Fournier gangrene medical therapy: Difference between revisions
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==Overview== | ==Overview== | ||
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.<ref name="pmid16927060">{{cite journal| author=Yanar H, Taviloglu K, Ertekin C, Guloglu R, Zorba U, Cabioglu N et al.| title=Fournier's gangrene: risk factors and strategies for management. | journal=World J Surg | year= 2006 | volume= 30 | issue= 9 | pages= 1750-4 | pmid=16927060 | doi=10.1007/s00268-005-0777-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16927060}}</ref> The spread of gangrene is rapid at the rate of 2–3 cm/h, hence early diagnosis and emergency surgical treatment is important.<ref name="pmid1736475">{{cite journal| author=Paty R, Smith AD| title=Gangrene and Fournier's gangrene. | journal=Urol Clin North Am | year= 1992 | volume= 19 | issue= 1 | pages= 149-62 | pmid=1736475 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1736475 }}</ref> | |||
==Medical Therapy== | |||
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.<ref name="pmid16927060">{{cite journal| author=Yanar H, Taviloglu K, Ertekin C, Guloglu R, Zorba U, Cabioglu N et al.| title=Fournier's gangrene: risk factors and strategies for management. | journal=World J Surg | year= 2006 | volume= 30 | issue= 9 | pages= 1750-4 | pmid=16927060 | doi=10.1007/s00268-005-0777-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16927060}}</ref> The spread of gangrene is rapid at the rate of 2–3 cm/h, hence early diagnosis and emergency surgical treatment is important.<ref name="pmid1736475">{{cite journal| author=Paty R, Smith AD| title=Gangrene and Fournier's gangrene. | journal=Urol Clin North Am | year= 1992 | volume= 19 | issue= 1 | pages= 149-62 | pmid=1736475 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1736475 }}</ref> | |||
====Antimicrobial Therapy==== | |||
* Fournier gangrene<ref>{{cite book | last = Gilbert | first = David | title = The Sanford guide to antimicrobial therapy | publisher = Antimicrobial Therapy | location = Sperryville, Va | year = 2015 | isbn = 978-1930808843 }}</ref> | |||
:* '''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]] | |||
===Nutritional Support=== | |||
The metabolic demands of Fournier gangrene patients are similar to those of other major [[trauma]] or [[burns]].<ref name="pmid25593960">{{cite journal| author=Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A| title=Current concepts in the management of necrotizing fasciitis. | journal=Front Surg | year= 2014 | volume= 1 | issue= | pages= 36 | pmid=25593960 | doi=10.3389/fsurg.2014.00036 | pmc=4286984 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25593960 }}</ref> 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. | |||
===Hyperbaric oxygen=== | |||
*Delivery of 100% oxygen ([[hyperbaric]]) at two or three times the atmospheric pressure for 30 to 90 minutes with three to four treatments daily.<ref name="pmid16509286">{{cite journal| author=Escobar SJ, Slade JB, Hunt TK, Cianci P| title=Adjuvant hyperbaric oxygen therapy (HBO2)for treatment of necrotizing fasciitis reduces mortality and amputation rate. | journal=Undersea Hyperb Med | year= 2005 | volume= 32 | issue= 6 | pages= 437-43 | pmid=16509286 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16509286 }} </ref> | |||
*Hyperbaric oxygen inhibits [[infection]] and [[exotoxin]] release.<ref name="pmid11199291">{{cite journal| author=Korhonen K| title=Hyperbaric oxygen therapy in acute necrotizing infections with a special reference to the effects on tissue gas tensions. | journal=Ann Chir Gynaecol Suppl | year= 2000 | volume= | issue= 214 | pages= 7-36 | pmid=11199291 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11199291 }} </ref> | |||
*It enhances efficacy of [[antibiotics]] by increasing local oxygen tension in tissue and augment oxidative burst and killing ability of [[leukocytes]].<ref>Hyperbaric oxygen therapy. http://onlinelibrary.wiley.com/doi/10.1080/110241500750008583/abstract (2016) Accessed on September 12, 2016</ref> | |||
