Fournier's Gangrene: outcome analysis at three tertiary hospitals in Harare Zimbabwe
Meki, Shingirirai Christopher
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Background: Fournier’s gangrene is a potentially life threatening, infective necrotizing fasciitis of the external genitalia and perineum. The average world mortality rate is between 20 – 30%. The factors associated with mortality are not universally accepted and have not been described in our environment. Main objective: To determine the disease related mortality rate and factors associated with mortality among patients admitted with a clinical diagnosis of Fournier’s gangrene at 3 tertiary hospitals in Harare, Zimbabwe. . Study Design: A prospective observational descriptive study on 51 consecutive patients with a clinical diagnosis of Fournier’s gangrene managed at 3 tertiary hospitals in Harare, Zimbabwe over a 2 year period. Materials and Methods: The study was done after approval by the relevant regulatory boards and after obtaining informed consent from the patients. Data on demographics, clinical history and physical examination, vital signs and laboratory values on admission were recorded on a designed data collection sheet. All patients received intravenous broad spectrum antibiotics and fluid resuscitation and surgical debridement. The number and time to first surgical debridement and any additional surgical procedures performed were recorded. The patients were followed up from admission till discharge from hospital or death. The patients were stratified according to outcome, whether dead or alive and comparison between survivors and non survivors was done to determine factors associated with mortality using chi squared or Fischer exact test for categorical variables and student t test for comparison of the means. Binary multiple regression analysis was performed to determine independent factors associated with mortality. Results: The disease related hospital mortality rate was 27% (14/51). The median hospital stay was 15 days. The median age of the 51 patients was 43 years. The patients that did not survive were significantly older than those that survived (58.36 + 21.04 vs 42.76 + 14.40 years)(p=0.021). The presence of at least one comorbity was associated with an increased mortality (p=0.007).HIV was the commonest risk factor accounting for 36% of the cases Neither the presence of HIV nor diabetes mellitus was assocaited with mortality. Renal failure at presentation was signficantly associated with mortality, with a rate of 70% among patients.(p=0.001). The urogenital tract source of infection was associated with increased mortality (p=0.01) while a cutaneous source was associted with survival. (p=0.003). E coli and staphylococcus aures were the commonest pathogens isolated. A delay in first surgical debridement beyond 24 hours from time of admision was signficantly associated with an increased mortality (p=0.04).The number of debridement did not differ significantly between survivors and non survivors. A body surface area involvement of > 5% and abdominal involvement was also signficantly associated with higher mortality. The admitting clinal and biochemical parameters signficantly associated with non survivors were a high respiratory rate, low haemoglobin, hyperkalemia, elevated blood urea nitrogen and elevated creatinine. There was no factor that was independently associated with mortality after multiple logistic regression analysis. Conclusion: Fournier’s gangrene remains a potentially fatal condition in our enviroment with a mortality rate of 27%. On univariate analysis an older age, presence of renal failure on admission, a urogenital source of infection, severe sepsis, abdominal involvement, anemia, hyperkalemia and delay in surgical debridement is associated with mortality in our enviroment. The presence of HIV and diabetes mellitus and number of surgical debridement does not seem to affect mortality in our enviroment.