Emergent Treatment of Gas Gangrene
- Author: Lee Stuart Jacobson, MD, PhD; Chief Editor: Rick Kulkarni, MD more...
Gas gangrene, a subset of necrotizing myositis, is an infectious disease emergency associated with extremely high morbidity and mortality. Organisms in the spore-forming clostridial species, including Clostridium perfringens, Clostridium septicum, and Clostridium novyi, cause most of the cases . A nonclostridial form is caused by a mixed infection of aerobic and anaerobic organisms. The hallmarks of this disease are rapid onset of myonecrosis with muscle swelling, severe pain, gas production, and sepsis.[1, 2, 3]
Clostridium species are gram-positive, spore-forming, anaerobic rods normally found in soil and the gastrointestinal tract of humans and animals. They most often cause disease in the setting of trauma or surgery but can also occur spontaneously in the absence of definite risk factors or exposures. Not all wounds contaminated with clostridia develop gas gangrene; the myonecrosis seems to only develop when sufficient devitalized tissue is present to support anaerobic metabolism.
Traumatic gas gangrene and surgical gas gangrene occur through direct inoculation of a wound. With a compromised blood supply, the wound has an anaerobic environment that is ideal for C perfringens, the cause of 80-95% of cases of gas gangrene.[4, 5]
Spontaneous gas gangrene is most often caused by hematogenous spread of C septicum from the gastrointestinal tract in patients with colon cancer or other portals of entry. Neutropenic and immunocompromised patients are also at risk. The organism enters the blood via a small break in the gastrointestinal mucosa and subsequently seeds muscle tissue. Unlike C perfringens, C septicum is aerotolerant and can infect normal tissues.
With C perfringens, the local and systemic manifestations of infection are due to the production of potent extracellular protein toxins by the bacteria. These are most notably alpha-toxin (a phospholipase C) and theta-toxin (a thiol-activated cytolysin). These toxins hydrolyze cell membranes, cause abnormal coagulation leading to microvascular thrombosis (further extending the borders of devascularized and thus anaerobic tissue), and have direct cardiodepressive effects. Furthermore, the products of tissue breakdown, including creatine phosphokinase, myoglobin, and potassium, may cause secondary toxicity and renal impairment.
Significant and refractory anemia may also be present in patients with gas gangrene. This effect is a direct consequence of toxin-mediated hemolysis of RBCs when significant amounts of alpha toxin are released into the bloodstream. Alpha toxin has negative inotropic effects on cardiac myocytes contributing to the severe, refractory hypotension seen in some cases of gas gangrene. Theta toxin causes a cytokine cascade, which results in peripheral vasodilation similar to that seen in septic shock. Vaccination of experimental animals against alpha and theta toxins substantially decreases the severity of infection.
Estimates of incidence of gas gangrene vary; however, with improvements in surgical technique and wound care, cases are relatively rare. Data from 1975 estimate 900-1000 cases per year, or 0.03-5.2% of open wounds, depending on type of wound and treatment. Clostridial contamination of wounds may be common, although in the absence of deep injury or significant devitalized tissue, myonecrosis and productive infection do not typically occur.
No data are published, but incidence is probably higher internationally than in the United States. Incidence is highest in areas with poor access to proper wound care. The incidence of surgically acquired infection is higher in areas where sterile technique and surgical hygiene may be imperfect.
Mortality from traumatic gas gangrene is greater than 25%.
Mortality from nontraumatic gas gangrene caused by C septicum ranges from 67-100%.
Occurrence is not age specific.
Diabetic peripheral vascular disease and other chronic immunocompromised states that can predispose individuals to gas gangrene are more prevalent in older populations.[8, 9]
Trott AT. Skin and Soft-tissue Infections. Wolfson AB, et al, eds. Harwood-Nuss’ Clinical Practice of Emergency Medicine. 4th ed. Lippincott Williams & Wilkins; 2005. 715-717.
Folstad SG. Soft tissue infections. Tintinalli JE, et al, eds. Emergency Medicine: A Comprehensive Study Guide. 6th ed. McGraw Hill; 2004. 979-986.
Meislin HW, Guisto JA. Soft tissue infections. Marx JA, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 5th ed. Mosby-Year Book; 2002. 1944-1955.
Stevens DL. The pathogenesis of clostridial myonecrosis. Int J Med Microbiol. 2000 Oct. 290(4-5):497-502. [Medline].
Brook I. Recovery of anaerobic bacteria from wounds after lawn-mower injuries. Pediatr Emerg Care. 2005 Feb. 21(2):109-10. [Medline].
