The presentation, management and outcomes of Fournier’s gangrene at a tertiary urology referral centre in South Africa

Abstract

Background. Fournier’s gangrene (FG) is a clinically relevant condition with a high mortality rate. In South Africa (SA) most affected patients present at district and regional level hospitals. It is important for doctors to recognise the condition and accurately assess patients with FG to decide which of them need urgent referral to a tertiary centre. Objectives. To review the presentation, management and outcomes of patients with FG at a tertiary urology referral centre, with the specific intention of identifying prognostic factors and assessing the validity of the Fournier’s Gangrene Severity Index (FGSI). Methods. A retrospective chart review was performed of all patients treated for FG over a 5-year period at Grey’s Hospital in Pietermaritzburg, SA. HIV-positive patients were compared with patients with diabetes mellitus (DM). The FGSI was calculated for each patient. Regression analysis was performed to identify risk factors. Results. Forty-four patients (mean age 51 years) were treated for FG, corresponding to 8.8 patients per year. HIV was the commonest comorbidity, followed by DM. HIV-positive patients presented at a younger age than non-HIV-positive patients (p<0.001). On average the patients underwent 1.33 debridements, and 45.5% required transfusion. All were treated with broad-spectrum antibiotics. The overall mortality rate was 11.4% and the mean hospital length of stay was 26 days. There was no difference between the mean age of survivors and non-survivors (p=0.752). There was no association between mortality, HIV, DM or number of debridements. The mean (standard deviation) FGSI was significantly different in patients who died (15.4 (4.78)) and those who survived (5.92 (4.09)) (p<0.001). There was a significant association between FGSI >9 and mortality (p=0.017). FGSI >9 predicted 44.4% mortality, and FGSI ≤9 predicted 95.5% survival. A combination of FGSI >9, debridement outside the perineum (onto the abdominal wall, chest or limbs) and requirement for organ support was present in 80.0% of patients who died and was a significant risk factor for mortality (p=0.002). Conclusions. In a resource-constrained environment such as SA, outcome prediction is necessary to enable resource allocation. Patients with an FGSI >9 have a high risk of mortality and will benefit from ICU care. The combination of FGSI >9, requirement for organ support and extension beyond the perineum is associated with a very high risk of mortality and may be useful as an exclusion criterion when allocating scarce resources.

S Afr Med J 2018;108(8):671-676