Fournier gangrene: Difference between revisions
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==Clinical Features== | ==Clinical Features== | ||
[[File:Fournier-Gangrene.png|thumb|Fournier's Gangrene]] | [[File:Thumbnail_IMG_9537.jpg|thumb|Early Fournier's Gangrene with classic spotted area of ecchymosis (right lower scrotum) and draining lesion (mid scrotum). Draining lesions are not always present initially and even small areas of ecchymosis should be considered highly concerning for Fournier's Gangrene.]] | ||
[[File:PMC3560168 JCAS-5-273-g004.png|thumb| | [[File:Fournier-Gangrene.png|thumb|Progression of Fournier's Gangrene to larger draining lesion.]] | ||
[[File:PMC3560168 JCAS-5-273-g004.png|thumb|Fournier's Gangrene]] | |||
*Initial event is usually local trauma or extension of a UTI or perianal infection<ref name="Shyam" /> | *Initial event is usually local trauma or extension of a UTI or perianal infection<ref name="Shyam" /> | ||
**Gangrene develops over 2-7 days | **Gangrene develops over 2-7 days | ||
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*[[Antibiotics]] - Must cover [[gram positive]], [[gram negative]], and [[anaerobes]] | *[[Antibiotics]] - Must cover [[gram positive]], [[gram negative]], and [[anaerobes]] | ||
**[[Vancomycin]] + ([[imipenem]] 1gm IV q24hr '''OR''' [[meropenem]] 500mg-1gm IV q8hr '''OR''' [[piperacillin-tazobactam]] 3.375gm to 4.5gm IV q6h) +/- ([[clindamycin]] 600mg-900mg IV q8h '''OR''' [[metronidazole]] 1gm IV then 500mg IV q8h) | **[[Vancomycin]] + ([[imipenem]] 1gm IV q24hr '''OR''' [[meropenem]] 500mg-1gm IV q8hr '''OR''' [[piperacillin-tazobactam]] 3.375gm to 4.5gm IV q6h) +/- ([[clindamycin]] 600mg-900mg IV q8h '''OR''' [[metronidazole]] 1gm IV then 500mg IV q8h) | ||
**[[Piperacillin-Tazobactam]] 3.375-4.5g q6hr and [[linezolid]] 600mg q12hr is an alternative regimen<ref>Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America [published correction appears in Clin Infect Dis. 2015 May 1;60(9):1448. Dosage error in article text]. Clin Infect Dis. 2014;59(2):e10-e52. doi:10.1093/cid/ciu444</ref> | |||
*Aggressive supportive care, including fluid resuscitation (and [[Vasopressors|pressors]], if indicated) | *Aggressive supportive care, including fluid resuscitation (and [[Vasopressors|pressors]], if indicated) | ||
Latest revision as of 21:12, 13 July 2023
Background
- Life-threatening polymicrobial necrotizing fasciitis of perineum, genitalia, or perianal area.
- Mostly bacteria lower GI system - B. fragilis and E. coli
- Obliterative endarteritis of subcutaneous arterioles leads to gangrene of overlying skin[1]
- Mortality - often cited as 20-40%, but up to 80% in some studies[2]
Risk Factors
- Diabetes mellitus (most common)
- Hypertension
- Alcoholism
- Advanced age
- Para/Quadriplegic
- Males>Females (10:1)[1], (likely under-diagnosed in women[2])
Clinical Features
- Initial event is usually local trauma or extension of a UTI or perianal infection[1]
- Gangrene develops over 2-7 days
- Marked pain, localized swelling, crepitus, ecchymosis to genital or perineal area.
- Fever
- Malodorous purulent drainage
- In late or severe cases, patient may present in septic shock
Differential Diagnosis
Testicular Diagnoses
- Scrotal cellulitis
- Epididymitis
- Fournier gangrene
- Hematocele
- Hydrocele
- Indirect inguinal hernia
- Inguinal lymph node (Lymphadenitis)
- Orchitis
- Scrotal abscess
- Spermatocele
- Tinea cruris
- Testicular rupture
- Testicular torsion
- Testicular trauma
- Testicular tumor
- Torsion of testicular appendage
- Varicocele
- Pyocele
- Testicular malignancy
- Scrotal wall hematoma
Evaluation
Work-up
- CBC - very elevated leukocytosis
- CMP - hyponatremia
- ESR
- CRP
- Lactate
- Type and Screen
- Wound Culture
- Blood Cultures
- CT Abdomen/pelvis (only if diagnosis unclear or if requested by surgery/urology)
Evaluation
- Clinical diagnosis, based on history and physical exam
- LRINEC score here: Necrotizing fasciitis
Management
- Immediate surgery and urology consult for surgical debridement (gangrene can spread at rate of 2-3 cm/hr[1])
- Antibiotics - Must cover gram positive, gram negative, and anaerobes
- Vancomycin + (imipenem 1gm IV q24hr OR meropenem 500mg-1gm IV q8hr OR piperacillin-tazobactam 3.375gm to 4.5gm IV q6h) +/- (clindamycin 600mg-900mg IV q8h OR metronidazole 1gm IV then 500mg IV q8h)
- Piperacillin-Tazobactam 3.375-4.5g q6hr and linezolid 600mg q12hr is an alternative regimen[3]
- Aggressive supportive care, including fluid resuscitation (and pressors, if indicated)
Disposition
- Admit to ICU
See Also
References
- ↑ 1.0 1.1 1.2 1.3 Shyam DC, Rapsang AG. Fournier's gangrene. Surgeon. 2013 Aug;11(4):222-32. doi: 10.1016/j.surge.2013.02.001.
- ↑ 2.0 2.1 Wróblewska M et al. Fournier's gangrene: current concepts. Pol J Microbiol. 2014;63(3):267-73.
- ↑ Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America [published correction appears in Clin Infect Dis. 2015 May 1;60(9):1448. Dosage error in article text]. Clin Infect Dis. 2014;59(2):e10-e52. doi:10.1093/cid/ciu444