Can we predict poor prognosis in Fournier gangrene?

Abstract

Aim: Fournier’s gangrene (FG) is a rapidly progressing and highly mortal necrotizing fasciitis that develops due to polymicrobial infection of the genital, perineal and perianal regions. Advanced age, comorbidities, width of the infected area, leukocyte-lymphocyte ratio, number of debridement performed, and Fournier’s gangrene severity index (FGSI) score are reported as prognostic factors for FG. In our study, we aimed to present the clinical and laboratory findings that can be used to predict poor prognosis in Fournier gangrene. Methods: In this retrospective cohort study, the files of 83 patients treated for FG were retrospectively analyzed. Demographic data, laboratory findings, treatments, age adjusted Charlson comorbidity index (ACCI), FGSI score, LRINEC score, complications and mortality were noted. Risk factors affecting mortality were determined. Results: Male/female ratio was 7.3. The mean age of the patients were 55.4 years. The mortality rate was 21.7%. The mean ACCI scores (Mortality group: 6.00 (2.72), survivors’ group: 2.66 (2.39)) and FGSI scores (Mortality group; 11.22 (3.2), survivors’ group; 3.25 (2.08)) of non-surviving patients were higher than those of survivors (P<0.001, P<0.001, respectively). Also, the mean neutrophil-lymphocyte ratio (Mortality group: 21.05 (15.67), survivors’ group: 11.62 (10.50), (P=0.013), and the mean LRINEC score (Mortality group: 7.17 (2.03), survivors’ group: 3.18 (2.59)) (P=0.001) were higher among non-survivors. Cut off values for FGSI score, LRINEC, ACCI, and neutrophil / lymphocyte ratio were 7.5 (94.4% sensitivity and 95.4% specificity), 4.5 (94.4% sensitivity and 67.7% specificity), 3.5 (77.8% sensitivity and 73.8% specificity), and 8.70 (72.2% sensitivity and 52.3% specificity), respectively, in predicting mortality. Mortality was higher in female patients compared to males (P=0.02), and among the diabetics (P=0.05). Conclusion: We think that risk factors such as advanced age, diabetes, female gender, high ACCI score, high FGSI scores, high LRINEC scores and high neutrophil lymphocyte ratio are predictive of poor prognosis in FG.

Keywords

• Fournier's gangrene
• mortality
• risk factors

Fournier gangreninde kötü prognozu ön görebilirmiyiz?

Abstract

Amaç: Fournier gangreni (FG), genital, perineal ve perianal bölgelerin polimikrobiyal enfeksiyonuna bağlı olarak gelişen, hızla ilerleyen ve oldukça ölümcül bir nekrotizan fasiittir. İleri yaş, komorbiditeler, enfekte bölgenin genişliği, lökosit-lenfosit oranı, debridman sayısı, Fournier'in kangren şiddet indeksi (FGSI) skoru FG için prognostik faktörler olarak gösterilmiştir. Çalışmamızda fournier gangreninde kötü prognozu tahmin etmede kullanılabilecek klinik ve laboratuvar bulgularını sunmayı amaçladık. Yöntemler: Bu retrospektif kohort çalışmada FG tedavisi gören 83 hastanın dosyası incelendi. Demografik veriler, laboratuvar bulguları, tedaviler, yaşa göre düzenlenmiş Charlson komorbidite indeksi (ACCI), FGSI skoru, LRINEC skoru, komplikasyonlar ve mortalite dosyalardan kaydedildi. Mortaliteyi etkileyen risk faktörleri belirlendi. Bulgular: Erkek / kadın oranı 7,3 idi. Ortalama yaş 55,4 idi. Ölüm oranı % 21,7 olarak saptandı. Mortalitesi olan hastaların ortalama ACCI skorları (mortalite grubu; 6,00 (2,72) - sağ kalanlar grubu; 2,66 (2,39)) ve FGSI skorları (mortalite grubu; 11,22 (3,2) - sağ kalanlar grubu; 3,25 (2.08)), sağ kalanlardan daha yüksekti (sırasıyla, P<0,001, P<0,001). Ayrıca ortalama nötrofil-lenfosit oranı (mortalite grubu; 21,05 (15,67) - hayatta kalanlar grubu; 11,62 (10,50)) (P=0,013) ve ortalama LRINEC skoru (mortalite grubu; 7,17 (2,03) - hayatta kalanlar grubu; 3,18 (2,59)). FGSI skoru için kesme değeri 7,5 (%94,4 duyarlılık ve %95,4 özgüllük), LRINEC için 4,5 (%94,4 duyarlılık ve %67,7 özgüllük), ACCI 3,5 için (%77,8 duyarlılık ve %73,8 özgüllük), nötrofil / lenfosit oranı için mortaliteyi öngörmede 8,70 (%72,2 duyarlılık ve %52,3 özgüllük) olarak saptandı. Kadın hastalarda mortalite erkeklere göre daha yüksekti (P=0,02) ve diyabetli hastalarda mortalite daha yüksekti (P=0,05). Sonuç: İleri yaş, diyabet, kadın cinsiyet, yüksek ACCI skoru, yüksek FGSI skoru, yüksek LRINEC skoru ve yüksek nötrofil lenfosit oranı gibi risk faktörlerinin FG'de kötü prognozu öngörmede kullanılabileceğini düşünmekteyiz.

