ORIGINAL ARTICLE

Less is more? Antibiotic duration and outcomes in

Fournier’s gangrene

Margaret Hedgecock Lauerman, MD, Olga Kolesnik, MD, Kinjal Sethuraman, MD,
Ronald Rabinowitz, MD, Manjari Joshi, MD, Emily Clark, MS, Deborah Stein, MD,
Thomas Scalea, MD, and Sharon Henry, MD, Baltimore, Maryland

BACKGROUND: Antibiotic management of Fournier’s gangrene (FG) is without evidence-based guidelines and is based on expert opinion. The ef-
fect of duration of antibiotic therapy on outcomes in FG is unknown.
METHODS: A retrospective review was performed of FG patients from 2012 to 2015 at a single institution. Patients were managed by our in-
stitutional practice of complete primary wound closure as possible, with antibiotic duration according to physician judgment. Pa-
tients were stratified into multiple durations of antibiotic administration.
RESULTS: Overall, 168 patients with FG were included. When examining multiple stratifications of antibiotic therapy of 7 days or less, 8 days
to 10 days, 11 days to 14 days, or 15 days or more of antibiotics, there was no significant difference in mortality (p = 0.11), primary
closure (p = 0.75), surgical site infection (SSI) (p = 0.52), or Clostridium difficile infection (p = 0.63). There were no cases of re-
current FG in any antibiotic stratification. Mortality was not increased (p = 1.00) and ability to achieve primary closure was not
decreased (p = 0.08) with initial antibiotic therapy exclusive of cultured organisms.
CONCLUSION: Shorter antibiotic courses for patients in whom source control is obtained and initial antibiotic selection exclusive of many resistant
organisms were not associated with worse outcomes in FG. (J Trauma Acute Care Surg. 2017;83: 443–448. Copyright © 2017
Wolters Kluwer Health, Inc. All rights reserved.)
LEVEL OF EVIDENCE: Therapeutic, level IV.
KEY WORDS: Necrotizing fasciitis; Fournier’s gangrene; antibiotics.

F ournier’s gangrene (FG) is a serious diagnosis with mortality

ranging from 6% to 40%.1–15 Wide debridement is often re-
quired for local source control, and residual perineal wounds can
be substantial. Patients with necrotizing infections often present
with sepsis and organ dysfunction and can be critically ill.16,17
Most prior research on necrotizing infections has focused on
predictors of mortality, with surgical factors such as spread of
disease and time to debridement associated with higher mortality.17,18
Long-term management of open wounds created with debride-
ment of FG ranges from primary wound closure to healing by sec-
ondary intention, skin grafting, and creation of fasciocutaneous
flaps. The optimal strategy associated with lowest mortality and
least morbidity has not been clearly identified.12–15,19–23
The optimal duration of antibiotic therapy in FG is simi-
larly poorly elucidated, as is the effect antibiotic duration has
on mortality and other outcomes, such as ability to achieve com-
plete primary wound closure, occurrence of surgical site infec-
tion (SSI) and development of recurrent FG. Expert opinions
for antibiotic duration in necrotizing infections guide clinical
care,24–26 with continuation of antibiotics until the patient is
clinically well and debridements have been completed. Recent
Submitted: February 6, 2017, Revised: March 20, 2017, Accepted: April 30, 2017,
Published online: Month May 22, 2017.
From the Division of Trauma and Critical Care, R Adams Cowley Shock Trauma Cen-
ter, University of Maryland, Baltimore, Maryland.
Address for reprints: Margaret Lauerman, MD, R Adams Cowley Shock Trauma Center,
22 South Greene St, Baltimore, MD 21201; email: mlauerman@umm.edu.
DOI: 10.1097/TA.0000000000001562
J Trauma Acute Care Surg
Volume 83, Number 3
studies have examined duration of antibiotics in infections such
as intra-abdominal infections and ear infections, but unfortunately,
similar data do not exist for necrotizing soft tissue infections.27,28
Shorter courses of antibiotics generally reduce the risk of
the development of antibiotic resistance and development of
Clostridium difficile colitis.29,30 However, too short of an antibi-
otic duration may place patients at risk for recurrent FG, SSI, or
inability to achieve complete primary wound closure. The aim of
this study was to investigate the effect of duration of antibiotic
therapy on outcomes in FG. We hypothesized that shorter dura-
tion antibiotic therapy would not be associated with increased
mortality, increased rates of associated infections, or decreased
rates of primary closure.
PATIENTS AND METHODS
A retrospective review was performed at a single institu-
tion, the University of Maryland Medical Center R Adams
Cowley Shock Trauma Center, over a 3-year period from 2012
to 2015. Institutional review board approval was obtained before
beginning the review. Only patients ages 18 years and older were
included. FG was defined as a necrotizing infection requiring
perineal debridement and was exclusive of patients who under-
went incision and drainage of a perineal abscess. Patients who
underwent perineal exploration for concern for FG without de-
bridement were similarly excluded.
Patients with FG were managed according to our institu-
tional practice. Patients undergo sequential debridements, typically
every 48 hours or 72 hours until the perineal wound contains
only healthy, viable tissue. If possible when the debridements
443

