A diabetic develops a severe perineal infection with skin necrosis, subcutaneous crepitance, and drainage of a thin, watery, grayish and foul-smelling fluid. Management should consist of:

a. Gram stain of the fluid, which will likely demonstrate multiple bacteria including predominantly gram-positive rods

b. A CT scan is indicated in a stable patient to define the extent of the disease

c. Broad spectrum antibiotics followed with prompt extensive debridement is indicated

d. A safe guideline is to resect infected necrotic tissue so that a several centimeter margin of grossly normal, healthy tissue can be achieved

The presence of severe perineal infection (referred to as Fournier gangrene when this process involves the perineum and scrotum in males) is associated with a continued high mortality despite aggressive and appropriate therapy. The clinical description provided would suggest an underlying soft tissue necrosis. In a stable patient radiologic studies including a CT scan to define the extent of the disease and the presence of pelvic infection is indicated. Gram stain will likely show evidence of polymicrobial organisms but the presence of Clostridia marked by gram-positive rods would suggest involvement with this organism. Prompt, aggressive and extensive debridement to remove all devitalized and affected tissue and the addition of broad spectrum antibiotics, fluid resuscitation, hemodynamic monitoring, and nutritional support would appear to afford the patient the best chance of survival. The clearest guidelines to determine the limits of resection involve removal of clearly infected, necrotic tissue so that margins several centimeters into grossly normal, healthy tissue are achieved. Because the entire perineal region and buttocks are frequently involved in these patients, performance of a fecal stream diversion by means of a colostomy often provides improved wound care and patient management, although it is not invariably a positive outcome.