A patient with Type 2 diabetes on metformin + empagliflozin develops a painless swelling in the perineum with foul-smelling discharge and crepitus. Temperature is 38.9°C, WBC 22,000, blood glucose 420 mg/dL. What is the most appropriate immediate management?

• A Intravenous broad-spectrum antibiotics and ICU admission
• B Hyperbaric oxygen therapy + IV antibiotics
• C Discontinue empagliflozin, optimize glucose, IV antibiotics
• D Emergency surgical debridement + IV antibiotics + discontinue empagliflozin ✓

Explanation

This is Fournier's gangrene (necrotizing fasciitis of the perineum), a rare but serious adverse effect associated with SGLT2 inhibitors. The FDA issued a black-box warning for this complication. Immediate surgical debridement is life-saving and cannot be delayed — antibiotics alone are insufficient for necrotizing fasciitis. SGLT2 inhibitors must be stopped. The mechanism involves urogenital glucose spillage promoting polymicrobial infection. Delay in surgical intervention dramatically increases mortality.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.