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

Discussion

FG is a rare, life threatening disease with a clinical course that remains challenging to predict. Early identification of patients at high risk for mortality allows rapid advancement of care and may provide survival benefit. While many institutions including our own use computed tomography (CT) scans to detect free air within the soft tissues, ultrasound has been reported to be of benefit for bedside detection of free air when CT is not readily available.[10] The FGSI score is the most widely used prognostic tool in the management of FG. Table S1 lists the single center studies that have attempted to validate the prognostic value of the FGSI.[2–5,7,11–19]

In addition, more recently, two larges database-based studies were published in the United States showing substantially lower mortality rates of 7.5% and 10%.[20,21] The mortality rate reported in this study is in line with these recent publications suggesting improved outcomes for FG patients compared to the higher mortality rates often cited in textbooks.

Based on the previous decade of experience presented here, the mortality rates of FG have improved over the past twenty years and more closely resemble the lower rates sited above of 7–10%. It is also worth noting that the FGSI is predictive of mortality and LOS in the setting of a low mortality rate. Possible reasons for a lower mortality rate include the early use of broad-spectrum antibiotics, ICU care involvement, better recognition of the disease on the primary care provider level and shorter time to debridement. A recent study compared early debridement versus conservative management of early FG (equivocal cases) and confirmed early debridement led to shorter hospital stays and better clinical outcomes.[22] No studies directly attempt to identify causes of a lower mortality rate but the above study shows that clinical care is likely responsible and not that the pathophysiology of the disease has changed.

In addition to validation of the FGSI as a predictor of morbidity and mortality, our results also showed a surprising lack of association between FGSI and 5 of its 9 constituent variables. This implies that changes in these 5 variables do not correspond to an overall increase in mortality, and therefore may not add value to the scoring system. This allows for the possibility that a modified FGSI with fewer variables may yield similar, or even superior, prognostic results. A simpler evaluation system could presumably improve utilization or implementation in the clinical setting.

A recent 2014 study by Lin et al. found that a simplified scoring system using only 3 clinical variables was non-inferior to FGSI in predicting patient mortality in an 85-patient series.[21] If a reliable, simplified scoring system can be developed that is easier for clinicians to calculate, the likelihood of clinical use increases. The findings of this paper further support that such a system may offer improved predictions of clinical outcomes.

Our study is not without its limitations. The small number of mortalities,[3] represent a statistical limitation to the study. In addition, the retrospective nature of the study limits the possible prognostic variables to those that were recorded accurately at the time of hospitalization. Other studies have shown several other clinical factors to be associated with increased mortality. Variables such as increased surface area, delayed treatment onset, advanced age, cirrhosis, anorectal vs. penoscrotal source, and immunocompromised status have all been shown to result in increased incidence of death.[11,17,23,24] Incorporating these factors into the FGSI or a newly designed scoring system may improve prognostic accuracy.

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