Keywords

• Fournier gangreni
• Mortalite
• Risk faktörleri

References

1. 1. Smith GL, Bunker CB, Dinneen MD. Fournier’s gangrene. Br J Urol. 1998;81:347-55.
2. 2. Korkut M, Içöz G, Dayangaç M, Akgün E, Yeniay L, Erdoğan O, et al. Outcome analysis in patients with Fournier’s gangrene: report of 45 cases. Dis Colon Rectum. 2003;46:649-52.
3. 3. Aşgın N, Satılmış Ş. Which antibiotics should we prefer empirical treatment of urinary tract infections in elderly patients? J Surg Med. 2019;3(12):856-60.
4. 4. Thwaini A, Khan A, Malik A, Cherian J, Barua J, Shergill I, et al. Fournier’s gangrene and its emergency management. Postgrad Med J. 2006;82:516-9.
5. 5. Sorensen MD, Krieger JN, Rivara FP, Klein MB, Wessells H. Fournier’s gangrene: management and mortality predictors in a population based study. J Urol. 2009;182:2742-7.
6. 6. Kahramanca Ş, Kaya, O, Özgehan, G, Irem B, Dural I, Küçükpınar T, et al. Are neutrophil-lymphocyte ratio and platelet-lymphocyte ratio as effective as Fournier’s gangrene severity index for predicting the number of debridements in Fourner’s gangrene? Ulus Travma Acil Cerr Derg. 2014;Mar;20(2):107-12.
7. 7. Laor E, Palmer LS, Tolia BM, Reid RE, Winter HI. Outcome prediction in patients with Fournier’s gangrene. J Urol. 1995;154:89-92.
8. 8. Sallami S, Maalla R, Gammoudi A, Ben Jdidia G, Tarhouni L, Horchani A. Fournier’s gangrene: what are the prognostic factors? Our experience with 40 patients. Tunis Med. 2012;Oct;90(10):708-14.

9. 9. Wong CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004;32(7):1535–41.
10. 10. Yilmazlar T, Ozturk E, Ozguc H, Ercan I, Vuruskan H, Oktay B. Fournier’s gangrene: an analysis of 80 patients and a novel scoring system. Tech Coloproctol. 2010;14:217-23.
11. 11. Lin TY, Ou CH, Tzai TS, Tong YC, Chang CC, Cheng HL, et al. Validation and simplification of Fournier's gangrene severity index. Int J Urol. 2014;Jul;21(7):696-701.
12. 12. Selvi I, Aykac A, Baran O, Burlukkara S, Ozok U, Sunay MM. A different perspective for morbidity related to Fournier's gangrene: which scoring system is more reliable to predict requirement of skin graft and flaps in survivors of Fournier's gangrene? Int Urol Nephrol. 2019;Aug;51(8):1303-11.
13. 13. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chron Dis. 1987;40:373.
14. 14. Eke N. Fournier's gangrene: a review of 1726 cases. Br J Surg. 2000;87:718-28.
15. 15. Yücel M, Özpek A, Başak F, Kılıç A, Ünal E, Yüksekdağ S, et al. Fournier's gangrene: A retrospective analysis of 25 patients. Ulus Travma Acil Cerrahi Derg. 2017;23:400-4.
16. 16. Montrief T, Long B, Koyfman A, Auerbach J. Fournier Gangrene: A Review for Emergency Clinicians. J Emerg Med. 2019 Oct;57(4):488-500.
17. 17. Göktaş C, Yıldırım M, Horuz R, Faydacı G, Akça O, Cetinel CA. Factors affecting the number of debridements in Fournier's gangrene: our results in 36 cases. Ulus Travma Acil Cerrahi Derg. 2012 Jan;18(1):43-8.
18. 18. Mallikarjuna MN, Vijayakumar A, Patil VS, Shivswamy BS. Fournier’s gangrene: Current Practices. ISRN Surg. 2012;2012:937–42.
19. 19. Yanar H, Taviloglu K, Ertekin C, Guloglu R, Zorba U, Cabioglu N, et al. Fournier’s gangrene: risk factors and strategies for management. World J Surg. 2006;30:1750-4.
20. 20. Barupal SR, Soni ML, Barupal R. Factors Affecting Mortality Following Necrotizing Soft-Tissue Infections: Randomized Prospective Study. J Emerg Trauma Shock. 2019;12:108-16.
21. 21. Hsiao CT, Chang CP, Huang TY, Chen YC, Fann WC. Prospective Validation of the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) Score for Necrotizing Fasciitis of the Extremities. PLoS One. 2020;Jan 24;15(1):e0227748.
22. 22. Gönüllü D, Ilgun AS, Demiray O, Sayar S, Er AM, Kır G, et al. The Potential Prognostic Significance of the Laboratory Risk Indicator for the Necrotizing Fasciitis (LRINEC) Score in Necrotizing Fasciitis. Chirurgia. 2019;May-Jun;114(3):376-83.
23. 23. Czymek R, Frank P, Limmer S, Schmidt A, Jungbluth T, Roblick U, et al. Fournier’s gangrene: is the female gender a risk factor? Langenbecks Arch Surg. 2010;395:173-80.
24. 24. Chawla SN, Gallop C, Mydlo JH. Fournier’s gangrene: an analysis of repeated surgical debridement. Eur Urol. 2003;43:572-5.
25. 25. Yim SU, Kim SW, Ahn JH, Cho YH, Chung H, Hwang EC, et al. Neutrophil to Lymphocyte and Platelet to Lymphocyte Ratios Are More Effective than the Fournier's Gangrene Severity Index for Predicting Poor Prognosis in Fournier's Gangrene. Surg Infect (Larchmt). 2016;Apr;17(2):217-23.