Gas Gangrene Treatment & Management
- Author: Hoi Ho, MD; Chief Editor: Burke A Cunha, MD more...
The combination of aggressive surgical debridement and effective antibiotic therapy is the determining factor for successful treatment of gas gangrene.
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.
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.
In spite of increasing clindamycin resistance among anaerobes, cases of clindamycin-resistant C perfringens are exceptional.[29, 30]
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.
Patients with gas gangrene frequently have end-organ failure and other concomitant serious medical conditions that require intensive supportive care.
Serum calcium monitoring
Monitoring serum calcium may need special attention when large areas of necrotic fat may lead to its deposition.
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).[31, 32] 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.
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,[34, 35] although a more recent (2014) study reported that HBO therapy increased survival rates in necrotizing soft-tissue infections.
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.
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.
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.
See the list below:
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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