournier Gangrene Severity Index, Age-adjusted Charlson Comorbidity Index, and Sequential Organ Failure System score were shown to be associated with mortality in Fournier’s gangrene. Diagnostic accuracies of Uludag Fournier Gangrene Severity Index, Age-adjusted Charlson Comorbidity Index, and Sequential Organ Failure System score for prediction of mortality were higher than that of Fournier Gangrene Severity Index.

Fournier's Gangrene in Females: Presentation and Management at a Tertiary Center

ObjectiveTo report and compare presentation and management of Fournier's Gangrene (FG) in female vs male patients at a single tertiary care center. MethodsPatient demographics, clinical characteristics, treatments and outcomes were summarized and compared between males and females who were treated for FG from 2011 to 2018 at a single institution. ResultsOf the 143 patients treated for FG at our institution, 33 (23%) were female. Female patients were predominantly white (82%), with a median (IQR) age of 55 (46, 59). Median female boby mass index (BMI) was 42.1 (32, 50.4). Female patients’ wound cultures were polymicrobial mix of gram positive and gram negative organisms. Median number of debridements for females was 2 (1,3). The most common anatomic region of gangrene involvement in females was labia (76%) followed by perineum (55%) and gluteus/buttocks (42%). Mortality rate during initial admission was 6% for females.Female patients had a higher median BMI than males (42.1 vs 33.7 respectively; P = .003). FG severity index, length of hospital stay, number of debridements, and wound cultures were comparable to males. The surgical team managing initial debridements differed with females managed primarily by general surgery and males primarily by urology. Mortality rate was comparable to men (6% vs 7%, P >.05). ConclusionFemale patients with FG have greater BMI but similar clinical presentation, microbiologic characteristics and mortality rate compared to men. Urologists have little involvement during initial management for females at our institution.

Sodium-glucose co-transporter-2 inhibitors and the risk of urosepsis: A multi-site, prevalent new-user cohort study.

To compare urosepsis rates in patients with type 2 diabetes treated using sodium-glucose co-transporter-2 inhibitors (SGLT2i) with dipeptidyl peptidase-4 inhibitors (DPP4i) in a real-world setting. We conducted a matched cohort study using a prevalent new-user design with time-conditional propensity scores. New users of SGLT2i from seven Canadian provinces and the UK were matched to DPP4i users. The primary outcome was hospitalization with a diagnosis of urosepsis and the secondary outcome was Fournier's gangrene. Site-specific hazard ratios for urosepsis comparing SGLT2i with DPP4i were estimated using Cox proportional hazards models and pooled using a random effects meta-analysis. We included 208 244 users of SGLT2i and 208 244 users of DPP4i. Among SGLT2i users, 42% initiated canagliflozin, 31% dapagliflozin and 27% empagliflozin. During a mean follow-up of 0.9 years, patients initiating SGLT2i had a lower rate of urosepsis compared with those receiving DPP4i. The pooled adjusted hazard ratio was 0.58 (95% confidence interval [CI]: 0.42-0.80). The incidence rates of Fournier's gangrene were numerically similar in SGLT2i (0.08 per 1000 person-years; 95% CI: 0.05-0.13) and DPP4i users (0.14; 95% CI: 0.09-0.21). In this large, multi-site study, we did not observe an increased risk for urosepsis associated with SGLT2i compared with DPP4i among patients with type 2 diabetes in a real-world setting.

Characteristics of microflora involved in the development of purulent paraproctitis and its sensitivity to ozone

Annotation. Despite significant advances in surgery to overcome purulent complications, the development of acute paraproctitis remains an extremely pressing problem, accounting for up to 4% of surgical pathology. This article is devoted to the study of the microbial spectrum of pathogens that contribute to the development of acute paraproctitis and Fournier gangrene, as the extreme degree of exposure of the subcutaneous adipose tissue of the external genitalia and perianal area in men. To study the microbial spectrum of pathogens of this pathology used the rules of intake, transportation of the studied material according to the Order of the Ministry of Health of Ukraine No. 234 on the organization of prevention of nosocomial infections in obstetric hospitals. The identification of isolated cultures was performed considering morphological, cultural and biochemical characteristics. Biochemical typing was performed using PLIVA diagnostic test systems – Lachema a. s. Brno, Czech Republic (NEFERMtest 24, STAPHYtest 16, ENTEROtest 24). To evaluate the effectiveness of the decontamination effect of ozonized sodium chloride solution, a quantitative suspension test was introduced with the introduction of a suspension of microorganisms isolated from the test material, followed by seeding on dense nutrient media to calculate the number of viable cells to reduce the exposure to the specified ex ante. The purpose of the study was to study the disinfecting effect of ozonated sodium chloride solution to improve the effectiveness of treatment of patients with acute paraproctitis. The results of the study indicate that the use of ozonated sodium chloride solution has significant advantages over the use of 0.02% solution of furacilin and decasan in the treatment of patients with acute paraproctitis and significantly reduces the risk of complications and accelerates the recovery of patients. The results of the research prove that the ozonated solution of sodium chloride in two dilutions (1:1), in contrast to other antiseptics, retains bactericidal action against the whole spectrum of bacteria that are most often involved in the development of acute paraproctitis. Thus, we consider it appropriate to include this solution in the scheme of complex treatment of patients with acute paraproctitis.

