Fournier's Gangrene: A Modern Analysis of Predictors of Outcomes

Jeffrey D. Sparenborg; Jacob A. Brems; Andrew M. Wood; Jonathan J. Hwang; Krishnan Venkatesan

Disclosures

Transl Androl Urol. 2019;8(4):374-378. 

In This Article

Abstract and Introduction

Abstract

Background: Fournier's gangrene (FG) is a rapidly progressing necrotizing fasciitis that carries a significant morbidity and mortality. The present study sought to identify the predisposing factors related to FG and validate the Fournier's Gangrene Severity Index (FGSI) score as a prognostic tool in the care of the Fournier's patient.

Methods: Medstar Washington Hospital Center records were searched from January 2003 to February 2015 for all patients with a diagnosis code of FG, n=42. Epidemiologic data was collected for patients and used to calculate an FGSI score.

Results: The average age was 53.45 yrs and M/F ratio was 39:1. Patients presented with an average 2.675 predisposing factors; the most common was diabetes mellitus (n=21) followed by hypertension (n=18). The most common etiology was periscrotal (n=25) next to perirectal (n=9). Streptococcus was the most common source of infection (n=14). Patients on average required three surgical interventions. The average and median hospitalization period was 19.625 and 11.5 days respectively. Eleven patients developed sepsis. Twenty-four (60%) patients experienced a complication. The overall mortality was 5% (n=2). The average FGSI on admission was 5.368. Multivariate analysis showed FGSI score correlates with more surgical intervention, longer hospitalization, sepsis, complication and mortality.

Conclusions: The FGSI score predicts a greater likelihood of more surgical interventions, longer hospitalization period, sepsis, complications and mortality within this patient population. Diabetes mellitus continues to be the most common predisposing factors in FG patients. The mortality rate of 5% is much less than the historically reported 20–30% and may reflect improved understanding and care of this aggressive disease.

Introduction

Fournier's gangrene (FG) is an aggressive, rapidly progressing, necrotizing fasciitis of the perineal and genital region. The disease initially described by Alfred Fournier in 1883 was a polymicrobial life threatening infection of unknown origin occurring in otherwise healthy young men.[1] Mortality rates were initially reported in the range of 20–30%, which remains the accepted textbook mortality.[2–6] However, this disease is now known to occur in a wide age range, frequently in older patients, and usually with an identifiable infectious source. Urinary extravasation, perirectal and periurethral skin infections serve as the common nidus of infection. Diabetes, immunosuppressed states and obesity often contribute to its rapid progression.[7,8]

Despite the advantage of a known etiology, evidence-based management is still challenging. Because of wide variability in presentation, clinical course, and mortality rates, it can be difficult to predict which patients warrant the most aggressive approach.

In an effort to risk stratify these patients, Laor et al. devised the FG Severity Index Score (FGSI) to predict mortality in patients with FG. The FGSI is a scoring system that consists of 9 lab parameters and vital signs, measured at presentation, each assigned a score from 0 to 4 based on deviation from the normal range. Specifically, Laor et al. found a dramatic increase in mortality (from 22% to 75%) once the FGSI score rose above 9.[9] In the intervening 20 years, several case series have attempted to validate the predictive utility of this score with mixed results.

Based on an extensive review of the literature, there has not been a recent case series at a level 1 trauma center in the United States that has evaluated the validity of the FGSI. Our study aims to validate the FGSI as a prognostic tool for predicting patient morbidity and mortality in this environment.

Comments

3090D553-9492-4563-8681-AD288FA52ACE

processing....