eMedicine Specialties > Emergency Medicine > Genitourinary
Fournier Gangrene: Treatment & Medication
Updated: Mar 4, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Emergency Department Care
- Aggressive resuscitation in anticipation of surgery
- Airway management if indicated
- Crystalloid replacement if dehydrated or displaying signs of shock
- Supplemental oxygen, IV access, and continuous cardiac monitoring
- Early, broad-spectrum antibiotics; examples include the following:
- Ampicillin/sulbactam
- Ticarcillin/clavulanate
- Piperacillin/tazobactam
- Penicillinase-resistant penicillin, aminoglycoside, and metronidazole or clindamycin
- Coverage for methicillin-resistant Staphylococcus aureus, such as vancomycin
- Tetanus prophylaxis is indicated if soft-tissue injury is present.
- Irrigation with superoxidized water and packing with gauze soaked with zinc peroxide and hydrogen peroxide may be helpful.
Consultations
- Fournier gangrene is a surgical emergency. Surgical consultation is imperative.
- Immediate urologic consultation is mandatory.
Medication
The goals of pharmacotherapy are to reduce morbidity and to control the infection.
Antibiotics
Initiate early broad-spectrum antibiotics as soon as possible. Providing coverage for gram-positive, gram-negative, aerobic, and anaerobic bacteria is essential. Penicillins and beta-lactamase inhibitors or triple antibiotics are potential choices.
Vancomycin (Vancocin)
Potent antibiotic directed against gram-positive organisms and active against enterococci species. Useful to treat septicemia and skin structure infections. Indicated for patients who cannot receive or have failed to respond to penicillins and cephalosporins or for those who have infections with resistant staphylococci. For abdominal penetrating injuries, combine with an agent active against enteric flora and/or anaerobes.
To avoid toxicity, assay of vancomycin trough levels after the third dose drawn 0.5 h prior to next dosing currently is recommended. May need to adjust dose in patients diagnosed with renal impairment (use CrCl).
Adult
500-2000 mg/d IV divided tid/qid for 7-10 d
Pediatric
40 mg/kg/d IV divided tid/qid for 7-10 d
Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal failure, neutropenia; red man syndrome is caused by too rapid IV infusion (dose given over a few min) but rarely happens when dose given IV over 2 h administration or as PO or IP administration; red man syndrome is not an allergic reaction
Ampicillin-sulbactam sodium (Unasyn)
Drug combination that uses a beta-lactamase inhibitor with ampicillin; covers skin, enteric flora, and anaerobes; not ideal for nosocomial pathogens.
Adult
1.5 (1 g ampicillin + 0.5 g sulbactam) to 3 g (2 g ampicillin + 1 g sulbactam) IV/IM q6-8h; not to exceed 4 g/d sulbactam or 8 g/d ampicillin
Pediatric
<3 months: Not established
3 months to 12 years: 100-200 mg ampicillin/kg/d (150-300 mg Unasyn) IV divided q6h
>12 years: Administer as in adults; not to exceed 4 g/d sulbactam or 8 g/d ampicillin
Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal failure; if rash occurs, evaluate and differentiate from hypersensitivity reaction
Ticarcillin and clavulanate potassium (Timentin)
Inhibits biosynthesis of cell wall mucopeptide and is effective during active growth stage; antipseudomonal penicillin plus beta-lactamase inhibitor that provides coverage against most gram-positive and gram-negative organisms and most anaerobes; contains 4.7-5 mEq of sodium per gram.
Adult
200-300 mg/kg/d IV divided into equal doses q6h; usual dose is 3-4 g q4-6h
Pediatric
Preterm to 1 week: 75 mg/kg IV q8h
2 weeks to 1 month: 75 mg/kg IV q6h
>1 month: (3 dosing schedules exist)
(A) 3.1 g IV q6h
(B) 75 mg/kg IV q6h
(C) 100 mg/kg IV q12h
Tetracyclines may decrease effects of ticarcillin; high ticarcillin concentrations may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels
Documented hypersensitivity; do not treat severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis with oral penicillin during acute stage
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy; caution in patients with hepatic insufficiencies; perform urinalysis, BUN, and creatinine determinations during therapy, and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions
Piperacillin/tazobactam (Zosyn)
Antipseudomonal penicillin plus beta-lactamase inhibitor; inhibits biosynthesis of cell wall mucopeptide and is effective during the stage of active multiplication.
Adult
12 g piperacillin/1.5 g tazobactam IV for 7-10 d in divided doses of 3.375 g q6h
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Tetracyclines may decrease effects of ticarcillin; high ticarcillin concentrations may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels
Documented hypersensitivity; do not treat severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis with an oral penicillin during the acute stage
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Perform CBC prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy; exercise caution in patients diagnosed with hepatic insufficiencies; perform urinalysis, BUN, and creatinine determinations during therapy, and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions
Gentamicin (Gentacidin, Garamycin)
Aminoglycoside antibiotic used for gram-negative bacterial coverage; commonly used in combination with both an agent against gram-positive organisms and one that covers anaerobes; consider using when penicillins or other less toxic drugs are contraindicated, when bacterial susceptibility tests and clinical judgment indicate use, and in mixed infections caused by susceptible strains of staphylococci and gram-negative organisms; dosing regimens are numerous and are adjusted based on CrCl and changes in the volume of distribution; may be administered IV/IM.
