Synergistic Soft Tissue Infections of the Perineum Philip Iorianni, M.D.,* Gregory C. Oliver, M.D.-~ From the * George Washington University and Kaiser Permanente Medical Center, Washington, D. C, and the {Robert Wood Johnson Medical Center a n d Muhlenberg Regional Medical Center, Plainfield, New Jersey Seven patients with necrotizing soft tissue infections of the perineum are described. Predisposing factors related to infection were present in four patients (diabetes mellitus, multiple myeloma, HIV, and a poorly defined immunodeficiency syndrome). Anaerobic and facultative anaerobic bacteria were cultured in each case. Two patients required skin graft closure of the debrided wounds, with the remaining wounds closed by contracture and epithelialization. A diverting sigmoid colostomy to facilitate wound care was performed on one patient who had complete dissolution of all anal sphincters. The role of hyperbaric oxygen therapy in four patients was of uncertain value. [Key words: Necrotizing fasciitis; Fournier's gangrene] Iorianni P, Oliver GC. Synergistic soft tissue infections of the perineum. Dis Colon Rectum 1992;35:640-644.
baric oxygen ( H B O ) and surgical reconstruction therapy are the subject of this report. PATIENTS AND
METHODS
Seven patients with necrotizing soft tissue infections of the p e r i n e u m and urogenital area were treated at the G e o r g e Washington University Hospital b e t w e e n 1987 and 1988. Two of the seven patients received initial evaluation at local hospitals before their referral to this institution. The patients ranged in age from 25 to 80 years; five were males and two were females. A detailed history and physical examination were obtained on each patient, followed by a laboratory profile and radiographic studies. All patients were stabilized prior to definitive treatment. Initial intensive care unit m a n a g e m e n t was necessary in three of seven patients. When the patient's condition permitted, operating room evaluation and deb r i d e m e n t of all nonviable tissue were performed. Upon initial evaluation, Gram's stains were obtained along with aerobic and anaerobic cultures. Broad-spectrum antibiotic coverage was initiated before operative m a n a g e m e n t and adjusted based on culture sensitivity patterns. The HBO medical service evaluated each patient for consideration of treatment with this ancillary modality. Four of seven patients concomitantly u n d e r w e n t hyperbaric therapy. Hyperbaric therapy entailed placement of patients in a single-unit c h a m b e r at two atmospheres of pressure, 100 p e r c e n t oxygen for 90 minutes. One patient had therapy started preoperatively, three postoperatively. Three of seven patients u n d e r w e n t three days of therapy, with one patient u n d e r g o i n g therapy for seven days. Each patient had two or three HBO treatments per day.
N
ecrotizing skin and subcutaneous tissue infections are u n c o m m o n surgical p r o b l e m s often diagnosed late in their course. Subcutaneous and fascial necrosis may be present before the late diagnostic skin changes (edema, erythema, crepitus, and bullae) are evident. The high overall morbidity and mortality rates from these infections are attributed to delays in diagnosis, age of patients, and associated diseases (diabetes mellitus, arteriosclerosis, and malnutrition).>3 A low mortality is present with the necrotizing soft tissue infections of the extremities (9 percent), c o m p a r e d with those of the p e r i n e u m and urogenital region (2060 percent)2'5 This latter anatomic region is more difficult to evaluate and does not lend itself easily to surgical extirpation. 6'7 We report seven patients with necrotizing soft tissue infections of the p e r i n e u m and urogenital area who p r e s e n t e d or were transferred to the G e o r g e Washington University Hospital. The clinical presentations, risk factors, bacteriology, and m o d e s of therapy for treatment including hyperThis study was completed at the George Washington University I lospital, Department of Surgery. Read at the meeting of The American Society of Colon and Rectal Surgeons, Anaheim, California,June 12 to 17, 1988. Address reprint requests to Dr. Iorianni: Kaiser Permanente Medical Center, 10810 Connecticut Avenue, Kensington, Maryland 20895. 640
RESULTS Clinical Manifestations The time interval from the onset of symptoms until clinical presentation varied from one day to
Vol. 35, No. 7
SYNERGISTIC INFECTIONS OF THE PERINEUM
Bacteriology
