Surviving Fournier's gangrene: Multivariable analysis and a novel scoring system to predict length of stay

Summary

Background

There is no contemporary scoring system to predict hospital length of stay and morbidity in Fournier's gangrene. A retrospective study was conducted to formulate a scoring system to predict duration of hospitalization, resource utilization, need for reconstruction, morbidity and mortality.

Methods

A retrospective chart review was performed on 54 patients treated for FG from 2010–2016 at LAC+USC Medical Center, the largest public hospital in Los Angeles County. Strobe guidelines were followed and the study was approved by the IRB. Predictors of LOS, morbidity, mortality and resource utilization were identified and univariate linear regressions performed to determine significance. Significant univariate predictors were used to develop a novel scoring system, the Combined Urology and Plastics Index (CUPI). The CUPI score was then compared to existing scoring systems for predicting length of stay.

Results

The mean patient age was 49.3, and the mean BMI was 28.6. Patients on average were hospitalized for 37.5 days, with a mean of 8.3 days in the ICU. Three patients (5.6%) died during their hospital stay, and 33 (61%) required reconstructive surgery. Multivariate logistic modeling showed that BMI (p = 0.001) and alkaline phosphatase (p < 0.001) correlated with decreasing length of stay, while age at admission was not significantly correlated (p = 0.369). Univariate analysis of existing scoring systems showed that FGSI, LRINEC, NLR, and CCI were not significantly correlated with length of stay, while the newly calculated CUPI score was shown to be a significant predictor of longer hospital stays (p = 0.001).

Discussion

Early emphasis on supportive care, nutrition, and involvement of reconstructive surgeons can decrease LOS in patients with Fournier's gangrene. The CUPI score on admission may be a useful tool for predicting LOS in this population.

Introduction

Fournier's gangrene is a rapidly progressive necrotizing fasciitis of the genital, perineal and perianal regions caused by bacterial infection. Within the last thirty years, the natural history of Fournier's gangrene has changed, transitioning from a disease with mortality reported as high as 50% to a disease with a much lower mortality rate of approximately 10% or less.1, 2, 3, 4 These advances are likely due to more aggressive debridement and intervention with IV antibiotics, as well as advances in critical care.⁵ Subsequently, several recent studies have reported improved survival in Fournier's gangrene.1, 2, 4, 6, 7, 8

In the past, scoring systems for Fournier's gangrene were designed to predict mortality. However, patients with Fournier's gangrene are increasingly surviving this disease due to improved intervention, and subsequent survivors require lengthy hospital stays including pelvic debridement and the need for reconstruction.1, 9 Therefore, the focus of Fournier's management is shifting from preventing mortality to reducing morbidity, resource utilization and length of hospital stay, and as such, updated scoring systems are needed to predict these parameters.1, 10, 11 To date, there is no scoring system in use for predicting length of stay in patients with Fournier's gangrene.

It is the aim of this study to identify patient factors associated with hospital length of stay in patients with Fournier's gangrene, and to use these factors to create a novel scoring system that can accurately predict length of stay at the time of admission. Through the use of such a scoring system, patients requiring more extensive hospital management can be identified. Consequently, resources will be better allocated to patients based on a systematic assessment of healthcare needs, with the goal of improving patient outcomes and reducing hospital costs.