European Journal of Cardiovascular Medicine

Fournier's gangrene is a severe form of necrotizing fasciitis of the perineum and genitalia, typically caused by a polymicrobial infection. Most individuals with Fournier's gangrene also associated with comorbid conditions, such as diabetes, alcoholism, and other related disorders.

The Fournier’s Gangrene Severity Index (FGSI) is a valuable prognostic tool for predicting mortality and survival outcomes in patients with Fournier’s gangrene. Reconstructive interventions are required when significant tissue defects arise from extensive tissue damage.

AIM:

• To study the etiology and microbiological factors associated with Fournier’s gangrene.
• To study the reconstructive procedures performed in patients with Fournier’s gangrene.
• To evaluate the outcomes of Fournier’s gangrene based on the Fournier’s Gangrene Severity Index (FGSI).
• To assess the mortality rates associated with Fournier’s gangrene in relation to the FGSI.

Study area: Katuri medical college and hospital, (KMCH) Guntur.

Study period: May 2022 to April 2024

Study population Patients presenting to the outpatient department and emergency department of KMCH.

OBJECTIVES OF THE STUDY:

1. To analyze the various etiological and predisposing factors contributing to the development of Fournier’s gangrene.
2. To analyse the progression of Fournier’s gangrene in relation to the timing of patient presentation.
3. To evaluate the outcomes of Fournier’s gangrene based on the Fournier’s Gangrene Severity Index (FGSI).

Inclusion criteria:

Patients presenting with gangrene of genitalia and perineum

- Age more than 12 years

Exclusion criteria:

- Age less than 12 years.

Sample size: 40.

All patients eligible by inclusion and exclusion criteria were included in the study.

This study includes a total of 40 cases that were studied prospectively over a period of two years that were treated as inpatient basis at KMC&H from May 2022 to April 2024.

INCIDENCE SEX WISE:

INCIDENCE AGEWISE:

CAUSATIVE FACTORS:

COMORBID FACTORS:

MICROBES ISOLATED:

Polymicrobial presentation – 80%

Average number of isolates per culture- 2.12

In percentage of isolated organisms. E. coli was the most common (47.0%), followed by Streptococcus (41.1%), Klebsiella (35.3%), and Pseudomonas (26.5%). Other organisms included Staphylococcus (17.7%), Enterococcus and Proteus (11.8% each), Bacteroides (8.9%), and Acinetobacter (5.9%)

EXTENT OF INVOLVEMENT:

NUMBER OF DEBRIDEMENTS REQUIRED:

PATIENTS REQUIRING RECONSTRICTIVE PROCEDURES

TYPES OF RECONSTRUCTIVE PROCEDURES NEEDED:

MORTALITY:

FGSI SCORES:

FGSI SCORE IN NON – SURVIVOURS:

FGSI SCORE IN SURVIVORS:

SEXWISE INCIDENCE

In a large series conducted male to female ratio was 10: 1 (Eke, 2000)¹. The following is the list of male to female ratio in the various studies conducted. As per Basoglu et al., 2007² study the M:F ratio was 44:1, as per Baek et al., 2003³ study M:F ratio was 14:2, as per Kim KM et al., 2010⁴study M:F ratio was25:2, as per Villlanueva-Saenz et al., 2002⁵ study M:F ratio was 28:0, in present study M:F ratio was 34:6, significant female involvement.

AGEWISE INCIDENCE:

The average age of incidence in 1945 was 40.9 years. In many studies conducted at present it usually ranges from 50 to 70 years. The following is the list of age wise incidence in a few conducted studies. As per Basoglu et al., 2007² clinical study the mean age was 54.0, as per Kim KM et al., 2010⁴ clinical study the mean age was 52.8, as per Yeniyol et al., 2004⁶ clinical study mean age was 51.7, as per Korkut et al., 2003⁷ clinical study mean age was 54.6, In our present study the mean age was 50.2 which was almost similar to the previous studies.

ORIGIN OF INFECTION:

In a large studies from Eke et al., 2000⁸ the source of infection was 21% anorectal, 19% urological, 24% dermatological and idiopathic in the remaining 34% of cases.

In present study the source of infection is 35.3% anorectal, 20.6% urological, 14.7% dermatological and idiopathic in the remaining 29.4% of cases.

Anorectal origin is most common source according to Brunet et al.,2000⁹ – 34% and El Mejjad et al.,2002¹⁰ – 42%, which was similar to the present study.

