Gas Gangrene Treatment & Management

  • Author: Hoi Ho, MD; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Aug 16, 2011
 

Medical Care

The combination of aggressive surgical debridement and effective antibiotic therapy is the determining factor for successful treatment of gas gangrene.

  • Antibiotic therapy
    • In animal models, prompt treatment with antibiotics significantly improves survival rates.
    • Historically, penicillin G in dosages of 10-24 million U/d was the drug of choice. Currently, a combination of penicillin and clindamycin is widely used.[18]
    • Recent studies show that protein synthesis inhibitors (eg, clindamycin, chloramphenicol, rifampin, tetracycline) may be more effective because they inhibit the synthesis of clostridial exotoxins and lessen the local and systemic toxic effects of these proteins.[26]
    • In spite of increasing clindamycin resistance among anaerobes, cases of clindamycin-resistant C perfringens are exceptional.[27, 28]
    • A combination of clindamycin and metronidazole is a good choice for patients allergic to penicillin.
    • A combination of penicillin and metronidazole may be antagonistic and is not recommended. Because other nonclostridial bacteria are frequently found in gas gangrene tissue cultures, additional antimicrobial coverage is indicated.
    • Although approved for treating complicated skin and soft-tissue infections, newer antibiotics such as daptomycin, linezolid, and tigecycline have not been studied in patients with gas gangrene; therefore, they should not be used as primary antibiotics for treating this condition.
  • Intensive care: Patients with gas gangrene frequently have end-organ failure and other concomitant serious medical conditions that require intensive supportive care.
  • Monitoring serum calcium may need special attention when large areas of necrotic fat may lead to its deposition.[25]
  • Adjuvant therapy: Recombinant human activated protein C (drotrecogin alfa activated) has been used as an adjuvant therapy for patients with severe sepsis who scored 25 or more on the Acute Physiology and Chronic Health Evaluation (APACHE II). However, the mortality rate was higher in patients who had single-organ dysfunction and had undergone surgery within 30 days prior to treatment with drotrecogin alfa activated than in control groups (subset analyses of the PROWESS and ADDRESS studies).[29, 30] In addition, aside from the serious bleeding that may be associated with drotrecogin alfa activated, repeated surgical debridement in patients with gas gangrene requires frequent interruption of the continuous infusion of this product. Therefore, the authors do not recommend this adjuvant therapy in the treatment of gas gangrene.
  • Hyperbaric oxygen (HBO) therapy
    • Since the 1960s, HBO therapy has been used in the United States for the treatment of gas gangrene; however, its use remains controversial.
    • Controlled prospective studies on human subjects have not evaluated the impact of this treatment on survival. One reason for this is the low number of patients with gas gangrene. In addition, the therapeutic effect of HBO is difficult to reliably assess because of a lack of well-designed comparative studies.[31]
    • Many retrospective studies report increased survival in patients when HBO therapy is added to treatment with surgery and antibiotics. However, HBO therapy failed to show a survival advantage in 2 retrospective multicenter studies of the treatment of major necrotizing infections .[32, 33]
    • Studies of animal models show conflicting reports about enhanced survival associated with HBO therapy. Studies indicate that HBO therapy has a direct bactericidal effect on most clostridial species, inhibits alpha-toxin production, and can enhance the demarcation of viable and nonviable tissue prior to surgery. For these reasons, some authors recommend the use of HBO therapy before the initial debridement, if possible.
    • The most common regimen for HBO therapy involves administration of 100% oxygen at 2.5-3 absolute atmospheres for 90-120 minutes 3 times a day for 48 hours, then twice a day as needed.
    • In view of the frequent catastrophic outcomes in patients with gas gangrene, HBO therapy is an important adjunct to surgery and antimicrobial therapy, despite the lack of convincing clinical efficacy.
    • Potential risks in patients undergoing HBO therapy include pressure-related trauma (eg, barotraumatic otitis, pneumothorax) and oxygen toxicity (eg, myopia, seizures). Other common adverse effects include claustrophobia. Most adverse effects are self-limiting and resolve after termination of HBO therapy .[34]
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Surgical Care

  • Fasciotomy for compartment syndrome may be necessary and should not be delayed in patients with extremity involvement.
  • Copious irrigation should be performed with sterile normal saline solutions and/or 3% liquid hydrogen peroxide.
  • Debridement of all wounds should be performed as soon as possible, with removal of badly damaged, contaminated, and necrotic tissue, especially in patients who tmight have been contaminated by soil, farm land, or dirty water.
  • If the wounds were treated elsewhere and closed, it is safest to reopen them, clean them, and leave them open with negative-pressure wound dressing therapy (if available) or just a sterile dressing.
  • Perform daily debridement as needed to remove all necrotic tissue until the wound has clean and healthy granulation tissue.
  • Amputation of the extremity may be necessary and life saving.
  • Abdominal involvement requires excision of the body wall musculature.
  • Uterine gas gangrene following septic abortion usually necessitates hysterectomy.
  • If faced with limited resources and extreme conditions caused by natural disasters such as an earthquake and/or tsunami, surgical care with the above-described principles also can be performed with the patient under local and/or regional analgesia.
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Consultations

  • General surgeon
  • Orthopedic surgeon
  • HBO service specialist, if the facility is available or within proximity
  • Infectious disease specialist
  • Hematologist or oncologist
  • Gastroenterologist, especially for patients recovering from spontaneous gas gangrene
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Contributor Information and Disclosures
Author

Hoi Ho, MD  Associate Dean for Faculty Affairs and Development, Professor, Department of Internal Medicine, Director, Center for Advanced Teaching and Assessment in Clinical Simulation (ATACS), Paul L Foster School of Medicine, Texas Tech University Health Sciences Center; Consulting Physician, University Medical Center

Hoi Ho, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for the Advancement of Science, American College of Forensic Examiners, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Coauthor(s)

Juan B Figueroa-Casas, MD  Associate Professor, Division of Pulmonary and Critical Care Medicine, Texas Tech University Health Sciences Center at El Paso

Disclosure: Nothing to disclose.

David G Maxfield  Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

David G Maxfield, is a member of the following medical societies: American College of Physicians, Congress of Neurological Surgeons, and Texas Medical Association

Disclosure: Nothing to disclose.

Lorenzo B Aragon, MD  Associate Professor, Department of Family Medicine, Paul L Foster Texas Tech University Health Sciences Center; Medical Director, Ambrosio Guillen Texas State Veterans Home

Lorenzo B Aragon, MD is a member of the following medical societies: American Academy of Family Physicians, American Medical Directors Association, Society of Teachers of Family Medicine, and Texas Medical Association

Disclosure: Nothing to disclose.

Enes Kanlic, MD  Professor, Department of Orthopedic Surgery, Texas Tech University Health Science Center

Disclosure: Stryker Honoraria Speaking and teaching

Specialty Editor Board

Pranatharthi Haran Chandrasekar, MBBS, MD  Professor, Department of Internal Medicine, Director of Infectious Disease Fellowship, Harper Hospital, Wayne State University School of Medicine

Pranatharthi Haran Chandrasekar, MBBS, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

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

Disclosure: Baxter International and Johnson & Johnson Royalty Other

Eleftherios Mylonakis, MD  Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital

Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthors Jeffrey P Nelson, MD; Miguel Angel Pena-Ruiz, MD; and Karl C Bentley, MS, to the development and writing of this article.

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A patient developed gas gangrene after injecting cocaine. Clostridium septicum was isolated in both blood and wound cultures.
Gas feathering in the arm soft tissue of a patient with gas gangrene.
Extension of gas gangrene to the chest wall despite initial debridement.
 
 
 
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