Fournier gangrene medical therapy

Steven C. Campbell, M.D., Ph.D.; Associate Editor(s)-in-Chief: Yamuna Kondapally, M.B.B.S[1]; Jesus Rosario Hernandez, M.D. [2]

Fournier gangrene is a urological emergency requiring intravenous antibiotics and debridement (surgical removal) of necrotic (dead) tissue. Despite such measures, the mortality rate overall is 40%, but 78% if sepsis is already present at the time of initial hospital admission.^[1] The spread of gangrene is rapid at the rate of 2–3 cm/h, hence early diagnosis and emergency surgical treatment is important.^[2]

Fournier gangrene is a urological emergency requiring intravenous antibiotics and debridement (surgical removal) of necrotic (dead) tissue. Despite such measures, the mortality rate overall is 40%, but 78% if sepsis is already present at the time of initial hospital admission.^[1] The spread of gangrene is rapid at the rate of 2–3 cm/h, hence early diagnosis and emergency surgical treatment is important.^[2]

• Fournier gangrene^[3]

• If caused by streptococcus species or clostridia

• Preferred regimen: Penicillin G

• Polymicrobial

• Preferred regimen: Doripenem OR imipenem OR meropenem

• MRSA (methicillin resistant staphylococcus aureus) suspected

• Preferred regimen: vancomycin OR daptomycin

The metabolic demands of Fournier gangrene patients are similar to those of other major trauma or burns.^[4] Nutritional support to replace lost proteins and fluids from large wounds and/or the result of shock is required from the first day of a patient's hospital admission.

• Delivery of 100% oxygen (hyperbaric) at two or three times the atmospheric pressure for 30 to 90 minutes with three to four treatments daily.^[5]
• Hyperbaric oxygen inhibits infection and exotoxin release.^[6]
• It enhances efficacy of antibiotics by increasing local oxygen tension in tissue and augment oxidative burst and killing ability of leukocytes.^[7]
• These effects result in a reduced need for surgical debridement and improved morbidity and mortality in patients with necrotizing fasciitis.

Contraindications to hyperbaric oxygen are:^[8][9]

• Pneumothorax
• Cisplatin (which decreases the production of superoxide dismutase which is protective against damaging effects of high partial O2 pressure)
• Doxorubicin therapy

Side effects of hyperbaric oxygen are:

• Barotrauma of the middle ear
• Seizures
• Loss of respiratory drive in hypercapnic patients (therefore, frequent periods of breathing in room air are interposed when patients are on HBOT)
• Vasoconstriction

• Use of intravenous immune globulin is not FDA approved.
• If used, this treatment is restricted to critically ill patients with either staphylococcal or streptococcal infections.^[10]