Management

Whilst the usual principles of the ‘Sepsis 6’ are indicated, source control is surgical, and hence treatment involves prompt recognition, referral to the appropriate surgical specialty for your emergency department (this may be plastics, urology or general surgery) and IV antibiotics covering aerobes and anaerobes. Similar to vascular emergencies, the door to theatre time needs to be measured in minutes!

Regarding antibiotics, refer to local guidance regarding choice and duration, but a typical regime would be:

Meropenem 2g IV TDS, Clindamycin 1.2g IV QDS

With Linezolid 600mg IV BD (if previous MRSA or PVL suspected) and Gentamicin 5mg/kg stat dose if in septic shock/severe sepsis. 

Discuss with the on-call microbiology team as soon as practicable to help guide further therapy, expedite investigations and in some trusts, access to certain antimicrobials may be gatekept by microbiology/infectious diseases.

Additionally, the underlying pathophysiology leading to the gangrene (trauma, foreign body, drug use etc.) and comorbidities (diabetes, immunosuppression, malignancy etc.) also need to be managed concomitantly with the Fournier’s. Hyperbaric oxygen therapy is mentioned in the literature as a treatment option, increasing delivery of oxygen to tissues, however given the rapid spread of infection and surgery being the key intervention, it should be considered as an adjunct.