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Lauerman et al.
are completed, the wound is managed with complete primary
wound closure, defined as 100% apposition of the skin edges
of the wound. This focus on wound closure as the goal definitive
wound management technique in all patients allows investiga-
tion of complete primary wound closure as an outcome in FG.
Secondary intention healing was defined as management of a re-
sidual wound without complete closure of the wound. Patients
are referred for hyperbaric oxygen treatment, and focus is placed
on assuring adequate nutritional intake.
Debridements were defined as those occurring at our insti-
tution only and were exclusive of debridements which occurred
at referring institutions. Sepsis and septic shock were defined
according to the Sepsis-3 guidelines.31 Types I, II, and III bacte-
rial infections were defined according to standard criteria, with
type I a polymicrobial infection, Type II a gram positive only
infection, and Type III a gram negative only infection.32 At our
institution, antibiotic duration is not standardized but rather indi-
vidualized to each patient based on their clinical illness, ability
to achieve source control, and provider preference. However,
our infectious disease team often manages patients with FG in
conjunction with the surgical team, and antibiotic duration is de-
termined after discussion between the infectious disease and sur-
gical teams; patients with FG are not managed in completely
closed units. For this study, antibiotic duration excluded antibi-
otics received at other institutions in patients who were trans-
ferred. Recurrent FG was defined as a recurrent necrotizing
infection requiring debridement within 30 days of admission.
Time to final wound management was defined as time from ad-
mission to our institution until either wound closure or cessation
of debridement.
Statistical analysis was performed using SPSS version 24
(IBM, Armonk, NY). Univariate analysis was performed exam-
ining frequencies of the study variables. Visual inspection was
used to assess for normality of antibiotic duration. Bivariate test-
ing was performed with t tests, analysis of variance, χ2, and
Fisher's exact test. Logistic regression was performed in a for-
ward fashion for mortality including variables with significance
of p < 0.20 on bivariate testing for association with mortality.
Variance inflation factors (VIF) and χ2 test were used as regres-
sion diagnostics.
RESULTS
Overall 168 patients were included, with 93 (55.4%) pa-
tients younger than 60 years. Eighty (47.6%) patients had disease
spread beyond the perineum. Sixty-seven (39.9%) patients ulti-
mately underwent complete primary wound closure, and 101
(60.1%) underwent secondary intention healing as their defini-
tive wound management strategy. The admission mean Sequen-
tial Organ Failure Assessment (SOFA) score was 2.47 ± 3.04.
Seventeen (10.1%) patients required pressor administration on
admission, and 92 (54.8%) patients met sepsis criteria on admis-
sion. Medical comorbidities were common, with 105 (62.5%)
diabetic patients and 101 (60.1%) hypertensive patients, in addi-
tion to the 115 (68.5%) obese patients with a body mass index of
30 or greater. Six (3.6%) patients with FG died. C. difficile infec-
tion occurred in six (3.6%) patients, SSI in two (1.2%) patients,
and recurrent FG did not occur in any patients.
444
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J Trauma Acute Care Surg
Volume 83, Number 3
Overall, 28 (16.7%) patients received 7 days or less of an-
tibiotic therapy, 52 (30.1%) patients received 8 days to 10 days
of antibiotic therapy, 56 (33.3%) patients received 11 days to
14 days of antibiotic therapy, and 32 (19.0%) patients received
15 days or more of antibiotic therapy (Fig. 1). Mean duration
of antibiotic therapy was 11.6 days ± 6.14 days. There was no
significant difference in presenting physiology between patients
undergoing different durations of antibiotic therapy, with 3.6%,
11.5%, 10.7%, and 12.5% (p = 0.65) of patients requiring pres-
sor therapy on admission and 7.1%, 15.4%, 23.2%, and. 9.4%
(p = 0.18) of patients requiring mechanical ventilation on admis-
sion, respectively. Sepsis on admission was common, occurring
in 32.1%, 59.6%, 53.6%, and 68.8%, (p = 0.03) of patients, with
septic shock less common on admission, occurring in 3.6%,
1.9%, 5.4%, and 6.3% (p = 0.75) of patients among the anti-
biotic groups (Table 1).
The extent of infection was as well similar between antibi-
otic groups, with no significant difference seen in rates of wounds
isolated to the perineum (46.4% vs. 46.2% vs. 51.8% vs. 68.8%,
p = 0.20) or ability to achieve primary wound closure (35.7% vs.
44.2% vs. 35.7% vs. 43.8%, p = 0.75) between the antibiotic
groups. Similarly, for associated infections, rates of C. difficile co-
litis infection (3.6% vs. 3.8% vs. 5.4% vs. 0%, p = 0.63) and SSI
(0% vs. 1.9% vs. 0% vs. 3.1%, p = 0.52) were not significantly
different between these antibiotic groups. Lastly, there was no sig-
nificant difference in mortality (10.7% vs. 0% vs. 3.6% vs. 3.1%,
p = 0.11) between these antibiotic groups (Table 2).
The mean time from final wound management to antibi-
otic cessation was 4.8 days ± 7.2 days. Mean time from final
wound management to antibiotic cessation was not significantly
lower in patients who died compared with those who did not
die (0.17 days vs. 4.93 days, p = 0.11), higher in patients with
C. difficile infection compared to those without C. difficile infec-
tion (2.17 days vs. 4.85 days, p = 0.37) or lower in patients with
SSI compared to those without an SSI (11.50 days vs. 4.67 days,
p = 0.19). Nineteen patients had their antibiotics stopped before
final wound management.
Six (3.6%) patients were initially prescribed antibiotics that
did not cover the organism ultimately cultured from the wound,
and these patients all required alteration in antibiotic therapy.
Bacteria not covered by initial antibiotic therapy included:
Figure 1. Frequency of the categories of antibiotic duration in
Fournier’s gangrene.
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J Trauma Acute Care Surg
Volume 83, Number 3 Lauerman et al.

