8/4/2009

Gil Z. Shlamovitz, MD, FAAEM

Assistant Professor of Emergency Medicine, University of
Connecticut School of Medicine
Attending Physician, Emergency Department, Hartford Hospital,
Hartford, CT and Windham Hospital, Willimantic, CT

OBJECTIVES

Review of the current epidemiology

and microbiology of Fourniers
Gangrene.

Review of the current diagnostic

approach and treatment of Fourniers
Gangrene.

DEFINITION

Current: necrotizing
fasciitis of the perineal,
perineal,
perianal,, or genital areas
perianal

Original: necrotizing
infection of the male
genitalia
Jean-Alfred Fournier
(1832-1914)

Sorensen MD et al. Fournier's Gangrene: population based epidemiology and outcomes. J

Urol. 2009 May;181(5):2120-6. Epub 2009 Mar 14.

8/4/2009

EPIDIMIOLOGY

Frequency: 1.6/100,000 (USA)

Sex: 42:1 (M:F)

Age: 51 19

Mortality: 7.5% (4
(4--80)

Sorensen MD et al. Fournier's Gangrene: population based epidemiology and outcomes. J

Urol. 2009 May;181(5):2120-6. Epub 2009 Mar 14.

RISK FACTORS
Diabetes
Obesity
Alcohol misuse
Chemotherapy
Corticosteroid
C ti
t id use
HIV
Leukemia
Liver disease

Sorensen MD et al. Fournier's Gangrene: population based epidemiology and outcomes. J

Urol. 2009 May;181(5):2120-6. Epub 2009 Mar 14.
Thwaini A et al. Fournier's gangrene and its emergency management. Postgrad Med J. 2006
Aug;82(970):516-9.

ETIOLOGY

Gastrointestinal (30
(30--50%)
50%)

Genitourinary (20
(20--40%)
40%)

Malignancy, Trauma /
Instrumentation, IBD,
Diverticulitis, Infections
Infections, Trauma /
Instrumentation

Dermatologic (20
(20%)
%)

Pressure Ulcers, Trauma /

Surgical Wound Infection,
Hidradenitis Suppurativa

Thwaini A et al. Fournier's gangrene and its emergency management. Postgrad Med J. 2006
Aug;82(970):516-9.

8/4/2009

CAUSATIVE ORGANISMS
Escherichia

coli

Enterococcus

Bacteroides

Streptococcus

Proteus

Pseudomonas

Staphylococcus

Klebsiella

(MRSA)
Clostridium
Thwaini A et al. Fournier's gangrene and its emergency management. Postgrad Med J. 2006
Aug; 82(970): 516-9.
Burton MJ, Shah P, Swiatlo E: Community-acquired methicillin-resistant Staphylococcus
aureus as a cause of Fournier's gangrene. Am J Med Sci. 2008 Apr; 335(4): 327-8.
Kalorin CM, Tobin EH: Community associated methicillin resistant Staphylococcus aureus
causing Fournier's gangrene and genital infections. J Urol. 2007 Mar; 177(3): 967-71

CLINICAL PRESENTATION
Prodromal Symptoms
Intense Genital Pain &
Tenderness
Progression of Pain &
y
Erythema
Blistering
Dusky Appearance of
Skin
Frank Gangrene

Thwaini A et al. Fournier's gangrene and its emergency management. Postgrad Med J. 2006
Aug;82(970):516-9.

DIFFERENTIAL DIAGNOSIS

Cellulitis
Strangulated hernia
Scrotal abscess
Streptococcal
necrotizing
g fasciitis
Vascular occlusion
syndromes
Herpes simplex
Gonococcal balanitis
and edema

Pyoderma
gangrenousm
Allergic vasculitis
Polyarteritis nodosa
Necrolytic
y migratory
g
y
erythema
Warfarin necrosis
Ecthyma
gangrenosum

Thwaini A et al. Fournier's gangrene and its emergency management. Postgrad Med J. 2006
Aug;82(970):516-9.

8/4/2009

LABORATORY STUDIES

CBC

Wound Cultures

Electrolytes,

Blood Cultures

Bicarbonate, Renal

PT / PTT

Type & Screen

Functions

Blood Gases

ESR / CRP

Thwaini A et al. Fournier's gangrene and its emergency management. Postgrad Med J. 2006
Aug;82(970):516-9.

10

IMAGING STUDIES

Computerized Tomography
Asymmetric fascial thickening
Fat stranding
Subcutaneous emphysema
Fluid collections

Ultrasonography
Other pathology
Gas in Scrotal Wall

MRI

Levenson RB, Singh AK and Novelline RA: Fournier Gangrene: Role of Imaging.
RadioGraphics 2008; 28:519528

11

FOURNIERSS GANGRENE
SEVERITY INDEX SCORE (FGSIS) ?

