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right-hand column like this one does at the top

and clostridial species.15 Those with progressive disease, including septic shock, will require fluid restoration and vasopressors. Hyperbaric therapy has been proposed for management of FG to improve oxygenation to the tissues and increase healing times.2,7,9

TABLE 2. Laboratory Risk Indicator for Necrotizing Fasciitis* Laboratory Value


C-reactive protein (mg/L) <150 >150

0 4

White blood cell count (cells/µL) <15 15-25 >25

0 1 2

Hemoglobin (g/dL) <11 11-13.5 >13.5

0 1 2

Sodium (mEq/L) ≥135 <135

0 2

Creatinine (mg/dL) ≤1.6 >1.6

0 2

Glucose (mg/dL) ≤180 >180

0 1


*The LRINEC scoring system is used only for those patients with a suspected or diagnosed soft tissue infection. A total score >6 implies intermediate- and high-risk patients.8

TABLE 3. Common Antimicrobial Agents for Treatment of Fournier Gangrene10,12 Drug Class


Brand Name

Third-generation cephalosporins









β-lactamase inhibitors






Many of the risk factors associated with FG are preventable. Of the common comorbidities, alcohol use and hyperglycemia remain those most associated with morbidity and mortality.2,9,11 Simple measures of glycemic and hypertension control along with weight loss have been proposed as key factors for prevention. Numerous studies have been conducted to determine the role of the most common comorbidities in provoking FG, especially those deemed largely preventable.4,6,12 For example, some studies determined that glycosylated hemoglobin levels >7% or uncontrolled diabetes present the greatest risk.4,6,12,18 Similar studies were unable to consistently substantiate the correlation between uncontrolled diabetes and mortality, instead favoring other prognostic indicators such as chronic kidney disease (CKD), in particular CKD requiring hemodialysis.19-22 Despite these findings, strict conventional glycemic control as a means of risk reduction is strongly recommended. Prevention of FG should not be limited to outpatient strategies alone. During the course of the patient’s hospital stay and recovery, further care should be taken to reduce the hazards of additional trauma from procedures that could result in FG, particularly those to the gastrointestinal and genitourinary tracts.9,10,11 If trauma to the perineum has occurred, patients and healthcare professionals should be encouraged to clean the affected sites frequently, continue proper hand washing techniques, and remain vigilant for any signs of disease.23 Patients should be informed that if signs of infection manifest, prompt recognition and management should be sought.23 Prognosis


Some researchers and clinicians have advocated the use of scoring systems, such as the Fournier Gangrene Severity Index (FGSI), as a prognostic tool for patient mortality once the disease is confirmed.4 Although its academic merits are without question, the clinical utility of FGSI in early management is debatable.6 FGSI is meant to predict a patient’s likely mortality risk associated with the disease, not to guide clinical decision-making. FGSI analyzes temperature, heart rate, respiratory rate, white blood cell count, hematocrit, serum sodium, serum creatinine, and bicarbonate levels to create a value to predict patient mortality.15 A score from the FGSI >9 Continues on page 29 • THE CLINICAL ADVISOR • JUNE 2019 23

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June 2019 Clinical Advisor  

June 2019 Clinical Advisor