two weeks, with five of the seven patients presenting within two days. All complained of tenderness of the involved sites, with swelling and tenderness noted on physical examination. Five of the seven patients had necrotic skin or blebs at the time of diagnosis. Two patients presented with subcutaneous crepitus. Three patients were febrile on presentation. Two patients presented initially to outside hospitals and were managed with outpatient incision and drainage. These patients then returned within 24 to 36 hours with definitive local signs of the necrotizing process. /
Operative Management The original site of infection and the extent of disease were defined at the time of the first operative procedure (Table 1). Six patients underwent initial radical debridement of the skin, subcutaneous tissue, and fascia during their first operative procedure. One patient underwent incision and drainage with limited excision of tissues upon initial presentation. The number of operative interventions ranged from one to six (mean, 2.7), with an incomplete debridement requiring a greater number of operative interventions. The number of blood transfusions required in the operative or perioperative period ranged from 0 to 12 units of packed red blood cells (mean, 4.4 units). One patient had synergistic necrotizing cellulitis with extensive involvement of the anorectal sphincter muscles. Twenty-four hours after initial debridement, a colostomy was performed to divert the fecal stream and to complete a secondary debridement of the necrotic anal sphincter complex.
641
Gram's stains were obtained on all patients. Stains demonstrated white blood cells, Gram-positive cocci and Gram-negative rods. All patients' culture results demonstrated mixed flora. None of these infections could be traced to a single bacterial organism. Each patient's cultures grow both anaerobic and facultative anaerobic bacteria. The most common bacteria isolated were Bacteroides species, Peptostreptococcus, and Escherichia coli. One patient's culture grew scanty colonies of Clostridium perfringens and Clostridium bifermentans (Table 2).
Adjuvant Therapy Appropriate antibiotic therapy and dosing were given to all patients based upon final culture sensitivity patterns. Patients received 5 to 25 days of intravenous antibiotic therapy. HBO therapy did not correlate with changes in symptoms, mental Table 2.
Bacteriology Total Number of Isolates
Organisms
Anaerobic bacteria (Gram-positive)
Peptostreptococcus Propionibacterium Clostridium perfringens (scanty) Anaerobic bacteria (Gram-negative) Bacteroides (total) Facultative bacteria Streptococcus (total)
Staphylococcus epidermidis Enterobacteriaceae (total)
5 1 1
3 2 4
Table 1. Patient Profile
Patient No.
Age (yr)
Sex
Site of Origin
Extension of Infection
1
25
F
Pilonidal tract
Pilonidal tract, perirectal
2
30
M
Urethra
3
41
M
Scrotal abscess
4
57
M
Perirectal abscess
Right thigh, abdominal wall, chest, penis, scrotum Scrotum, groin, abdominal wall Perirectal region (and sphincters)
5
80
M
Right Groin
6 7
29 26
F M
Perirectal abscess Perirectal abscess
Right groin and flank, left groin Perirectal, buttock Perirectal
Associated Diseases Immunocompromised, low immunoglobulin and complement
HIV+, hepatitis Cardiac disease, diabetes, multiple myeloma
HIV+
642
IORIANNI AND OLIVER
status, temperature, or white blood cell count. There were no complications from HBO therapy. Nutritional evaluation was performed on each patient. Three patients had albumin levels less than 2.5 mg/dl on presentation. Caloric and protein requirements were met in all patients, with one patient requiring central hyperalimentation for 16 days. An associated immunocompromised state was identified in four of our patients. Only one of these four immunodeficient states was due to diabetes mellitus (Table 2).
Wound Care and Reconstructive Surgery All patients were managed with frequent dressing changes, resulting in a granulating base in all the wounds. Only one patient required a colostomy, and this was because the anal sphincters were excised to remove the necrotizing process. Two patients required split-thickness skin grafts for wound coverage, with the remaining wounds closed by contracture and epithelialization.
Mortality There was one death in this study group. A 57year-old male with a history of diabetes mellitus and cardiovascular disease experienced a twoweek delay in diagnosis before presenting to the surgical service. He died 36 hours after presentation and after two operative debridement sessions. Post-mortem examination revealed high-grade atherosclerotic heart disease, a recent myocardial infarction, and multiple myeloma.
