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Clostridial Gas Gangrene Treatment & Management

  • Author: Don R Revis, Jr, MD; Chief Editor: John Geibel, MD, DSc, MSc, MA  more...
 
Updated: Jul 16, 2014
 

Medical Care

Successful therapy requires rapid diagnosis and aggressive early treatment.[4] 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.

The reader is also referred to the 2014 guidelines published by the Infectious Diseases Society of America (IDSA) for the treatment of clostridial gas gangrene (see Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America).[6]

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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).
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Consultations

See the list below:

  • Infectious disease specialists
  • General, trauma, or burn surgeon
  • Plastic surgeon
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Diet

See the list below:

  • 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.
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Activity

See the list below:

  • Once patients have survived the critical period of illness, they may benefit from occupational or physical therapy to restore preinjury function.
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Contributor Information and Disclosures
Author

Don R Revis, Jr, MD Consulting Staff, Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Florida College of Medicine

Don R Revis, Jr, MD is a member of the following medical societies: American College of Surgeons, American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Charles V Sanders, MD Edgar Hull Professor and Chairman, Department of Internal Medicine, Professor of Microbiology, Immunology and Parasitology, Louisiana State University School of Medicine at New Orleans; Medical Director, Medicine Hospital Center, Charity Hospital and Medical Center of Louisiana at New Orleans; Consulting Staff, Ochsner Medical Center

Charles V Sanders, MD is a member of the following medical societies: American College of Physicians, Alliance for the Prudent Use of Antibiotics, The Foundation for AIDS Research, Southern Society for Clinical Investigation, Southwestern Association of Clinical Microbiology, Association of Professors of Medicine, Association for Professionals in Infection Control and Epidemiology, American Clinical and Climatological Association, Infectious Disease Society for Obstetrics and Gynecology, Orleans Parish Medical Society, Southeastern Clinical Club, American Association for the Advancement of Science, Alpha Omega Alpha, American Association of University Professors, American Association for Physician Leadership, American Federation for Medical Research, American Geriatrics Society, American Lung Association, American Medical Association, American Society for Microbiology, American Thoracic Society, American Venereal Disease Association, Association of American Medical Colleges, Association of American Physicians, Infectious Diseases Society of America, Louisiana State Medical Society, Royal Society of Medicine, Sigma Xi, Society of General Internal Medicine, Southern Medical Association

Disclosure: Received royalty from Baxter International for other.

Chief Editor

John Geibel, MD, DSc, MSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow

John Geibel, MD, DSc, MSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Received royalty from AMGEN for consulting; Received ownership interest from Ardelyx for consulting.

Additional Contributors

Fred A Lopez, MD Associate Professor and Vice Chair, Department of Medicine, Assistant Dean for Student Affairs, Louisiana State University School of Medicine

Fred A Lopez, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, Infectious Diseases Society of America, Louisiana State Medical Society

Disclosure: Nothing to disclose.

References
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