Severe bacterial skin infections

The severe bacterial diseases discussed herein are those that present dermatological lesions as their initial manifestations, for which the dermatologist is often called upon to give an opinion or is even the first to examine the patient. This review focuses on those that evolve with skin necrosis during their natural history, that is, necrotizing fasciitis, Fournier gangrene, and ecthyma gangrenosum. Notice that the more descriptive terminology was adopted; each disease was individualized, rather than being referred by the generic term “necrotizing soft tissue infections”. Due to their relevance and increasing frequency, infections by methicillin-resistant Staphylococcus aureus (MRSA) were also included, more specifically abscesses, furuncle, and carbuncle, and their potential etiologies by MRSA. This article focuses on the epidemiology, clinical dermatological manifestations, methods of diagnosis, and treatment of each of the diseases mentioned.

SUN-700 Fournier’s Gangrene and Diabetic Ketoacidosis Caused by Canagliflozin

IntroductionSodium glucose co-transporter 2 (SGLT2) inhibitors have become an appealing treatment for diabetes due to their favorable cardiac and renal outcomes. However, reports continue to emerge describing potentially life-threatening adverse events such as Fournier’s gangrene (FG) and diabetic ketoacidosis (DKA) associated with their use. Herein, we report a case of simultaneous FG and DKA in a patient taking canagliflozin.Case PresentationA 37-year-old woman with a history of type 2 diabetes mellitus, peripheral neuropathy, and morbid obesity (BMI of 45.8 kg/m2) presented to the hospital with left gluteal pain associated with dysuria despite 5-day treatment with trimethoprim/sulfamethoxazole for a presumed urinary tract infection. Approximately 1 month prior, sitagliptin and canagliflozin were added to her regimen due to poor glycemic control on metformin (HbA1c 9.8%). On examination her temperature was 36.9oC, pulse 117 beats/minute, blood pressure 144/79 mmHg and respiratory rate was 19 bpm. She appeared lethargic and had suprapubic tenderness and induration in the left gluteal region extending to the perineum. Laboratory findings revealed an arterial pH of 7.23 and PCO2 of 34 mmHg, a blood glucose of 402 mg/dL, serum bicarbonate 12mmol/L (20-30mmol/L), an elevated anion gap of 24mmol/L (7-17mmol/L) and a lactate of 1.8 mmol/L. Urinalysis showed 4+ glucose and 1+ ketones. Serum β-hydroxybutyrate was 2.49 mmol/L (0.02-0.27mmol/L). A CT scan of the abdomen and pelvis showed marked inflammatory changes with subcutaneous edema and air within the medial left gluteal soft tissues and locules of air extending into the presacral soft tissues suggestive of Fournier’s gangrene. The diagnoses of Fournier’s gangrene and DKA were made. The patient was started on empirical antibiotic treatment and required six surgical explorations with debridement. Interestingly, initial DKA management included only subcutaneous insulin. Only when serum ketones were identified and the anion gap persisted, insulin infusion with aggressive fluid resuscitation was initiated with successful resolution of anion gap metabolic acidosis. She was discharged with a urinary catheter, vacuum dressing, colostomy with instructions to start insulin glargine 18U and discontinue the oral anti-diabetic medications.DiscussionTo the best of our knowledge, this is the first case describing the simultaneous occurrence of two potentially fatal adverse effects of SGLT2 inhibitor therapy; Fournier’s gangrene and DKA. In light of the FDA’s warnings and the growing popularity of SGLT2 inhibitor therapy it is important to be mindful of their more serious and potentially fatal complications. It is also important to promptly terminate SGLT2 inhibitors when harmful adverse effects are suspected to prevent further progression.

Penile Necrotizing Fasciitis (Fournier's Gangrene) after Penile Prosthesis Implant in diabetic patient treated conservatively – A case report.

Background: Penile abscess and necrotizing fasciitis are very rare. Diabetes mellitus is the common risk factors. In our practice, this is the first reported case of penile necrotizing fasciitis after penile prosthesis insertion. Aim of the work: We intended to present our case of penile necrotizing fasciitis treated conservatively. A written consent has been signed by the patient to release information for this study.Case description: Our patient is a 52 years old male, who had a history of painless skin loss of the penis (ventral aspect of the lower parts of the shaft) for 7 days. The skin necrosis started 21 days after implantation of penile prosthesis. He had controlled type-2 diabetes mellitus. No specific signs were detected by general examination. There was discrete tenderness on penile wound; which was 2.5*4.2 cm of skin loss, with white patches, purulent discharge, elevated edges and erythema. The management consisted of use of antibiotics (oral combination of amoxicillin-clavulanic acid and local fusidic acid) with 0.9% normal saline washout on regular intervals. There was excellent wound healing with minimal tissue loss. Conclusion: Our case report revealed that, the serious complication of necrotizing fasciitis may occur after implantation of penile prosthesis. Surgical intervention was not indicated and conservative medical treatment was successful.