DISCUSSION Necrotizing soft tissue infections are uncommon problems that pose diagnostic and therapeutic challenges to the surgeon. The classification system for these types of infections is based on the infecting organisms and the presenting clinical picture. ~ These entities have been termed necrotizing anaerobic cellulitis, postoperative progressive bacterial synergistic gangrene, hemol~ic streptococcal gangrene, necrotizing fasciitis, Fournier's gangrene, synergistic necrotizing cellulitis, clostridial cellulitis, and clostridial myonecrosis. Of the seven patients in this group, one had necrotizing anaerobic cellulitis, five had necrotizing fasciitis, and one had synergistic necrotizing cellulitis. Nec-
Dis Colon Rectum, July 1992
rotizing fasciitis involves spread of the necrotizing process along the fascial planes, whereas synergistic necrotizing cellulitis is a process that involves the deep fascial planes and muscle. The overall prognosis of the latter is poor, with a reported mortality rate of 76 percent. 9 Fournier's gangrene is a form of necrotizing fasciitis or synergistic necrotizing cellulitis. The original report (1883) 1~detailed an idiopathic (probably Streptococcus pyogenes) infection of the male genitalia. Current thinking now relates this process to local trauma, extension from a urinary tract infection, or extension from the perineal area. 11 Whatever term one selects to describe this condition, it is early recognition of soft tissue necrosis and timely debridement that closely correlate with survival. Rea and Wyrick12 reported that survivors of necrotizing fasciitis (extremities and trunk) averaged four days from the onset of symptoms until therapy was begun whereas fatal cases averaged seven days. For infections involving the perineum, similar results have been reported. 6 Most patients presented herein had a sudden onset of progressive symptoms and signs suggesting such an infection. Admission hematologic and biochemical testing was of little help in arriving at the diagnosis, which is in agreement with other reported series.; Radiographic soft tissue air can be detected in 73 percent of necrotizing infections of the extremity. 13A computerized tomographic scan in Patient 1 showed soft tissue air, assisted in deciphering a complex clinical presentation, and facilitated an early diagnosis. Without the late skin changes, a high index of clinical suspicion must be maintained to arrive at an early diagnosis of this condition and to result in improved clinical outcomes. The mainstay of therapy is the operative removal of all nonviable tissue to margins at which the subcutaneous tissues can no longer be separated from the deep fascia. The fascial relationships in the urogenital and perirectal regions will define potential paths of extension of the infectious process. When the initial debridement is incomplete, the result is increased operative debridements, blood transfusions, antibiotic days, and prolonged hospital stay. A diverting colostomy was created in this study only when the infectious process destroyed the sphincter mechanism. Colostomy was not necessary for wound management in the other six patients. Wounds could be well managed with frequent dressing changes. Additionally, avoiding
Vol. 35, No. 7
SYNERGISTIC INFECTIONS OF THE PERINEUM
an abdominal incision to create a stoma prevents peritoneal spread of the septic process. These necrotizing infections may involve the lower abdominal wall, so stomal siting must be carefully considered if fecal diversion appears to be indicated. The bacterial flora causing necrotizing fasciitis has undergone considerable investigation since the initial studies by Meleney 14 in 1924. Most recently, Giuliano et al. 15 in 1977 showed that two bacteriologic profiles can be seen. The first was caused by S t r e p t o c o c c u s p y o g e n e s and the second by the combination of facultative and anaerobic bacteria. All patients in this report conformed to this latter group. The bacteriology of synergistic necrotizing cellulitis and nonclostridial anaerobic cellulitis is similar to this latter profile. One of our patients had laboratory growth of C l o s t r i d i u m p e r f r i n g e n s but did not have a clinical presentation of clostridial cellulitis or myonecrosis. This stresses the potential value of early evaluation of Gram's stains and careful culture techniques. Broad-spectrum antibiotic coverage should be administered when the diagnosis is first made and later directed by wound culture sensitivities. HBO therapy has been used mainly in cases of clostridial infections. 