Adult
Serious infections and normal renal function: 3 mg/kg/d IV/IM divided q8h
Life-threatening infections: 5 mg/kg/d IV/IM q6-8h
Loading dose: 1-2.5 mg/kg IV q8h
Maintenance dose: 1-1.5 mg/kg IV q8h
Each regimen must be followed by at least a trough level drawn on the third or fourth dose, 0.5 h before dosing, and may draw a peak level 0.5 h after the 30-min infusion; extended dosing regimen for pulmonary infections is 7 mg/kg/d divided q8h
Pediatric
<5 years with normal renal function: 2.5 mg/kg/dose IV/IM q8h
>5 years: 1.5-2.5 mg/kg/dose q8h or 6-7.5 mg/kg/d IV/IM divided q8h; not to exceed 300 mg/d with adjustments for renal function prn; monitor levels as in adults
Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents, thus prolonged respiratory depression may occur
Coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)
Documented hypersensitivity; non–dialysis-dependent renal insufficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment
Metronidazole (Flagyl)
Imidazole ring-based antibiotic active against anaerobes; usually used in combination with other antimicrobial agents, except when used for Clostridium difficile enterocolitis in which monotherapy is appropriate; active against various anaerobic bacteria and protozoa. Agent appears to be absorbed into cells of microorganisms that contain nitroreductase; then, unstable intermediate compounds are formed that bind DNA and inhibit synthesis, causing cell death.
Adult
Loading dose: Infuse 15 mg/kg IV over 1 h or 1 g for a 70-kg adult
Maintenance dose: 6 h following the loading dose, infuse 7.5 mg/kg IV over 1 h q6-8h or 500 mg for a 70-kg adult; not to exceed 4 g/d
Pediatric
15-30 mg/kg/d IV divided bid/tid; not to exceed 2 g/d
May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity of metronidazole; disulfiram reaction may occur with orally ingested ethanol
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy
Clindamycin (Cleocin)
Lincosamide useful in treatment against serious skin and soft-tissue infections caused by most staphylococci strains; also effective against aerobic and anaerobic streptococci, except enterococci; inhibits bacterial protein synthesis by inhibiting peptide chain initiation at the bacterial ribosome, where it preferentially binds to the 50S ribosomal subunit, causing bacterial growth inhibition.
Adult
600-1200 mg/d IV/IM divided q6-8h depending on degree of infection
Pediatric
8-16 mg/kg/d IV/IM divided tid/qid
Severe infections: May increase dose to 16-20 mg/kg/d divided tid/qid
Increases duration of neuromuscular blockade, induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin
Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis
Immunizations
Patients with fatal tetanus associated with Fournier gangrene have been documented in the literature. Patients with noncurrent tetanus status require immunization in the emergency department.
Diphtheria and tetanus toxoid (Decavac)
Tetanus toxoid is manufactured by first culturing Clostridium tetani and then detoxifying the toxin with formaldehyde. This toxoid commonly is combined with diphtheria toxoid, and both serve to induce production of serum antibodies to toxins produced by the bacteria.
Adult
0.5 mL IM
Primary immunization consists of 3 injections at 0, 2, and 6 mo; booster immunization is required q10y
Pediatric
0.5 mL IM
DTaP is recommended for children <7 y
Patients receiving immunosuppressants, including corticosteroids or radiation therapy, may remain susceptible despite immunization due to poor immune response; cimetidine may enhance or augment delayed-hypersensitivity responses to skin-test antigens; avoid concurrent use of medication with systemic chloramphenicol since it may impair amnestic response to tetanus toxoid; concurrent use of tetanus immune globulin may delay development of active immunity by several days (interaction is nevertheless clinically insignificant and does not preclude its concurrent use)
Documented hypersensitivity; a history of any type of neurological symptoms or signs following administration of this product; FDA recommends that elective tetanus immunization be deferred during any outbreak of poliomyelitis because tetanus toxoid injections are an important cause of provocative poliomyelitis
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use to treat actual tetanus infections, or for immediate prophylaxis of unimmunized individuals (use instead tetanus antitoxin, preferably human tetanus immune globulin) diminished antibody response to active immunization may be observed in patients receiving immunosuppressive therapy; better to defer primary diphtheria immunization until immunosuppressive therapy discontinued; routine immunization of symptomatic and asymptomatic HIV-infected persons is recommended
More on Fournier Gangrene |
| Overview: Fournier Gangrene |
| Differential Diagnoses & Workup: Fournier Gangrene |
 Treatment & Medication: Fournier Gangrene |
| Follow-up: Fournier Gangrene |
| References |
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References
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Further Reading
Keywords
Fournier gangrene, Fournier's gangrene, gangrene of the penis and scrotum, polymicrobial necrotizing fasciitis, infection of superficial perineal fascia