Fournier gangrene: pictorial review.

Fournier gangrene is an emergency condition that is associated with a high mortality rate. It is defined as a rapidly progressing infective necrotizing fasciitis of the perineal, perianal, and genital regions. Early diagnosis, broad-spectrum antibiotic coverage, and adequate surgical debridement are crucial and lead to better prognosis and patient survival. There is increasing utilization of computed tomography (CT) in the initial evaluation of Fournier gangrene. CT can confirm the diagnosis in equivocal cases, determine the source of infection, and evaluate the disease extent. In this pictorial review, we discuss the pathogenesis of Fournier gangrene and display the imaging spectrum with an emphasis on CT findings, including asymmetrical fascial thickening, soft tissue stranding, soft tissue gas, collection, and abscess formation. The infection originating from colorectal pathology, the affected anatomy, and the involvement of the abdominal wall are important predictors of mortality. The familiarity of the varied imaging appearance of Fournier gangrene is necessary to provide an accurate diagnosis, and evaluation of disease extent is crucial for optimal surgical debridement.

Extensive fournier gangrene with retroperitoneal involvement in a diabetic patient

Fournier’s gangrene is a rare, rapidly progressive, fulminant form of necrotizing fasciitis of the genital, perianal and perineal regions extending to the abdominal wall between the fascial planes. It is secondary to polymicrobial infection by aerobic and anaerobic bacteria with a synergistic action. A 42 year old male who is an alcoholic and diabetic on irregular treatment presented with scrotal swelling and pain for 5 days following a trauma. On examination, patient was febrile, tachypneic and had tachycardia. His scrotum was edematous and erythematous on right side with crepitus. Abdomen was warm on right side till umbilicus and had crepitus. He was in sepsis and had diabetic ketoacidosis, prerenal azotemia and mild impairment of liver function. A diagnosis of extensive Fournier gangrene with retroperitoneal involvement was made. Patient underwent scrotal exploration and aggressive debridement serially. Testis was spared. As patient improved with good wound care and glycemic control, wound was closed. Though our patient had retroperitoneal involvement without peritonitis, he was deferred laparotomy which significantly reduced the morbidity and mortality. It is one of the few reported case in the literature with retroperitoneal involvement.

A simplified prognostic scoring and grading system for Fournier’s gangrene

Background: Fournier’s gangrene is life threatening, necrotizing fasciitis, affecting external genetalia of male greater than female with mortality 7 to 53%. Fournier gangrene severity, LRINR and LNR scoring used to evaluate morbidity and mortality. Aim and objective of our study was to simplify a system, especially for Indian peripheral health centers which can predict mortality, morbidity.Methods: This study was conducted in department of surgery of Teerthankar Mahaveer University. Body mass index, blood urea nitrogen and patient demography used to develop the scoring system with minimum and maximum points and correlated our results.Results: Our simplified scoring system also has a direct bearing on mortality, morbidity, recovery and hospital stay. In our study 3 male and 2 females died.Conclusions: Simplified scoring and grading system will be helpful in predicting the morbidity and mortality, early surgical intervention, hospital stay, time for reconstruction.

Fournier's gangrene that initially mimicked pubic cellulitis in an elderly woman administered a Janus kinase inhibitor, methotrexate, and prednisolone for rheumatoid arthritis

This is the first reported case of FG during administration of a JAK inhibitor. The case appeared to be a less serious manifestation when first examined; however, extremely serious clinical features developed immediately after the withdrawal of TOF.

Fournier's gangrene in a two-month-old infant

Abstract We present a case of Fournier gangrene (FG) in a two-month-old male infant which admitted to the hospital with chief complaining of progressive scrotal swelling for two weeks. Scrotal ultrasonography showed a free fluid on right hemiscrotal and normal testicles size. Debridement was conducted to remove devitalized tissue. Forty days after the surgery, the patient remained well without any complication.

Fournier's gangrene during lenvatinib treatment: A case report

Fournier's gangrene is a rare and severe complication reported in patients with cancer treated with antiangiogenic drugs, most frequently with bevacizumab. The present report describes the case of an 80-year-old man with radioactive iodine-refractory metastatic thyroid cancer treated with lenvatinib (an oral multikinase inhibitor with antiangiogenic properties) who developed Fournier's gangrene in the absence of other known risk factors. To the best of our knowledge, this is the first case described during treatment with lenvatinib. The condition was likely due to a perturbation of vascular endothelial cells of the skin due to the inhibition of VEGF/VEGFR signaling. Fournier's gangrene may be a class effect of antiangiogenic treatment that clinicians should be aware of, as early diagnosis and treatment are associated with an improved outcome.