Medication Summary
The goals of pharmacotherapy in Fournier gangrene are to reduce morbidity and to control the infection. Broad-spectrum antibiotics should be given early in treatment. Tetanus prophylaxis is indicated if soft-tissue injury is present.
Antibiotics
Class Summary
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)
Vancomycin is a potent antibiotic directed against gram-positive organisms and active against enterococcal species. It is useful for the treatment of septicemia and skin structure infections.
Vancomycin is 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. Dose adjustment may be necessary in patients with renal impairment; follow creatinine clearance (CrCl).
Ampicillin-sulbactam sodium (Unasyn)
This is a drug combination that uses a beta-lactamase inhibitor with ampicillin; covers skin, enteric flora, and anaerobes; not ideal for nosocomial pathogens.
Ticarcillin and clavulanate potassium (Timentin)
This antipseudomonal penicillin plus beta-lactamase inhibitor provides coverage against most gram-positive and gram-negative organisms and most anaerobes. It contains 4.7-5 mEq of sodium per gram. Ticarcillin inhibits biosynthesis of bacterial cell wall mucopeptide and is effective during the active growth stage.
Piperacillin and tazobactam (Zosyn)
This combination of an antipseudomonal penicillin and a beta-lactamase inhibitor inhibits biosynthesis of bacterial cell wall mucopeptide and is effective during the stage of active multiplication.
Gentamicin
An aminoglycoside antibiotic used for gram-negative bacterial coverage, gentamicin is commonly used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Consider using gentamicin 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 on the basis of CrCl and changes in the volume of distribution. Gentamicin may be administered IV or IM.
Metronidazole (Flagyl)
Metronidazole is an imidazole ring-based antibiotic that is active against anaerobes. It is usually given in combination with other antimicrobial agents, except when used for Clostridium difficile enterocolitis, in which case monotherapy is appropriate.
Metronidazole is active against various anaerobic bacteria and protozoa. It 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.
Clindamycin (Cleocin)
Clindamycin is a lincosamide useful in treatment against serious skin and soft-tissue infections caused by most staphylococci strains; it is also effective against aerobic and anaerobic streptococci, except enterococci. This agent 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.
Immunizations
Class Summary
Fatal tetanus associated with Fournier gangrene has 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.
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Necrotizing infection results when the pathogen is extremely virulent or, most commonly, when a combination of microorganisms act synergistically in a susceptible immunocompromised host.
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Photomicrograph of Fournier gangrene (necrotizing fasciitis), oil immersion at 1000X magnification. Note the acute inflammatory cells in the necrotic tissue. Bacteria are located in the haziness of their cytoplasm. Courtesy of Billie Fife, MD, and Thomas A. Santora, MD.
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Photograph of a morbidly obese male with long-standing phimosis. This condition led to urinary incontinence, perineal diaper rash–like dermatitis, and urinary tract infection. Ultimately, he presented with exquisite perineal pain. An examination with the patient under anesthesia was necessary to discover the necrotizing infection that appeared to originate in the right bulbourethral gland. Courtesy of Thomas A. Santora, MD.
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Patient with Fournier gangrene following radical debridement. A dorsal slit was made in the prepuce to expose the glans penis. Urethral catheterization was performed. Incision into the point of maximal tenderness on the right side of the perineum revealed gangrenous necrosis that involved the anterior and posterior aspects of the perineum, the entirety of the right hemiscrotum, and the posterior medial aspect of the right thigh. The skin and involved fascia were excised from these areas. Reconstruction of this defect was performed in a staged approach. A gracilis rotational muscle flap taken from the right thigh was used to fill the cavity in the posterior right perineum as the first step. The remainder of the defect was covered with split-thickness skin grafts. This patient made a full recovery.
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Fascial envelopment of the perineum (male). Note how Colles fascia completely envelops the scrotum and penis. Colles fascia is in continuity cephalad to the level of the clavicles. In the inguinal region, this fascial layer is known as Scarpa fascia. Familiarity with this fascial anatomy, along with recognition that necrotizing fasciitis tends to spread along fascial planes, makes it easy to understand how a process that starts in the perineum can spread to the abdominal wall, the flank, and even the chest wall.
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Examination of an anesthetized man with alcoholism and known cirrhosis who presented with exquisite pain limited to the scrotum. Note the erythema of the scrotum and the look of skepticism on the face of one of the surgeons. Courtesy of Thomas A. Santora, MD.
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In a man with alcoholism and known cirrhosis who presented with exquisite pain limited to the scrotum, opening of the scrotum along the median raphe liberated foul-smelling brown purulence and exposed necrotic tissue throughout the mid scrotum. The testicles were not involved. Courtesy of Thomas A. Santora, MD.
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The same patient depicted in Images 6 and 7. Following resolution of the infection, the wound was covered with a split-thickness skin graft. The option of delayed primary closure of this wound was not chosen in this patient because of concern for tension on the closure. Courtesy of Thomas A. Santora, MD.
