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Fournier’s Gangrene: Management in a Poor Resource Setting

Abstract

Fournier’s gangrene is a rapidly progressive necrotizing infection of the external genitalia. We aim to share our clinical experience in the management of this disease. This was a retrospective study with data retrieved from the case note of patients seen with Fournier’s gangrene between January 2013 and April 2019. A total of 23 cases were analysed, who were all men, with a mean age of 47 years. The mean duration before presentation was 8 days. Perianal lesion was the most common aetiological factor occurring in 39% and the most common isolated organism was E. coli. The mean number of debridement was 1.5 while 2 patients required colostomy. The mortality rate was 9% in this study. Despite improvement in clinical care, Fournier’s gangrene remains a potentially fatal condition. Thus, aggressive resuscitation, debridement and judicious antibiotic therapy are required.

Introduction

Fournier’s gangrene is a polymicrobial synergistic necrotising fasciitis which affects the external genitals and perineum. A French venereologist, Jean Alfred Fournier, described five cases in clinical lectures in 1883 [1]. It is more common in men than in women. This condition is more common in diabetics, immunosuppressed, malnourished and alcoholics while being associated with significant morbidity and healthcare cost [2]. Initially thought to be idiopathic, more recently various aetiologies have been identified. The aetiologies have been classified into urogenital, anorectal, retroperitoneal, iatrogenic trauma and others [1, 3]. Fournier’s gangrene has been described as a synergism between aerobic and anaerobic bacteria; therefore, early surgical debridement and antibiotics are important in the management. Hyperbaric oxygen has been proposed as an adjunctive treatment; it increases leucocyte activity, reduces bacterial endotoxin production and increases the efficacy of some antibiotics. Hyperbaric oxygen therapy promotes wound healing by increasing angiogenesis and activity of fibroblasts [1]. The use of negative pressure wound therapy is also useful as it reduces bacterial colonisation, increases granulation tissue formation, increase blood supply and remove excess exudate. These advanced wound therapy are not usually available in resource limited environment. We therefore seek to present our experience in managing these cases in resource limited environment. Achieving better outcomes usually requires collaboration of the multidisciplinary team of urologists, plastic surgeons and endocrinologists [4].

Materials and Methods

The study was a single-centre retrospective study which was carried out in General Hospital, Marina, Lagos, the premier general hospital in Nigeria. It is a 225-bedded hospital which provides primary and secondary care services to a diverse group of people in the city of Lagos.

Records of all patients managed for Fournier’s gangrene between January 2013 and April 2019 at the General Hospital were retrieved. A total of 30 cases were managed, 25 case notes were retrieved while 23 with complete records were deemed suitable for analysis.

Statistical analysis was performed using SPSS version 20 by IBM Corporation USA. Descriptive variables were analysed by their frequency and measures of central tendency and dispersion were performed for quantitative variables.

Results

A total of 23 cases were analysed with age range of 22 to 93 years and a mean of 47 years; all were men (Fig. 1). The average duration of illness before presentation was 8 days but this ranged from 1 to 14 days. The most common symptom was scrotal swelling (95.7%) while the least common on presentation was exposure of the testes (42.9%). Majority of patients had fever (73.9%) and 8.7% had jaundice (Table 1). The mean pulse rate, respiratory rate and systolic blood pressure were 106.8, 27.4 and 118.4 respectively (Table 2). In 11 patients whose residual ulcer after debridement was estimated, the mean size was 120 cm2. Of the evaluated aetiological factors, perianal lesion was present in just over a third (39.1%) while no patient had scrotal trauma. No risk factor was identified in 39% of patients (Fig. 2).

Fig. 1
figure1

Age distribution

Table 1 Clinical features
Table 2 Vital signs and size of ulcer
Fig. 2
figure2

Aetiology

The laboratory parameters are shown in Table 3. Anaemia, packed cell volume less than 30%, was detected in 47.8%, mean white blood cell count was above 11,000 and renal impairment occurred in 34.8% (those with creatinine above 132 μmol/L).

