eMedicine Specialties > Infectious Diseases > Skin and Soft-Tissue Infections
Clostridial Gas Gangrene: Treatment & Medication
Updated: Jun 23, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
Successful therapy requires rapid diagnosis and aggressive early treatment. The physician must maintain a high index of suspicion for this uncommon but potentially fatal process. Any patient in whom clostridial gas gangrene is suspected should be considered critically ill.
- Obtain early consultation with a surgeon for debridement.
- Administer supplemental oxygen.
- Restore intravenous fluid volume and monitor urine output with an indwelling bladder catheter.
- Transfer to an intensive care unit that has telemetry and pulse oximetry.
- Ensure that tetanus immunity is adequate.
- Consider hyperbaric oxygen therapy.
- Clostridia lack superoxide dismutase, making them incapable of surviving in the oxygen-rich environment created within a hyperbaric chamber. This inhibits clostridial growth, exotoxin production, and exotoxin binding to host tissues.
- Hyperbaric oxygen therapy may also promote host polymorphonuclear cell function.
- Animal studies have clearly demonstrated a survival advantage when this therapy is combined with antibiotics and debridement. However, no randomized controlled studies of humans exist to support this finding.
- Hyperbaric oxygen should be used at the discretion of the treating physician but should never cause a delay in surgical debridement. Transporting a patient from one facility to another merely to administer hyperbaric oxygen probably is not warranted and may be detrimental.
- Administer therapy 3 times a day for 2 days, then twice a day for several more days, until the disease process is well under control.
- The dose is usually 2.5 atmospheres absolute (ATA) oxygen for 120 minutes or 3 ATA oxygen for 90 minutes. The pressure at sea level equals 1 ATA.
- Complications include fire, seizures, decompression sickness, middle ear barotrauma, and claustrophobia.
- The only absolute contraindication is the presence of an untreated pneumothorax.
Surgical Care
Clostridial gas gangrene represents a true surgical emergency.
- It requires prompt aggressive debridement of all involved tissues.
- Extensive extremity involvement may require amputation.
- Because the disease process may continue to involve additional tissue, daily exploration and further debridement may be necessary.
- Wound exploration reveals gas, watery discharge, and necrotic muscle. Muscle tissue may be pale, edematous, and may not bleed when cut or contract when stimulated with electricity.
- If the patient survives, the wound may be closed at a later date or allowed to heal secondarily (by wound contraction and spontaneous re-epithelialization).
Consultations
- Infectious disease specialists
- General, trauma, or burn surgeon
- Plastic surgeon
Diet
- Ensure that the patient receives adequate nutritional support during this period of increased energy requirements.
- During the period of critical illness, administration of enteral or parenteral nutrition may be required.
- Consultation with a nutritionist ensures optimal nutritional replacement.
- Frequently monitor nutritional status through serum markers and nitrogen balance determination.
Activity
- Once patients have survived the critical period of illness, they may benefit from occupational or physical therapy to restore preinjury function.
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Antibiotics
Penicillin is the preferred drug for clostridial infections. Patients allergic to penicillin may be treated with clindamycin or chloramphenicol.
Penicillin G (Pfizerpen)
Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms.
Adult
10-40 million U/d IV divided q4h
Pediatric
100,000-250,000 U/kg/d IV divided q4h
Probenecid can increase effects
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal impairment because some preparations may result in hyperkalemia
Clindamycin (Cleocin)
Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Adult
600 mg IV divided q8h
Pediatric
20 mg/kg IV divided q8h
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption
Documented hypersensitivity; regional enteritis; ulcerative colitis; severe hepatic impairment; antibiotic-associated colitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis
Chloramphenicol (Chloromycetin)
Effective against many gram-positive and gram-negative bacteria, including clostridia. Inhibits growth by binding to 50S ribosomal subunit.
Adult
500-1000 mg IV q6h
Pediatric
50-75 mg/kg/d IV divided q6h
Concurrently with barbiturates, serum levels may decrease while barbiturate levels may increase, causing toxicity; manifestations of hypoglycemia may occur with sulfonylureas; rifampin may reduce serum levels, presumably through hepatic enzyme induction; may increase effects of anticoagulants; may increase serum hydantoin levels, possibly resulting in toxicity (chloramphenicol levels may be increased or decreased)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Use only for indicated infections; serious and fatal blood dyscrasias (aplastic anemia, hypoplastic anemia, thrombocytopenia, granulocytopenia) can occur; evaluate baseline and perform periodic blood studies approximately every 2 d while in therapy; discontinue upon appearance of leukopenia, thrombocytopenia, anemia, or findings attributable to chloramphenicol; adjust dose in severe liver dysfunction
More on Clostridial Gas Gangrene |
| Overview: Clostridial Gas Gangrene |
| Differential Diagnoses & Workup: Clostridial Gas Gangrene |
 Treatment & Medication: Clostridial Gas Gangrene |
| Follow-up: Clostridial Gas Gangrene |
| References |
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References
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Further Reading
Keywords
clostridial gas gangrene, Clostridium gas gangrene, clostridial myonecrosis, myonecrosis, gangrene, soft tissue infection, Clostridium, Clostridium perfringens, C perfringens, Clostridium welchii, C welchii, Clostridium novyi, C novyi, Clostridium septicum, C septicum, Clostridium histolyticum, C histolyticum, Clostridium bifermentans, C bifermentans, Clostridium fallax, C fallax, battlefield injury, war wound, clostridia, compound fracture, frost bite, frostbite, bed sores, bedsores, pressure sores, burns, burn injury