30 patients over 15 years

Modified APACHE II score

Temp,
p, HR,, RR,, Na,, K,, Crt,
Crt, Hct,
Hct, WBC,, CO2
CO2

0 - 40

FGSIS > 9 75% Mortality

Laor E, Palmer LS, Tolia BM, Reid RE and Winter HI: Outcome prediction in patients with
Fourniers gangrene. J Urol 1995; 154: 89.
Corcoran AT, Smaldone MC, Gibbons EP, Walsh TJ and Davies NJ: Validation of the
Fournier's Gangrene Severity Index in a Large Contemporary Series. J Urol. 2008
Sep;180(3):944-8. Epub 2008 Jul 17

12

8/4/2009

TREATMENT - SURGICAL
Excisional

biopsy of the area of most concern

Thwaini A et al. Fournier's gangrene and its emergency management. Postgrad Med J. 2006
Aug;82(970):516-9.

13

TREATMENT - SURGICAL
Extensive

Surgical Debridement

Thwaini A et al. Fournier's gangrene and its emergency management. Postgrad Med J. 2006
Aug;82(970):516-9.

14

TREATMENT - SURGICAL
Intensive

wound care

Ozturk E, Ozguc H, Yilmazlar T: The use of vacuum assisted closure therapy in the
management of Fournier's gangrene. Am J Surg. 2009 May;197(5):660-5

15

8/4/2009

TREATMENT - SURGICAL
Fecal

Diversion

Reconstruction

Thwaini A et al. Fournier's gangrene and its emergency management. Postgrad Med J. 2006
Aug;82(970):516-9.

16

TREATMENT IN THE ED

IV, O2

Fluid Resuscitation

Analgesia

B dS
Broad
Spectrum
t
Antibiotics
A tibi ti

Correction of Electrolyte /
Metabolic Derangements

Urinary Diversion

Thwaini A et al. Fournier's gangrene and its emergency management. Postgrad Med J. 2006
Aug;82(970):516-9.

17

INITIAL ANTIBIOTICS
Piperacillin

/ Tazobactam

(Zosyn
Zosyn),
), plus Vancomycin

Ampicillin,, Gentamycin
Ampicillin
Gentamycin,,
Metronidazole,, plus
Metronidazole
Vancomycin

Thwaini A et al. Fournier's gangrene and its emergency management. Postgrad Med J. 2006
Aug;82(970):516-9.

18

8/4/2009

CLINDAMYCIN ?

Stevens DL, Bryant AE, Hackett SP. Antibiotic effects on bacterial viability, toxin production,
and host response. Clin Infect Dis 1995;20(Suppl 2):S1547.
Stevens DL, Maier KA, Mitten JE. Effect of antibiotics on toxin production and viability of
Clostridium perfringens. Antimicrobial Agents Chemother 1987;31(2):2138.
Stevens DL, Gibbons AE, Bergstrom R, et al. The Eagle effect revisited: efficacy of
clindamycin, erythromycin, and penicillin in the treatment of streptococcal myositis. J Infect Dis
1988;158(1):238.
Zimbelman J, Palmer A, Todd J. Improved outcome of clindamycin compared with
beta-lactam antibiotic treatment for invasive Streptococcus pyogenes infection. Pediatr
Infect Dis J 1999;18(12):1096100.
Stevens DL, Ma Y, Salmi DB, et al. Impact of antibiotics on expression of virulence associated
exotoxin genes in methicillin-sensitive and methicillin-resistant Staphylococcus
aureus. J Infect Dis 2007;195(2):20211.

19

CONSULTATIONS
General

Surgery

Urology
Infectious

Disease

Thwaini A et al. Fournier's gangrene and its emergency management. Postgrad Med J. 2006
Aug;82(970):516-9.

20

HYPERBARIC OXYGEN?

Mindrup SR, Kealey GP and Fallon B: Hyperbaric oxygen for the treatment of fournier's
gangrene. J Urol. 2005 Jun;173(6):1975-7.
Hollabaugh RS Jr, Dmochowski RR, Hickerson WL and Cox CE: Fournier's gangrene:
therapeutic impact of hyperbaric oxygen. Plast Reconstr Surg. 1998 Jan;101(1):94-100.
Pizzorno R, Bonini F, Donelli A, Stubinski R, Medica M and Carmignani G: Hyperbaric oxygen
in the treatment of Fourniers disease in 11 male patients. J Urol, 1997; 158: 837

21

8/4/2009

MEDICOLEGAL PITFALLS

Failure to realize that cutaneous

findings often underestimate the
extent of underlying disease

Failure to initiate early broadbroadspectrum antibiotics

Failure to obtain immediate

urologic / surgical consultation or
to transfer the patient to an
appropriate facility

Thwaini A et al. Fournier's gangrene and its emergency management. Postgrad Med J. 2006
Aug;82(970):516-9.

22

Gil Z. Shlamovitz, MD, FAAEM

Assistant Professor of Emergency Medicine, University of
Connecticut School of Medicine
Attending Physician, Emergency Department, Hartford Hospital,
Hartford, CT and Windham Hospital, Willimantic, CT