The following is the comparison of present study with Corcoran et al., 2008¹¹clinical study shows anorectal origin 38.2% and urogenital origin 11.8%, where as in present study

Anorectal origin is 35.3%, and urogenital origin is 20.6%.

COMORBID CONDITIONS:                             

Diabetes mellitus

Diabetes mellitus is known to be associated in 20 – 70% of patients Fournier’s gangrene (Morpurgo, 2002)¹². As per Laor et al., 1995 clinical study 30%, and as per Yanar H et al., 2006 clinical study 45.7%, as per Basoglu et al., 2007 clinical study 24.4%, as per Kim KM et al., 2010 clinical study 29.6%, in comparision with multiple studies, present study 36.2% was associated with DM, which is significantly similar with the previous studies.

Chronic alcoholism

Chronic alcoholism is associated with 25 – 50% of cases with Fournier’s gangrene (Clayton et al., 1990)¹³. In few studies it is found to be most common comorbid condition (Smith et al., 1998)¹⁴.

In present study chronic alcoholism is identified as a comorbid condition in 20.6% of case.

Microbiology

(Kuzaka B et al.,2018¹⁵) clinical study reported E coli, streptococcus and Bacteroides and (Smith et al .,1998)¹⁴ clinical study reported E coli, streptococcus and Bacteroides as the most commonly isolated microbes. Proud D et al., 2014¹⁶ proposed that most common organisms were E coli and streptococcus. According to them staphylococcus and enterococcus were commonly isolated more than Bacteroides.

It is postulated that, anaerobes even when present are less frequently isolated because of difficulty in preserving samples

In the present series E coli (47.0%) and streptococcus (41.1%) are the most commonly isolatedaerobes.Bacteroides are most commonly isolated anaerobes (8.9%).

(lewis et al., 2021¹⁷)reported polymicrobial isolation in 90% of cases and no growth in 5% of patients. Ferreira et al.,2007¹⁸ reported polymicrobial growth in 82.9% of cases. In the present study polymicrobial isolation is found in 79.4% of cases and no growth reported in 5.9% of patients.

According to (proud D et al) mean microbial number of 2 was identified in culture tests. According to (thwaini et al., 2006) mean number of isolates are approximately 3.In present study the average number of isolates found per case are 2.12.

Extent of involvement

Ferrira et al., 2007¹⁸ proposed that scrotal involvement found in 93.3% of cases and perineal involvement in 37.2% of cases. Anterior abdominal wall involvement 5.6%.

In the present series genital involvement is noted in 100% of cases, perineal involvement in 47.1% of cases and anterior abdominal wall involvement in 11.8% of cases. In the present study all cases have genital involvement irrespective of gender

MANAGEMENT:

Imaging could not be performed uniformly across all patients due to late presentation with extensive disease. Broad-spectrum antibiotics covering gram-positive organisms, gram-negative organisms, and anaerobes were empirically initiated and adjusted based on culture and sensitivity results. Comorbidities and complications were managed accordingly, and patients underwent multiple wound debridement’s.

Topical hydrogen peroxide was applied to all patients, showing positive outcomes with repeated debridement’s and daily dressings.

Per-urethral catheterization was performed in all cases. Suprapubic catheterization, colostomy, and rectal diversion were not used. Orchidectomy and penectomy were not needed, as there was no involvement of the testes or penis.

Surgical debridements:

100% mortality from Fournier’s gangrene has been reported when surgical debridements not performed (Adinolfi MF, 1983)²⁰, (Okeke LI., 2000)²¹, (Hasdemir AO, 2009)²².

In a study of 43 patients by Ferreira et al., 2007¹⁸ single debridement was performed in 35 patients, 7 patient’s were debrided twice and 1 patient was debrided thrice. The average number of debridement’s required is 3.5 procedures per patient according to Chawla SN, 2003²³.

In the present series, most patients underwent multiple surgical debridements. Maximum of 7 debridements were done in one patient, single debridement was done in 9 cases, double debridement was done in 11cases, triple debrident was done in 10 patients. The average number of debridements done is 2.7

RECONSTRUCTIVE PROCEDURES:

After the acute phase of infection has subsided the scrotum can be left alone for healing by secondary intention as it has remarkable capacity to regenerate (Thomas, 1956 ²⁴).

The reconstructive procedures can be performed at the same time of admission (De la cruz et al., 1996²⁵) or after the resolution of acute infectious process. In present study all the reconstructive procedures were performed after resolution of acute infectious process.

S Prakash, 1984 ²⁶ published a series of 43 cases. In most of the cases cover was provided with scrotal skin for scrotal defects and 58 the penile skin defects were covered with inner layer of prepuce which remained intact.

