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JU INSIGHT: Understanding the Prodromal Period of Necrotizing Soft Tissue Infections of the Genitalia (Fournier’s Gangrene) and the Incidence, Duration, and Risk Factors Associated With Potential Missed Opportunities for an Earlier Diagnosis: A Population-based Longitudinal Study
By: Bradley A. Erickson, MD, MS; Aaron C. Miller, PhD; Hayden L. Warner, MD; Justin N. Drobish, MD; Scott H. Koeneman, MS; Joseph E. Cavanaugh, PhD; Philip M. Polgreen, MD, MPH | Posted on: 01 Dec 2022
Erickson BA, Miller AC, Warner HL, et al. Understanding the prodromal period of necrotizing soft tissue infections of the genitalia (Fournier’s gangrene) and the incidence, duration, and risk factors associated with potential missed opportunities for an earlier diagnosis: a population-based longitudinal study. J Urol. 2022;208(6):1259-1267.
Study Need and Importance
Early, aggressive surgical interventions and improved intensive care have decreased necrotizing soft tissue infections of the genitalia (NSTIG) mortality to well below 10%. However, continued clinical improvements, including minimizing the need for debilitating surgery that leads to large volume skin loss, will require a better understanding of the NSTIG prodrome period. We used the IBM MarketScan Research Database and Medicaid claims from 2001 to 2020 (over 200 million enrollees) to describe NSTIG prodrome health care utilization.
What We Found
The NSTIG prodromic period begins almost 3 weeks before diagnosis. Within the 21-day diagnostic window, nearly 50% of the 8,098 NSTIG cohort patients presented to a health care facility with a symptomatically similar diagnosis (SSD, most commonly “urologic anatomical abnormalities” such as scrotal swelling; 64%), without the diagnosis of NSTIG being made (see Figure). Simulation models estimated that 41% of patients experienced diagnostic delay, averaging 6.2 days. Patient risk factors for delay included a history of recurrent urinary tract infections (OR 2.1; 95% CI 1.6-2.7) and morbid obesity (OR 1.8; 95% CI 1.5-1.9). Antibiotics were prescribed for 46% of cohort patients during SSD visits.
Limitations
While we presume that the majority of the symptomatically similar diagnoses obtained in the 21-day prior to cohort NSTIG diagnosis represent early stages of the necrotizing disease, this does not necessarily mean that clinical errors were made, nor that conventional early intervention would have prevented progression. The use of administrative data to describe clinical events and our incomplete understanding of how necrotizing infections develop and evolve limit the study.
Interpretation for Patient Care
Our study suggests there are significant opportunities for earlier intervention in NSTIG that may ultimately decrease overall disease morbidity. However, given the rarity of the disease relative to their SSDs, improvements in care will only occur if clinicians can better implement the diagnostic tools necessary to identify necrotizing infection.
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