16'iv As an adjuvant in the management of synergistic infections, the efficacy of HBO is still controversial. The theoretic role for HBO therapy in combating synergistic infections has made it an attractive therapeutic option. The experimental viability of facultative bacteria in atmospheric oxygen is more than 72 hours, while the survival time for anaerobes ranges from 45 minutes ( p e p t o s t r e p t o c o c c u s ) to more than 72 hours (Clostridiumperfringens).is Riegels-Nielsen et al. ~9 treated five patients with Fournier's gangrene using debridement, intravenous antibiotics, and HBO therapy. This study suggested a beneficial effect of HBO therapy; no evidence to support this position was offered. Gozal et al. 2~ reported a 12.5 percent mortality rate in 16 patients who received immediate debridement and broad-spectrum antibiotics followed by HBO therapy. Notably, the average interval from onset of symptoms to therapy was 26.6 hours. In comparing the seven patients herein presented, the return of vital parameters (temperature, heart rate, white blood cell count, and mental status) to normal correlated with complete removal of necrotic tissue. This finding was noted in our patients receiving and those not receiving HBO therapy. The degree to which HBO
643
treatment may limit the margin of soft tissue necrosis is uncertain. Mortality and morbidity rates for synergistic infections of the perineum remain high. Improvements in survival can be achieved with early diagnosis enhanced by maintaining a. high index of clinical suspicion. Such infections should receive immediate, aggressive surgical debridement of nonviable tissue and broad-spectrum antibiotic coverage. The need for supplemental nutritional support should be considered. Associated medical conditions that may contribute to or predispose a patient to this type of infection should be sought after and treated concurrently. A role for HBO therapy in this condition must be considered unproven and of questionable value. Cost and the remote location of the HBO unit to critically ill patients further detract from the potential utility. REFERENCES 1. Freischlag JA, Ajalat G, Busuttil RW. Treatment of necrotizing soft tissue infections--the need for a new approach. Am J Surg 1985;149:751-5. 2. Lamerton AJ. Fournier's gangrene: non-clostridial gas gangrene of the perineum and diabetes mellitus. J R Soc Med 1986;79:212-5. 3. Majeski JA, Alexander JW. Early diagnosis, nutritional support, and immediate extensive debridement improve survival in necrotizing fasciitis. Am J Surg 1983;145:784-7. 4. Enriquez JM, Moreno S, Devesa M, Morales V, Platas A, Vincente E. Fournier's syndrome of urogenital and anorectal origin: a retrospective, comparative study. Dis Colon Rectum 1987;30:33-7. 5. Flanigan RC, Kursh ED, McDougal WS, Persky L. Synergistic gangrene of the scrotum and penis secondary to colorectal disease. J Urol 1978;119: 369-71. 6. Oh C, Lee C, Jacobson JH. Necrotizing fasciitis of the perineum. Surgery 1982;91:49-51. 7. Rosenberg PH, Shuck JM, Tempest BD, Reed WP. Diagnosis and therapy of necrotizing soft tissue infection. Ann Surg 1978;87:430-4. 8. Baxter CA. Surgical management of soft tissue infections. Surg Clin North Am 1972;52:1483-99. 9. Stone HH, Martin JD. Synergistic necrotizing cellulitis. Ann Surg 1972;175:702-11. 10. Fournier AJ. Gangrene Foudrouante de la Verge. Semaine Med 1883;3:345-8. 11. Joo P, Peters wJ. Fournier's gangrene. Can J Surg 1985;28:180-2. 12. Rea WJ, Wyrick wJ. Necrotizing fasciitis. Ann Surg 1970;172:957-64.
644
IORIANNI AND OLIVER
13. Fisher JR, Conway MJ, Takeshita RT, Sandoval R. Necrotizing fasciitis--importance of roentgenographic studies for soft-tissue gas. JAMA 1979;241: 8O3-6. 14. Meleney FL. Hemolytic streptococcus gangrene. Arch Surg 1924;ix:317-64. 15. Giuliano A, Lewis F Jr, Hadley K, Blaisdell FW. Bacteriology of necrotizing fasciitis. Am J Surg 1977; 134:52-7. 16. Hitchcock CR, Bubrick MP. Gas gangrene infections of the small intestine, colon, and rectum. Dis Colon Rectum 1976; 19:112-9.