In the present series reconstructive procedure was performed for 17 patients out of 40 (45%). Those 17 patients were managed by primary closure and local skin flap. In that 1 patient required Split skin grafting + Primary closure And 1 patient required Split skin grafting + Implantation of testis in the thigh.

Mortality:

Mortality rate from the present study is 15%. The mortality rate from the various series

In Baek et al., 2003 clinical study was 6.3%, in Corcoran et al., 2008 clinical study was 10.3%, in Korkut et al., 2003 clinical study was 20%, in Erol et al., 2009 clinical study was 22.2%, in Yeniyol et al., 2004 clinical study was 24%, in Kim KM et al., 2010 Clinical study was 14.8%, in Basoglu et al., 2007 clinical study was 8.9%, in Yilmazler et al., 2010 clinical study was 21.3%, 59 mortality % of present study was similar with Kim KM et al., 2010 study.

FGSI SCORE:

The mean FGSI score among survivors in our study is 4.6 +/- 2.0. The mean FGSI score among non-survivors is 10 +/- 1.6. Various other studies have shown FGSI scores as illustrated below.

Laor et al., 1995 have reported that an FGSI score more than 9 indicated 75% probability of mortality whereas a score of 9 or less than 9 was associated with 78% probability of survival.

Kabay et al., 2008 proposed that FGSI score of less than 10.5 associated with 96% of survival and FGSI score of more than 10.5 associated with 96% of death. In the present series FGSI score of more than 10.5 is associated with 100% mortality and score of less than 10.5 is associated with 93.3% of survival.

SUMMARY AND CONCLUSION SUMMARY

Fourty patients were treated in the katuri medical college and hospital during the period from may 2022 to may 2024. - Highest number of patients was found from fourth and fifth decade of life and the mean age of presentation is 50.2 years. Mean age of presentation among deceased is 63 years which is significantly higher than mean age among survivors which is 48.3 years. - The male to female ratio is 34:6

• The source of the disease is most commonly genitourinary (40%) followed by anorectal (27.5%) and dermatological (12.5%) source. The cause is idiopathic in 20% of cases.
• Diabetes mellitus (47.5%) is the most common comorbid factor followed by chronic alcoholism (22.5%) and HIV (10%).
• Most commonly this disease is polymicrobial (80%).
• Most commonly isolated organisms include E coli (47.0%) followed by streptococci (41.1%) and klebsiella (35.3%).
• The bacteroides are the most commonly isolated anaerobes (8.9%).
• In majority of the cases disease is limited to the genitalia (52.9%).
• Multiple wound debridements are required. The average number of wound debridements required is 2.3.
• Primary closure was most common reconstructive procedure performed (32.5%).

Mortality associated with the disease was 15% - FGSI is a useful indicator for predicting survival and mortality associated with Fournier’s gangrene. - FGSI score of more than 10.5 is associated with 100% mortality and a score lesser than 10.5 is associated with 93.3% of survival

Fournier’s gangrene is commonly a disease of middle aged and elderly males. Source of infection is identifiable in most of the cases. Diabetes mellitus is the most common comorbid factor. The disease is polymicrobial in most of the cases. Early diagnosis of the disease and multiple wound debridements are required for improved survival. Extensive raw area following the infection and wound debridements can be managed by reconstructive procedures. In spite of aggressive management the disease carries significant mortality. Fournier’s gangrene severity index (FGSI) is a useful indicator for predicting survival and mortality associated with Fournier’s gangrene.

Ethics approval and consent to participate

List of abbrevations

FGSI-fourniers gangrene severity index; Dm-diabetes mellitus

Data Availability

Conflicts of interest

The author’s declare that there is no conflict of interest regarding publication of this paper.

Funding Statement

No Funding

Author’s Contributions

Dr. Seelam Srinivasa Reddy (ASSOCIATE PROFESSOR, MS Dept of General Surgery, Katuri Medical College and Hospital, Guntur).

Dr. Prasanth (ASSISTANT PROFESSOR MS Dept of General Surgery, Katuri medical college and Hospital, Guntur).

Dr. Ravipati Sai Krishna (ASSOCIATE PROFESSOR MS Dept of General Surgery, Katuri medical college and Hospital, Guntur).

Acknowledgements

Dr. Pragna Postgraduate in Department of General Surgery, Katuri Medical College and Hospital

Dr. Leela Prasad Postgraduate in Department of General Surgery, Katuri Medical College and Hospital

Supplementary Materials

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