TABLE 1. Demographic, Physiologic, and Comorbidity Variables in Patients With Fournier’s Gangrene Stratified by Antibiotic Duration
7 Days or Less of 8–10 Days of 11–14 Days of 15 Days or More of
Antibiotics (n = 28) Antibiotics (n = 52) Antibiotics (n = 56) Antibiotics (n = 32) p
Demographics
Age: 60 years and older, N (%) 15 (53.6%) 24 (46.2%) 23 (41.1%) 13 (40.6%) 0.69
Male sex, N(%) 19 (67.9%) 41 (78.8%) 38 (67.9%) 27 (84.4%) 0.25
Race, N (%)
White 11 (39.3%) 38 (73.1%) 31 (55.4%) 22 (68.8%) 0.04
African American 16 (57.1%) 11 (21.2%) 20 (35.7%) 8 (25.0%)
Other 1 (3.6%) 3 (5.8%) 5 (8.9%) 1 (3.1%)
Unknown 0 (0%) 0 (0%) 0 (0%) 1 (3.1%)
Outside hospital transfer, n (%) 26 (92.9%) 48 (92.3%) 56 (100%) 31 (96.9%) 0.19
Outside hospital operation, n (%) 8 (28.6%) 17 (32.7%) 20 (35.7%) 8 (25.0%) 0.75
Physiology on admission
Pressors, n (%) 1 (3.6%) 6 (11.5%) 6 (10.7%) 4 (12.5%) 0.65
Ventilator, n (%) 2 (7.1%) 8 (15.4%) 12 (23.2%) 3 (9.4%) 0.18
Heart rate, mean ± SD 98.54 ± 18.24 93.67 ± 17.38 100.61 ± 22.91 98.75 ± 16.75 0.31
Systolic blood pressure, mean ± SD 128.75 ± 23.87 129.02 ± 22.54 127.59 ± 22.17 130.59 ± 25.64 0.95
SOFA score, mean ± SD 1.50 ± 2.03 2.63 ± 3.03 2.52 ± 3.00 2.97 ± 3.75 0.28
Sepsis, n (%) 9 (32.1%) 31 (59.6%) 30 (53.6%) 22 (68.8%) 0.03
Septic shock, n (%) 1 (3.6%) 1 (1.9%) 3 (5.4%) 2 (6.3%) 0.75
Lactate, mean ± SD 1.92 ± 1.01 1.76 ± 0.66 2.04 ± 1.79 1.98 ± 0.84 0.70
WBC, mean ± SD 16.63 ± 7.92 18.06 ± 7.94 17.20 ± 8.03 15.45 ± 6.89 0.51
Creatinine, mean ± SD 1.56 ± 1.60 1.83 ± 1.55 1.75 ± 2.26 1.59 ± 1.09 0.89
Comorbidities
Hypertension, n (%) 16 (57.1%) 34 (65.4%) 34 (60.7%) 17 (53.1%) 0.71
Hyperlipidemia, n (%) 12 (42.9%) 19 (36.5%) 18 (32.1%) 7 (21.9%) 0.35
Diabetes mellitus, n (%) 18 (64.3%) 36 (69.2%) 34 (60.7%) 17 (53.1%) 0.51
HIV, n (%) 1 (3.6%) 2 (3.8%) 3 (5.4%) 0 (0%) 0.63
Chronic kidney disease, n (%) 2 (7.1%) 8 (15.4%) 7 (12.5%) 2 (6.3%) 0.52
COPD, n (%) 3 (10.7%) 10 (19.2%) 2 (3.6%) 3 (9.4%) 0.07
Congestive heart failure, n (%) 1 (3.6%) 6 (11.5%) 4 (7.1%) 1 (3.1%) 0.42
BMI≥30, n (%) 16 (57.1%) 41 (78.8%) 37 (66.1%) 21 (65.6%) 0.21
BMI, body mass index; N, number; COPD, chronic obstructive pulmonary disease; HIV, human immunodeficiency virus.