Dis Colon Rectum, July 1992
17. Schweigel JF, Shim SS. A comparison of the treatment of gas gangrene with and without hyperbaric oxygen. Surg Gynecol Obstet 1973;136:969-70. 18. Rolfe RD, Hentges DJ, Campbell BJ, Barrett JT. Factors related to the oxygen tolerance of anaerobic bacteria. Appl Environ Microbiol 1978;36:306-13. 19. Riegels-Nielsen P, Hesselfeldt-Nielsen J, Bang-Jensen E, Jacobsen E. Fournier's gangrene: 5 patients treated with hyperbaric oxygen. J Urol 1984;132: 918-20. 20. Gozal D, Ziser A, Shupak A, Ariel A, Melamed Y. Necrotizing fasciitis. Arch Surg 1986;121:233-5.
baric oxygen ( H B O ) and surgical reconstruction therapy are the subject of this report. PATIENTS AND
METHODS
Seven patients with necrotizing soft tissue infections of the p e r i n e u m and urogenital area were treated at the G e o r g e Washington University Hospital b e t w e e n 1987 and 1988. Two of the seven patients received initial evaluation at local hospitals before their referral to this institution. The patients ranged in age from 25 to 80 years; five were males and two were females. A detailed history and physical examination were obtained on each patient, followed by a laboratory profile and radiographic studies. All patients were stabilized prior to definitive treatment. Initial intensive care unit m a n a g e m e n t was necessary in three of seven patients. When the patient's condition permitted, operating room evaluation and deb r i d e m e n t of all nonviable tissue were performed. Upon initial evaluation, Gram's stains were obtained along with aerobic and anaerobic cultures. Broad-spectrum antibiotic coverage was initiated before operative m a n a g e m e n t and adjusted based on culture sensitivity patterns. The HBO medical service evaluated each patient for consideration of treatment with this ancillary modality. Four of seven patients concomitantly u n d e r w e n t hyperbaric therapy. Hyperbaric therapy entailed placement of patients in a single-unit c h a m b e r at two atmospheres of pressure, 100 p e r c e n t oxygen for 90 minutes. One patient had therapy started preoperatively, three postoperatively. Three of seven patients u n d e r w e n t three days of therapy, with one patient u n d e r g o i n g therapy for seven days. Each patient had two or three HBO treatments per day.
N
ecrotizing skin and subcutaneous tissue infections are u n c o m m o n surgical p r o b l e m s often diagnosed late in their course. Subcutaneous and fascial necrosis may be present before the late diagnostic skin changes (edema, erythema, crepitus, and bullae) are evident. The high overall morbidity and mortality rates from these infections are attributed to delays in diagnosis, age of patients, and associated diseases (diabetes mellitus, arteriosclerosis, and malnutrition).>3 A low mortality is present with the necrotizing soft tissue infections of the extremities (9 percent), c o m p a r e d with those of the p e r i n e u m and urogenital region (2060 percent)2'5 This latter anatomic region is more difficult to evaluate and does not lend itself easily to surgical extirpation. 6'7 We report seven patients with necrotizing soft tissue infections of the p e r i n e u m and urogenital area who p r e s e n t e d or were transferred to the G e o r g e Washington University Hospital. The clinical presentations, risk factors, bacteriology, and m o d e s of therapy for treatment including hyperThis study was completed at the George Washington University I lospital, Department of Surgery. Read at the meeting of The American Society of Colon and Rectal Surgeons, Anaheim, California,June 12 to 17, 1988. Address reprint requests to Dr. Iorianni: Kaiser Permanente Medical Center, 10810 Connecticut Avenue, Kensington, Maryland 20895. 640
RESULTS Clinical Manifestations The time interval from the onset of symptoms until clinical presentation varied from one day to
Vol. 35, No. 7
SYNERGISTIC INFECTIONS OF THE PERINEUM
Bacteriology
two weeks, with five of the seven patients presenting within two days. All complained of tenderness of the involved sites, with swelling and tenderness noted on physical examination. Five of the seven patients had necrotic skin or blebs at the time of diagnosis. Two patients presented with subcutaneous crepitus. Three patients were febrile on presentation. Two patients presented initially to outside hospitals and were managed with outpatient incision and drainage. These patients then returned within 24 to 36 hours with definitive local signs of the necrotizing process. /
Operative Management The original site of infection and the extent of disease were defined at the time of the first operative procedure (Table 1). Six patients underwent initial radical debridement of the skin, subcutaneous tissue, and fascia during their first operative procedure. One patient underwent incision and drainage with limited excision of tissues upon initial presentation. The number of operative interventions ranged from one to six (mean, 2.7), with an incomplete debridement requiring a greater number of operative interventions. The number of blood transfusions required in the operative or perioperative period ranged from 0 to 12 units of packed red blood cells (mean, 4.4 units). One patient had synergistic necrotizing cellulitis with extensive involvement of the anorectal sphincter muscles. Twenty-four hours after initial debridement, a colostomy was performed to divert the fecal stream and to complete a secondary debridement of the necrotic anal sphincter complex.