Table 3 Laboratory results and other parameters

Eight patients had cultures with 3 of those having more than one organism cultured. Fifty percent (4) grew Escherichia coli; Klebsiella, the next most common organism, grew in 3 patients. Both Staphylococcus sp. and Proteus grew in a patient each but Pseudomonas was isolated in 2 patients. The sensitivity pattern is frequently multiresistant to common antibiotics (amoxyclav, ceftriaxone, ceftazidime, cefuroxime, ciprofloxacin). However, the organisms were usually sensitive to meropenem.

An average of 44 days was spent on admission and a mean of about 4 pt of blood was transfused. About half (47.8%) received no blood transfusion; however, colostomy was performed in 2 patients. Areas of the body involved by the disease are identified in Fig. 3. Sixty-five percent had their debridement done bedside while the remaining was performed in theatre. About one quarter (26%) of patients required 2 sessions of debridement, 9% had three sessions and the mean number of sessions of debridement was 1.5. A significant proportion of ulcers (52.2%) in these patients healed by secondary intention while 2(8.7% of patients) had delayed wound closure. Skin grafting and flap closure were performed in (13%) and (4.3%) of patients respectively. One patient with extensive disease was referred for wound closure that will require plastic surgical expertise while two patients (9%) died.

Fig. 3
figure3

Areas of the body affected

Discussion

Fournier’s gangrene is necrotising fasciitis affecting the perineal region. It is known to affect both males and females; however, in our study, only male patients were affected.

The age range observed in our study (range 22–93 with a mean of 47 years) is similar to others in literature [4,5,6]. However, a lower median age of 34 years was reported in a study from Tanzania [7]. The mean interval before presentation of 8 days is similar to another study in Southeast Nigeria [6].

The aetiologic risk factor was perianal lesion which occurred in just under half of our patients, similar to observations by Ghnnam in Egypt and another study from Turkey [5, 8]. This is different from the observation of Aji et al. who reported urethral stricture as their most common risk factor [4]. Diabetes mellitus, thought to be the most important risk factors in some studies [9, 10], occurred in 3 patients as the second most common risk factor while retroviral disease and multiple myeloma occurred in one patient respectively.

Although only 18% required transfusion in a study by Benjelloun, more than half of our patients required blood transfusion [11]. Renal impairment occurred in about one-third of patients compared to what was reported in a recent study by Caliskan et al. [12] The organism most commonly identified in this study was E. coli, similar to the findings of other studies [8, 13].

Serial debridement, frequently done bedside (65%), was effective for a substantial number of our patients. This was performed with local anaesthesia and sedation; necrotic tissues were surgically removed until edges of the wound bled freely, haemostasis secured and dressings applied. However, patients with extensive lesion involving anterior abdominal wall and groin or patients requiring colostomy or suprapubic cystostomy had their procedures done in the theatre. These multiple sessions of debridement, average of 1.5 in our study, is consistent with the finding of other investigators [14].

None of our patients had their testis removed in contrast to the findings of some recent studies [12, 15]. This is because the testes derive their blood supply from the gonadal artery a branch of the aorta whereas the scrotal and penile skin obtain their arterial supply from the internal and external pudendal arteries [1]. Of the two patients who required sigmoid colostomy, one had rectal laceration as part of multiple traumatic injuries while the other had extensive perianal disease extending to the anal margin. A patient had suprapubic cystostomy because of urethral stricture. This is unlike what was reported in a particular study which had a high rate of suprapubic cystostomy, about 60% [16]. Our patients had twice daily hypertonic saline sitz bath with regular dressing with hydrogen peroxide and EUSOL (Edinburgh University Solution of Lime) at an initial stage and later honey dressing. The honey dressing is proposed to give a superior cosmetic outcome [17].

All patients had broad-spectrum antibiotics, with the use of third-generation cephalosporin and metronidazole being the commonest. In certain cases such as those with extensive lesions or a certain patient admitted in shock, meropenem and metronidazole were employed. Antitetanus prophylaxis was administered to all patients. This is because in our practice setting, it is difficult to obtain immunisation records of patients.