vancomycin-resistant Enterococcus in three patients, Klebsiella
in one patient, and Escherichia coli in two patients. Initial anti-
biotic therapy not covering the bacteria ultimately cultured in-
cluded: clindamycin, vancomycin and piperacillin-tazobactam
in two patients; vancomycin and piperacillin-tazobactam in
two patients; linezolid and piperacillin-tazobactam in one patient;
and vancomycin, ertapenem and metronidazole in one patient.
Mortality rates (0% vs. 3.7%, p = 1.00) and rates of complete
primary wound closure (0% vs. 41.1%, p = 0.08) were not sig-
nificantly different in patients with inadequate initial antibiotic
therapy when compared with patients whose initial antibiotic
therapy was adequate.
Given the potential for confounding variables, logistic re-
gression was performed for factors associated with mortality in
bivariate analysis, including: lactate, white blood cell (WBC)
count, SOFA score, heart rate, systolic blood pressure, human
immunodeficiency virus, chronic kidney disease, sepsis, wounds
isolated to the perineum, and antibiotic duration (data not shown).
In logistic regression, WBC (odds ratio, 0.88; 95% confidence in-
terval, 0.78–0.99; p = 0.03) and lactate (odds ratio, 1.93; 95%
confidence interval, 1.26–2.96; p = 0.003) were significantly as-
sociated with mortality. All other variables were not associated
with mortality, including antibiotic duration. χ2 Test indicated
good model fit, and all VIF were less than 10, with a mean
VIF 1.39.
DISCUSSION
In FG, antibiotic duration is quite varied in clinical prac-
tice. After stratifying antibiotic duration into subgroups, there
was no association seen with shorter antibiotic courses and
multiple outcome measures, including complete primary wound
closure, SSI, C. difficile infection, and mortality. There is no
high-grade evidence to define the optimal duration of antibiotic
therapy, unlike other infections, such as ear infections or intra-
abdominal infections,27,28 and duration of antibiotic therapy in
FG is therefore based on expert opinion.24–26
Surgical management of FG at the R Adams Cowley
Shock Trauma Center occurs in a standardized fashion, focusing
on complete primary wound closure as the optimal definitive
wound management strategy, with secondary intention healing
for residual wounds if complete primary wound closure is not
achievable. Flap creation and early skin graft placement are
not routinely pursued outside of specific indications, such as

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Lauerman et al. Volume 83, Number 3