*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:<ref name="pmid1924583">{{cite journal| author=Kindwall EP, Gottlieb LJ, Larson DL| title=Hyperbaric oxygen therapy in plastic surgery: a review article. | journal=Plast Reconstr Surg | year= 1991 | volume= 88 | issue= 5 | pages= 898-908 | pmid=1924583 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1924583 }} </ref><ref name="pmid10458334">{{cite journal| author=Capelli-Schellpfeffer M, Gerber GS| title=The use of hyperbaric oxygen in urology. | journal=J Urol | year= 1999 | volume= 162 | issue= 3 Pt 1 | pages= 647-54 | pmid=10458334 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10458334 }} </ref> | |||
*[[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 [[hypercapnia|hypercapnic]] patients (therefore, frequent periods of breathing in room air are interposed when patients are on [[hyperbaric oxygen|HBOT]]) | |||
*[[Vasoconstriction]] | |||
===IV γ-globulin=== | |||
*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]].<ref name="pmid16686841">{{cite journal| author=Darabi K, Abdel-Wahab O, Dzik WH| title=Current usage of intravenous immune globulin and the rationale behind it: the Massachusetts General Hospital data and a review of the literature. | journal=Transfusion | year= 2006 | volume= 46 | issue= 5 | pages= 741-53 | pmid=16686841 | doi=10.1111/j.1537-2995.2006.00792.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16686841 }} </ref> | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
[[Category:Emergency mdicine]] | |||
[[Category:Disease]] | |||
[[Category:Up-To-Date]] | |||
[[Category:Infectious disease]] | |||
[[Category:Surgery]] | |||
[[Category:Orthopedics]] | |||
[[Category:Dermatology]] | |||
Latest revision as of 21:47, 29 July 2020
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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]
Overview
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]
Medical Therapy
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]
Antimicrobial Therapy
- Fournier gangrene[3]
- If caused by streptococcus species or clostridia
- Preferred regimen: Penicillin G
- Polymicrobial
-
- MRSA (methicillin resistant staphylococcus aureus) suspected
- Preferred regimen: vancomycin OR daptomycin
Nutritional Support
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.
Hyperbaric oxygen
- 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
IV γ-globulin
- 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]
References
- ↑ 1.0 1.1 Yanar H, Taviloglu K, Ertekin C, Guloglu R, Zorba U, Cabioglu N; et al. (2006). "Fournier's gangrene: risk factors and strategies for management". World J Surg. 30 (9): 1750–4. doi:10.1007/s00268-005-0777-3. PMID 16927060.
- ↑ 2.0 2.1 Paty R, Smith AD (1992). "Gangrene and Fournier's gangrene". Urol Clin North Am. 19 (1): 149–62. PMID 1736475.
- ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
- ↑ Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A (2014). "Current concepts in the management of necrotizing fasciitis". Front Surg. 1: 36. doi:10.3389/fsurg.2014.00036. PMC 4286984. PMID 25593960.
- ↑ Escobar SJ, Slade JB, Hunt TK, Cianci P (2005). "Adjuvant hyperbaric oxygen therapy (HBO2)for treatment of necrotizing fasciitis reduces mortality and amputation rate". Undersea Hyperb Med. 32 (6): 437–43. PMID 16509286.
- ↑ Korhonen K (2000). "Hyperbaric oxygen therapy in acute necrotizing infections with a special reference to the effects on tissue gas tensions". Ann Chir Gynaecol Suppl (214): 7–36. PMID 11199291.
- ↑ Hyperbaric oxygen therapy. http://onlinelibrary.wiley.com/doi/10.1080/110241500750008583/abstract (2016) Accessed on September 12, 2016
- ↑ Kindwall EP, Gottlieb LJ, Larson DL (1991). "Hyperbaric oxygen therapy in plastic surgery: a review article". Plast Reconstr Surg. 88 (5): 898–908. PMID 1924583.
- ↑ Capelli-Schellpfeffer M, Gerber GS (1999). "The use of hyperbaric oxygen in urology". J Urol. 162 (3 Pt 1): 647–54. PMID 10458334.
- ↑ Darabi K, Abdel-Wahab O, Dzik WH (2006). "Current usage of intravenous immune globulin and the rationale behind it: the Massachusetts General Hospital data and a review of the literature". Transfusion. 46 (5): 741–53. doi:10.1111/j.1537-2995.2006.00792.x. PMID 16686841.