641
Gram's stains were obtained on all patients. Stains demonstrated white blood cells, Gram-positive cocci and Gram-negative rods. All patients' culture results demonstrated mixed flora. None of these infections could be traced to a single bacterial organism. Each patient's cultures grow both anaerobic and facultative anaerobic bacteria. The most common bacteria isolated were Bacteroides species, Peptostreptococcus, and Escherichia coli. One patient's culture grew scanty colonies of Clostridium perfringens and Clostridium bifermentans (Table 2).
Adjuvant Therapy Appropriate antibiotic therapy and dosing were given to all patients based upon final culture sensitivity patterns. Patients received 5 to 25 days of intravenous antibiotic therapy. HBO therapy did not correlate with changes in symptoms, mental Table 2.
Bacteriology Total Number of Isolates
Organisms
Anaerobic bacteria (Gram-positive)
Peptostreptococcus Propionibacterium Clostridium perfringens (scanty) Anaerobic bacteria (Gram-negative) Bacteroides (total) Facultative bacteria Streptococcus (total)
Staphylococcus epidermidis Enterobacteriaceae (total)
5 1 1
3 2 4
Table 1. Patient Profile
Patient No.
Age (yr)
Sex
Site of Origin
Extension of Infection
1
25
F
Pilonidal tract
Pilonidal tract, perirectal
2
30
M
Urethra
3
41
M
Scrotal abscess
4
57
M
Perirectal abscess
Right thigh, abdominal wall, chest, penis, scrotum Scrotum, groin, abdominal wall Perirectal region (and sphincters)
5
80
M
Right Groin
6 7
29 26
F M
Perirectal abscess Perirectal abscess
Right groin and flank, left groin Perirectal, buttock Perirectal
Associated Diseases Immunocompromised, low immunoglobulin and complement
HIV+, hepatitis Cardiac disease, diabetes, multiple myeloma
HIV+
642
IORIANNI AND OLIVER
status, temperature, or white blood cell count. There were no complications from HBO therapy. Nutritional evaluation was performed on each patient. Three patients had albumin levels less than 2.5 mg/dl on presentation. Caloric and protein requirements were met in all patients, with one patient requiring central hyperalimentation for 16 days. An associated immunocompromised state was identified in four of our patients. Only one of these four immunodeficient states was due to diabetes mellitus (Table 2).
Wound Care and Reconstructive Surgery All patients were managed with frequent dressing changes, resulting in a granulating base in all the wounds. Only one patient required a colostomy, and this was because the anal sphincters were excised to remove the necrotizing process. Two patients required split-thickness skin grafts for wound coverage, with the remaining wounds closed by contracture and epithelialization.
Mortality There was one death in this study group. A 57year-old male with a history of diabetes mellitus and cardiovascular disease experienced a twoweek delay in diagnosis before presenting to the surgical service. He died 36 hours after presentation and after two operative debridement sessions. Post-mortem examination revealed high-grade atherosclerotic heart disease, a recent myocardial infarction, and multiple myeloma.
