Guideline sources The following summarized guidelines for the evaluation and management of fournier's gangrene are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2022), the World Society of Emergency Surgery (WSES/AAST 2021), the Surgical Infection Society Europe (SIS-E/WSES 2018), the Eastern Association for the Surgery of Trauma (EAST 2018), and the Infectious Diseases Society of America (IDSA 2014). 1 2 3 4 5 Calculator Laboratory Risk Indicator for Ne Guidelines 1. Classification and risk stratification Risk stratification: consider using Laboratory Risk Indicator for Necrotising Fasciitis score for an early diagnosis and Fournier's Gangrene Severity Index for prognosis and risk stratification https://web.pathway.md/diseases/rect5iux52FsxdhU2 1/5 6/29/23, 4:07 AM Fournier's gangrene Pathway of patients with suspected Fournier's gangrene. C 2. Diagnostic investigations Clinical examination: consider eliciting a focused medical history and performing a physical examination, including DRE, in patients with suspected Fournier's gangrene. C Laboratory tests: Consider obtaining the following laboratory tests to assess the status of patients with suspected Fournier's gangrene and signs of systemic infection or sepsis: CBC inflammatory markers (such as, CRP, procalcitonin) serum creatinine electrolytes blood gas analysis. C Show 2 more Computed tomography: Consider obtaining CT in stable patients with suspected Fournier's gangrene. C Do not obtain CT in patients with Fournier's gangrene and hemodynamic instability persisting after proper resuscitation. D 3. Medical management Hemodynamic support: initiate prompt appropriate hemodynamic support in patients with Fournier's gangrene. B Antibiotic therapy: As per EAU 2022 guidelines, initiate broad-spectrum antibiotics in patients with Fournier's gangrene at presentation, with subsequent refinement according to culture and clinical response. A As per AAST 2021 guidelines, initiate empiric antimicrobial therapy as soon as the diagnosis of Fournier's gangrene is suspected. B Show 2 more As per WSES 2018 guidelines, initiate prompt appropriate antibiotic therapy in patients with Fournier's gangrene. B As per IDSA 2014 guidelines: Initiate broad-spectrum empiric antibiotic therapy (such as vancomycin or linezolid plus piperacillin-tazobactam or a carbapenem, or plus ceftriaxone and metronidazole) in patients with suspected or documented necrotizing fasciitis, including coverage for aerobes, anaerobes, group A streptococci, and MRSA. B Administer penicillin plus clindamycin in patients with documented group A streptococcal necrotizing fasciitis. B https://web.pathway.md/diseases/rect5iux52FsxdhU2 2/5 6/29/23, 4:07 AM Fournier's gangrene Pathway Adjunctive treatment: do not use adjunctive treatments (such as hyperbaric oxygen therapy, negative-pressure therapy, or honey-soaked dressings) in patients with Fournier's gangrene except in the context of clinical trials. D 4. Surgical interventions Surgical management (general principles): Consider planning surgical management of early and delayed surgical sequelae in patients with Fournier's gangrene with a multidisciplinary and skilled team. C Consider using a multidisciplinary and tailored approach based upon the extent of perineal involvement, the degree of fecal contamination, and the possible presence of sphincter or urethral damage. C Surgical management, timing: As per AAST/WSES 2021 guidelines: Perform surgical intervention in patients with Fournier's gangrene as soon as possible. B Do not delay surgical intervention because of the imaging. D As per EAST 2018 guidelines, perform early initial debridement within 12 hours of diagnosis in patients with necrotizing soft tissue infection. B As per SIS-E/WSES 2018 guidelines, perform early and extensive initial surgical debridement to improve survival in patients with Fournier's gangrene. B Surgical management, technique: As per AAST/WSES 2021 guidelines: Consider removing all necrotic tissue. C Consider performing orchiectomy or other genital surgery only if strictly necessary and possibly based on a urologic consultation. C As per SIS-E/WSES 2018 guidelines, consider performing fecal diversion, either by colostomy or fecal tube system with or without negative pressure therapy, in cases of Fournier's gangrene with fecal contamination. C Surgical management, revision: As per EAU 2022 guidelines, perform repeated surgical debridement within 24 hours of presentation. A As per AAST/WSES 2021 guidelines: Consider planning repeat surgical revisions (exploration and debridement) according to patient conditions. C Consider performing seriated surgical revisions until the patient is free of necrotic tissue. C 5. Specific circumstances Patients with urosepsis: use the qSOFA score to identify patients with potential sepsis. A Show 5 more https://web.pathway.md/diseases/rect5iux52FsxdhU2 3/5 6/29/23, 4:07 AM Fournier's gangrene Pathway 6. Follow-up and surveillance Indications for surgical consultation: obtain prompt surgical consultation for patients with aggressive infections associated with signs of systemic toxicity or suspicion of necrotizing fasciitis or gas gangrene. B Clinical findings Symptoms Past medical history Fever Immunocompromising condition Sepsis Vital signs Neurological exam Hypotension Signs of shock Altered mental status Tachycardia Lab findings Integument exam ESR Gangrene blood glucose Hemorrhagic bullae serum CRP Skin blisters serum creatinine Skin crepitus serum sodium Skin erythema Skin induration Skin tenderness Skin ulceration Tissue necrosis Hematological findings WBC count Studies 2017 INSTINCT In ICU patients with necrotizing soft tissue infection, intravenous polyspecific IgG was not superior to placebo with respect to physical component summary score at 6 m. Martin B Madsen et al. Intensive Care Med. 2017 Nov. References 1. Antonio Tarasconi, Gennaro Perrone, Justin Davies et al. Anorectal emergencies: WSES AAST guidelines. World J Emerg Surg. 2021 Sep 16;16 1 48. Open 2. Sartelli M, Guirao X, Hardcastle TC et al. 2018 WSES/SIS E consensus conference: recommendations for the management of skin and soft-tissue infections. World J Emerg Surg. 2018 Dec 14;13 58. Open https://web.pathway.md/diseases/rect5iux52FsxdhU2 4/5 6/29/23, 4:07 AM Fournier's gangrene Pathway 3. G. Bonkat, R. Bartoletti, F. Bruy re et al. EAU Guidelines on Urological Infections. EAU. 2022. Open 4. Stevens DL, Bisno AL, Chambers HF et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014 Jul 15;59 2):e10 52. Open 5. Rondi B Gelbard, Paula Ferrada, D Dante Yeh et al. Optimal timing of initial debridement for necrotizing soft tissue infection: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2018 Jul;85 1 208 214. Open https://web.pathway.md/diseases/rect5iux52FsxdhU2 5/5