TABLE 2. Operative Variables and Outcomes for Patients With Fournier’s Gangrene Stratified by Antibiotic Duration
7 Days or Less of 8–10 Days of 11–14 Days of 15 Days or More of
Antibiotics (n = 28) Antibiotics (n = 52) Antibiotics (n = 56) Antibiotics (n = 32) p
Bacterial type
Type I, n (%) 17 (60.7%) 34 (65.4%) 34 (60.7%) 25 (78.1%) 0.41
Type II, n (%) 4 (14.3%) 11 (21.2%) 13 (23.2%) 5 (15.6%)
Type III, n (%) 1 (3.6%) 1 (1.9%) 0 (0%) 1 (3.1%)
Cultures negative, n (%) 1 (3.6%) 0 (0%) 0 (0%) 0 (0%)
No cultures, n (%) 5 (17.9%) 6 (11.5%) 9 (16.1%) 1 (3.1%)
Operative variables
Wound isolated to perineum, n (%) 13 (46.4%) 24 (46.2%) 29 (51.8%) 22 (68.8%) 0.20
Complete primary wound closure, n (%) 10 (35.7%) 23 (44.2%) 20 (35.7%) 14 (43.8%) 0.75
Colostomy, n (%) 5 (17.9%) 4 (7.7%) 8 (14.3%) 4 (12.5%) 0.57
Total debridements, mean ± SD 2.18 ± 0.98 2.63 ± 0.93 2.68 ± 1.03 2.97 ± 1.33 0.04
Outcomes
Mortality, n (%) 3 (10.7%) 0 (0%) 2 (3.6%) 1 (3.1%) 0.11
Clostridium difficile infection, n (%) 1 (3.6%) 2 (3.8%) 3 (5.4%) 0 (0%) 0.63
Recurrent FG, n (%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) —
SSI, n (%) 0 (0%) 1 (1.9%) 0 (0%) 1 (3.1%) 0.52

for coverage of a concurrent urinary fistula, although they re-
main options.12–15,19–23
Antibiotic therapy at our institution is generally initiated
with broad-spectrum antibiotics covering gram positive (includ-
ing methicillin resistant Staphylococcus aureus), Gram-negative,
and anaerobic organisms, with alterations for patient allergies
or if cultures from the referral institution are already available.
If there is concern for toxin production, clindamycin is added,
and consideration given to intravenous immunoglobulin. Once
cultures are available, antibiotics are narrowed to cover only or-
ganisms isolated in operative cultures.
Depending on provider preference, patients either receive
a set course of antibiotic therapy, such as a 14-day course of an-
tibiotics, or have their antibiotics stopped after surgical source
control has been obtained and they have clinically improved,
without a set-course of therapy. In this review, patients with
shorter antibiotic durations most likely had antibiotics stopped
after source control was obtained and clinical improvement
was seen, rather than undergoing a set course of therapy.
Necrotizing infections may encompass a significant body
surface area.17 One potential concern with using shorter courses
of antibiotics in FG is that the infection could spread farther
than with longer antibiotic courses, decreasing ability to achieve
complete primary wound closure and leaving patients with
larger wounds. However, rapid surgical source control is a tenet
of FG treatment, and patients in this review had source control
obtained in two to three operative debridements. Likely due to
this quick provision of source control, neither an increase of
spread of infection beyond the perineum nor a decrease in rate
of complete primary wound closure with shorter courses of anti-
biotics was seen, and shorter courses of antibiotics in FG do not
seem to be associated with disease extension.
C. difficile infections are common in necrotizing infec-
tions,17 with duration of antibiotic therapy associated with the
development of C. difficile infection overall.29 A shorter course
of antibiotics may decrease a patient's risk of developing this po-
tentially fatal hospital-acquired infection without decreasing the
likelihood of wound closure or increasing the likelihood of
spread of the infection. Our rate of C. difficile infection despite
the sometimes protracted courses of antibiotics in FG was quite
low, and duration of antibiotics does not seem to influence devel-
opment of C. difficile infection in this patient cohort.
Rates of SSI in FG are poorly defined in the literature,
with closure of these previously infected wounds created by
FG debridement potentially placing patients at risk for SSI.
One downside of shorter courses of antibiotics is potentially an
increased rate of SSI; however, despite the complete primary
closure of wounds in approximately one third of patients in this
review, the rate of SSI occurrence was quite low overall and in all
antibiotic duration stratifications.
Another potential downside of shorter courses of antibi-
otic therapy is recurrent FG if the initial infection is undertreated
with antibiotics. In this analysis, no cases of recurrent FG were
seen with any antibiotic duration. With a surgical strategy incor-
porating serial debridements until the wound is clear of infection
and necrotic tissue, and judicious use of antibiotics, recurrent
FG seems to be an infrequent occurrence.
For most patients with FG, our broad initial antibiotic se-
lection practices provided adequate coverage for bacteria ulti-
mately cultured from the wound. However, a small percentage
of patients had operative cultures remarkable for organisms re-
sistant to the initial antibiotics chosen. A significant mortality
increase was not seen in patients with inadequate initial antibi-
otic coverage, although none of these patients had complete
primary wound closure. Given the number of patients in this
cohort, it is not possible to determine whether this low rate of
complete primary wound closure was due to initially narrow an-
tibiotic coverage, is a reflection of a more severe infection, or is
due to another unmeasured factor. Beginning antibiotic coverage
in all patients with FG inclusive of resistant organisms identified
in only 3.6% of patients would result in over treatment of a sig-
nificant number of patients. Given the low mortality seen, this
is difficult to justify. Reserving non–first-line antibiotic agents
to patients with culture proven resistant infections seems the