DISCUSSION Necrotizing soft tissue infections are uncommon problems that pose diagnostic and therapeutic challenges to the surgeon. The classification system for these types of infections is based on the infecting organisms and the presenting clinical picture. ~ These entities have been termed necrotizing anaerobic cellulitis, postoperative progressive bacterial synergistic gangrene, hemol~ic streptococcal gangrene, necrotizing fasciitis, Fournier's gangrene, synergistic necrotizing cellulitis, clostridial cellulitis, and clostridial myonecrosis. Of the seven patients in this group, one had necrotizing anaerobic cellulitis, five had necrotizing fasciitis, and one had synergistic necrotizing cellulitis. Nec-
Dis Colon Rectum, July 1992
rotizing fasciitis involves spread of the necrotizing process along the fascial planes, whereas synergistic necrotizing cellulitis is a process that involves the deep fascial planes and muscle. The overall prognosis of the latter is poor, with a reported mortality rate of 76 percent. 9 Fournier's gangrene is a form of necrotizing fasciitis or synergistic necrotizing cellulitis. The original report (1883) 1~detailed an idiopathic (probably Streptococcus pyogenes) infection of the male genitalia. Current thinking now relates this process to local trauma, extension from a urinary tract infection, or extension from the perineal area. 11 Whatever term one selects to describe this condition, it is early recognition of soft tissue necrosis and timely debridement that closely correlate with survival. Rea and Wyrick12 reported that survivors of necrotizing fasciitis (extremities and trunk) averaged four days from the onset of symptoms until therapy was begun whereas fatal cases averaged seven days. For infections involving the perineum, similar results have been reported. 6 Most patients presented herein had a sudden onset of progressive symptoms and signs suggesting such an infection. Admission hematologic and biochemical testing was of little help in arriving at the diagnosis, which is in agreement with other reported series.; Radiographic soft tissue air can be detected in 73 percent of necrotizing infections of the extremity. 13A computerized tomographic scan in Patient 1 showed soft tissue air, assisted in deciphering a complex clinical presentation, and facilitated an early diagnosis. Without the late skin changes, a high index of clinical suspicion must be maintained to arrive at an early diagnosis of this condition and to result in improved clinical outcomes. The mainstay of therapy is the operative removal of all nonviable tissue to margins at which the subcutaneous tissues can no longer be separated from the deep fascia. The fascial relationships in the urogenital and perirectal regions will define potential paths of extension of the infectious process. When the initial debridement is incomplete, the result is increased operative debridements, blood transfusions, antibiotic days, and prolonged hospital stay. A diverting colostomy was created in this study only when the infectious process destroyed the sphincter mechanism. Colostomy was not necessary for wound management in the other six patients. Wounds could be well managed with frequent dressing changes. Additionally, avoiding
Vol. 35, No. 7
SYNERGISTIC INFECTIONS OF THE PERINEUM
an abdominal incision to create a stoma prevents peritoneal spread of the septic process. These necrotizing infections may involve the lower abdominal wall, so stomal siting must be carefully considered if fecal diversion appears to be indicated. The bacterial flora causing necrotizing fasciitis has undergone considerable investigation since the initial studies by Meleney 14 in 1924. Most recently, Giuliano et al. 15 in 1977 showed that two bacteriologic profiles can be seen. The first was caused by S t r e p t o c o c c u s p y o g e n e s and the second by the combination of facultative and anaerobic bacteria. All patients in this report conformed to this latter group. The bacteriology of synergistic necrotizing cellulitis and nonclostridial anaerobic cellulitis is similar to this latter profile. One of our patients had laboratory growth of C l o s t r i d i u m p e r f r i n g e n s but did not have a clinical presentation of clostridial cellulitis or myonecrosis. This stresses the potential value of early evaluation of Gram's stains and careful culture techniques. Broad-spectrum antibiotic coverage should be administered when the diagnosis is first made and later directed by wound culture sensitivities. HBO therapy has been used mainly in cases of clostridial infections. 