Microbiological characteristics and real-world antibiotic therapy regimens in Fournier Gangrene: A systematic review

Background and objective: Fournier’s gangrene is a rare (incidence ~ 1·6 per 100 000) but life-threatening necrotising infection of the perineum with high mortality (20–40%) despite antimicrobial therapy, prompt surgical debridement, and intensive care. Evidence on pathogens, resistance, and antibiotic management is largely derived from retrospective series. Our aim was to synthesize the microbiological spectrum and empiric regimens, and identified evidence gaps. Methods: We performed a systematic review following PRISMA and the Cochrane Handbook; the protocol was registered in PROSPERO (CRD42023489596). We included studies of adults with Fournier’s gangrene reporting microbiological findings and/or antibiotic therapy. Key findings and limitations: Across 88 studies (n = 4229), median length of stay was 24 days, mean symptom duration before admission was 7 days, and median mortality was 17%. Infections were polymicrobial in 66%. The most frequent isolates were Escherichia coli (30%), Streptococcus spp (11%), Pseudomonas aeruginosa (7%), and Staphylococcus aureus (6%); fungi accounted for 2%. Empiric regimens were heterogeneous (57 studies; n = 2958); ceftriaxone plus an aminoglycoside and metronidazole was most common (29%). Only 19% of patients received guideline-concordant therapy. Resistance data were available in seven studies and showed resistance to commonly used agents (23–64%). Conclusion and clinical implications: Empiric antimicrobial management is geographically variable, with low guideline adherence and clinically relevant resistance. Prospective, standardised studies with uniform sampling and reporting are needed to define locally adapted empiric strategies and improve alignment with contemporary recommendations. Patient Summary We reviewed 88 studies on Fournier’s gangrene, a rare but life-threatening infection. Most cases were caused by several bacteria at the same time, most often E. coli . Empiric antibiotic treatments varied widely, and many patients did not receive therapy recommended by guidelines. Resistance to common antibiotics was frequent.High-quality studies are needed to define the best treatments and improve patient outcomes.