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J Trauma Acute Care Surg
Volume 83, Number 3
most appropriate approach to antibiotic stewardship in patients
with FG.
A critical question for antibiotic duration in FG is the du-
ration of antibiotics required after wound management is com-
pleted. In this review there was no significant association of
SSI, C. difficile infection, or mortality with time from final wound
management to cessation of antibiotics, and many patients had
their antibiotics stopped even before definitive wound manage-
ment. Antibiotics can likely be quickly stopped when surgical
source control is obtained, even if definitive wound management
has not been completed, although prospective research will be
required however to determine the optimal duration of antibiotic
therapy after source control is obtained as source control is a dif-
ficult variable to accurately evaluate retrospectively.
Limitations of this review include its retrospective nature.
We are unable to account for effects of factors not included in
this dataset. While this review included a large number of pa-
tients for a single-institution study given the rarity of FG, the
overall small patient population makes type II error possible.
Many of the outcomes of FG, including SSI, recurrent FG, and
mortality are rare. Operations at referral institutions and antibi-
otics given at referral institutions were not included given that
full medical records from referral institutions were not always
available, and may underestimate the total debridements per-
formed and duration of antibiotics. Although this study focuses
on the outcomes of patients with FG, the effect of development
of multi-drug resistant pathogens in both the FG patients and
other patients in the hospital is unknown. Although multiple
clinical outcomes were investigated in this study, another impor-
tant factor with antibiotic duration will be cost and should be an
avenue of future research. Additionally, the rationale for stop-
ping antibiotics is often not available, with clinical variables
such as WBC, temperature, and hemodynamics often influenc-
ing that decision.
With a mean duration of antibiotics of almost 12 days re-
ported in this study, the courses of antibiotics for FG in this study
may be overall longer than what is often prescribed in clinical
practice at many high-volume centers. Antibiotics are often
stopped after source control is obtained, and the patient has clin-
ically improved, but, in this retrospective review, patients may
have undergone longer courses of antibiotics for concurrent in-
fections rather than for FG (such as osteomyelitis or bacteremia).
It is unknown whether patients receiving longer courses of anti-
biotics would have had worse outcomes with shorter courses
of antibiotics. However, without these longer courses of antibi-
otics, comparison to shorter courses of antibiotics would not
be feasible.
Patients with FG often present with concurrent medical
comorbidities, sepsis, and organ dysfunction. In this retrospec-
tive study, shorter courses of antibiotics were not associated with
worse outcomes, including C. difficile infection, SSI, and mor-
tality, although these outcomes were all quite rare. Current anti-
biotic selection practices which exclude resistant gram negative
bacteria and vancomycin-resistant Enterococcus appear valid
as well.
AUTHORSHIP
M.L. contributed to the literature search, study design, data collec-
tion, data analysis, data interpretation, writing, and critical revision. O.K.
© 2017 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Lauerman et al.
contributed to the study design, data collection, data interpretation, and
critical revision. K.S. contributed to the data interpretation and critical re-
vision. R.R. contributed to the study design, data interpretation, and crit-
ical revision. M.J. contributed to the study design, data interpretation, and
critical revision. E.C. contributed to the study design and critical revision.
D.S. contributed to the data interpretation and critical revision. T.S. contrib-
uted to the study design, data interpretation, and critical revision. S.H.
contributed to the study design, data interpretation, and critical revision.
DISCLOSURE
Conflicts of Interest and Sources of Funding: M.L. is ATOX study sub-
investigator. O.K. has nothing to disclose. K.S. has nothing to disclose.
R.R. is Allergan speakers bureau. M.J. is Pfizer consultancy and ATOX study
subinvestigator, DOD grants. E.C. has nothing to disclose. D.S. has noth-
ing to disclose. T.S. has nothing to disclose. S.H. is ATOX study site pri-
mary investigator.
Funding: None from NIH, Welcome Trust, or HHMI.
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