16'iv As an adjuvant in the management of synergistic infections, the efficacy of HBO is still controversial. The theoretic role for HBO therapy in combating synergistic infections has made it an attractive therapeutic option. The experimental viability of facultative bacteria in atmospheric oxygen is more than 72 hours, while the survival time for anaerobes ranges from 45 minutes ( p e p t o s t r e p t o c o c c u s ) to more than 72 hours (Clostridiumperfringens).is Riegels-Nielsen et al. ~9 treated five patients with Fournier's gangrene using debridement, intravenous antibiotics, and HBO therapy. This study suggested a beneficial effect of HBO therapy; no evidence to support this position was offered. Gozal et al. 2~ reported a 12.5 percent mortality rate in 16 patients who received immediate debridement and broad-spectrum antibiotics followed by HBO therapy. Notably, the average interval from onset of symptoms to therapy was 26.6 hours. In comparing the seven patients herein presented, the return of vital parameters (temperature, heart rate, white blood cell count, and mental status) to normal correlated with complete removal of necrotic tissue. This finding was noted in our patients receiving and those not receiving HBO therapy. The degree to which HBO
643
treatment may limit the margin of soft tissue necrosis is uncertain. Mortality and morbidity rates for synergistic infections of the perineum remain high. Improvements in survival can be achieved with early diagnosis enhanced by maintaining a. high index of clinical suspicion. Such infections should receive immediate, aggressive surgical debridement of nonviable tissue and broad-spectrum antibiotic coverage. The need for supplemental nutritional support should be considered. Associated medical conditions that may contribute to or predispose a patient to this type of infection should be sought after and treated concurrently. A role for HBO therapy in this condition must be considered unproven and of questionable value. Cost and the remote location of the HBO unit to critically ill patients further detract from the potential utility. REFERENCES 1. Freischlag JA, Ajalat G, Busuttil RW. Treatment of necrotizing soft tissue infections--the need for a new approach. Am J Surg 1985;149:751-5. 2. Lamerton AJ. Fournier's gangrene: non-clostridial gas gangrene of the perineum and diabetes mellitus. J R Soc Med 1986;79:212-5. 3. Majeski JA, Alexander JW. Early diagnosis, nutritional support, and immediate extensive debridement improve survival in necrotizing fasciitis. Am J Surg 1983;145:784-7. 4. Enriquez JM, Moreno S, Devesa M, Morales V, Platas A, Vincente E. Fournier's syndrome of urogenital and anorectal origin: a retrospective, comparative study. Dis Colon Rectum 1987;30:33-7. 5. Flanigan RC, Kursh ED, McDougal WS, Persky L. Synergistic gangrene of the scrotum and penis secondary to colorectal disease. J Urol 1978;119: 369-71. 6. Oh C, Lee C, Jacobson JH. Necrotizing fasciitis of the perineum. Surgery 1982;91:49-51. 7. Rosenberg PH, Shuck JM, Tempest BD, Reed WP. Diagnosis and therapy of necrotizing soft tissue infection. Ann Surg 1978;87:430-4. 8. Baxter CA. Surgical management of soft tissue infections. Surg Clin North Am 1972;52:1483-99. 9. Stone HH, Martin JD. Synergistic necrotizing cellulitis. Ann Surg 1972;175:702-11. 10. Fournier AJ. Gangrene Foudrouante de la Verge. Semaine Med 1883;3:345-8. 11. Joo P, Peters wJ. Fournier's gangrene. Can J Surg 1985;28:180-2. 12. Rea WJ, Wyrick wJ. Necrotizing fasciitis. Ann Surg 1970;172:957-64.
644
IORIANNI AND OLIVER
13. Fisher JR, Conway MJ, Takeshita RT, Sandoval R. Necrotizing fasciitis--importance of roentgenographic studies for soft-tissue gas. JAMA 1979;241: 8O3-6. 14. Meleney FL. Hemolytic streptococcus gangrene. Arch Surg 1924;ix:317-64. 15. Giuliano A, Lewis F Jr, Hadley K, Blaisdell FW. Bacteriology of necrotizing fasciitis. Am J Surg 1977; 134:52-7. 16. Hitchcock CR, Bubrick MP. Gas gangrene infections of the small intestine, colon, and rectum. Dis Colon Rectum 1976; 19:112-9.
Dis Colon Rectum, July 1992
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