Another limitation of our practice setting is the limited use of blood investigations or imaging in diagnosing or prognosticating in Fournier’s gangrene. Since patients make out of pocket payment for healthcare, blood investigation results may be delayed for up to 72 h or more, thus limiting the use of Fournier’s Gangrene Severity Index (FGSI) and Laboratory Risk Indicator for Necrotizing fasciitis (LRINEC) scores in the immediate assessment of these cases. Thus, the diagnosis was made based on the clinical appearance. FGSI was first described by Laor and a score of 9 is correlated with increased mortality and other studies have observed similar findings [18,19,20,21]. However, a recent review of cases from a tertiary centre in Sweden and other European centres did not find a significant correlation with mortality [15, 22, 23].

Other challenges encountered in managing these patients include lack of facilities for hyperbaric oxygen therapy and negative pressure wound therapy. Several studies have documented a reduction in mortality in Founier’s gangrene treated with hyperbaric oxygen as this is thought to be due to the increase in oxygen tension in the tissues which disrupts the synergism between aerobes and anaerobes [24,25,26]. Mindrup et al., however, did not document a reduction in mortality with hyperbaric oxygen [27]. Vacuum-assisted wound closure is associated with less dressing changes and shorter period of hospitalisation [26, 28,29,30].

There are important limitations to the current study. These include a limited number of patients in a retrospective study and a lack of use of the FGSI in scoring. Lastly, this is a single-centre experience which may limit generalisation of the results.

Fournier’s gangrene is a highly fatal condition with mortality quoted in the range of 16% in a large review [3]. Nonetheless, we recorded 9% mortality similar to what is reported in the literature [4, 31].

Conclusion

Fournier’s gangrene, despite advances in technology, is a rapidly progressive and potentially fatal infectious condition. Aggressive surgical debridement with judicious use of antibiotics and local wound care is important to avoid morbidity and mortality.

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Author information

Correspondence to Benjamin Olasunkanmi Odusanya.

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The authors declare that they have no conflict of interest.

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Approval of the ethical committee of General hospital Lagos was obtained. Patient anonymity and confidentiality were maintained at all times.

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Informed consent of patients whose pictures were used in the study was obtained and they were re-assured that no identifying body parts will be shown.

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Appendix

Appendix

PROFORMA: FOURNIER’S GANGRENE

HOSPITAL NUMBER

AGE

GENDER

DURATION BEFORE PRESENTATION

CLINICAL FEATURES

Scrotal pain

Scrotal swelling

Discharge

Discoloration

Exposure of testis

Fever

Pallor

Dehydration

Heart rate

Respiratory rate

Blood pressure

Hypotension

Size of ulcer

Areas affected

scrotum anterior wallscrotum posterior wall perineum ischiorectal fossa penis anterior abdominal wall others

Presence of perianal lesion

Urethral instrumentation

Urethral stricture

Scrotal trauma

Comorbidities:

Diabetes

If yes duration

Immunosuppression

Others state:

INVESTIGATION RESULT

FBC : PCVWBC DIFF.PLATELETS

ELECTROLYTES UREA AND CREATININE On admission

WOUND SWAB M/C/S

MANAGEMENT

Days before debridement

Debridement bedside or theatre

Average number of debridement

Antibiotics intravenous duration

Oral duration

Sitz bath

Duration before commencing sitz bath

Days on admission

Blood Transfusion yes no

No of pints transfused

Surgical closure

Type of surgical closure

Referral yes or no

Colostomy

Death

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Odusanya, B.O., Saliu, N.A. & Salami, O.A. Fournier’s Gangrene: Management in a Poor Resource Setting. SN Compr. Clin. Med. 2, 209–214 (2020). https://doi.org/10.1007/s42399-020-00226-y

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Keywords

  • Fournier’s gangrene
  • Necrotising fasciitis
  • Synergistic infection
  • Debridement
  • Risk factors