Headley AJ. Necrotizing soft tissue infections: a primary care review. Am Fam Physician. 2003 Jul 15. 68(2):323-8. [Medline].
Bryant AE. Biology and pathogenesis of thrombosis and procoagulant activity in invasive infections caused by group A streptococci and Clostridium perfringens. Clin Microbiol Rev. 2003 Jul. 16(3):451-62. [Medline].
Miller LG, Perdreau-Remington F, Rieg G, et al. Necrotizing fasciitis caused by community-associated methicillin-resistant Staphylococcus aureus in Los Angeles. N Engl J Med. 2005 Apr 7. 352(14):1445-53. [Medline].
Fridkin SK, Hageman JC, Morrison M, et al. Methicillin-resistant Staphylococcus aureus disease in three communities. N Engl J Med. 2005 Apr 7. 352(14):1436-44. [Medline].
Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 7th ed. Philadelphia, Pa: Elsevier; 2010. Vol 1-2: 1289-1322, 3103-3109.
Wolf R, Tuzun Y, Davidovici BB. Necrotizing soft tissue infections, including necrotizing fasciitis. Wolf R, Davidovici BB, Parish JL, Parish LC, eds. Emergency Dermatology. 1st ed. New York, NY: Caimbridge University Press; 2011. 75-80. [Full Text].
Anesti E, Brooks P, Majumder S. Images in emergency medicine. Gas gangrene. Ann Emerg Med. 2007 Jul. 50(1):14, 33. [Medline].
Arteta-Bulos R, Karim SM. Images in clinical medicine. Nontraumatic Clostridium septicum myonecrosis. N Engl J Med. 2004 Oct 21. 351(17):e15. [Medline].
Hussein QA, Anaya DA. Necrotizing soft tissue infections. Crit Care Clin. 2013 Oct. 29(4):795-806. [Medline].
Wang Y, Lu B, Hao P, Yan MN, Dai KR. Comprehensive treatment for gas gangrene of the limbs in earthquakes. Chin Med J (Engl). 2013 Oct. 126(20):3833-9. [Medline].
Frazee BW, Lynn J, Charlebois ED, Lambert L, Lowery D, Perdreau-Remington F. High prevalence of methicillin-resistant Staphylococcus aureus in emergency department skin and soft tissue infections. Ann Emerg Med. 2005 Mar. 45(3):311-20. [Medline].
Determann C, Walker CA. Clostridium perfringens gas gangrene at a wrist intravenous line insertion. BMJ Case Rep. 2013 Oct 9. 2013:[Medline].
Kitterer D, Braun N, Jehs MC, Schulte B, Alscher MD, Latus J. Gas Gangrene Caused By Clostridium Perfringens Involving the Liver, Spleen, and Heart in a Man 20 Years After an Orthotopic Liver Transplant: A Case Report. Exp Clin Transplant. 2013 Jul 24. [Medline].
Schneider DJ, Reid JS. Images in clinical medicine. Gas gangrene associated with occult cancer. N Engl J Med. 2000 Nov 30. 343(22):1615. [Medline].
Zacharias N, Velmahos GC, Salama A, Alam HB, de Moya M, King DR, et al. Diagnosis of necrotizing soft tissue infections by computed tomography. Arch Surg. 2010 May. 145(5):452-5. [Medline].
Kobayashi L, Konstantinidis A, Shackelford S, Chan LS, Talving P, Inaba K, et al. Necrotizing soft tissue infections: delayed surgical treatment is associated with increased number of surgical debridements and morbidity. J Trauma. 2011 Nov. 71(5):1400-5. [Medline].
Anaya DA, McMahon K, Nathens AB, Sullivan SR, Foy H, Bulger E. Predictors of mortality and limb loss in necrotizing soft tissue infections. Arch Surg. 2005 Feb. 140(2):151-7; discussion 158. [Medline].
Swartz MN. Clinical practice. Cellulitis. N Engl J Med. 2004 Feb 26. 350(9):904-12. [Medline].
Wang C, Schwaitzberg S, Berliner E, Zarin DA, Lau J. Hyperbaric oxygen for treating wounds: a systematic review of the literature. Arch Surg. 2003 Mar. 138(3):272-9; discussion 280. [Medline].
Smith-Slatas CL, Bourque M, Salazar JC. Clostridium septicum infections in children: a case report and review of the literature. Pediatrics. 2006 Apr. 117(4):e796-805. [Medline].
Temple AM, Thomas NJ. Gas gangrene secondary to Clostridium perfringens in pediatric oncology patients. Pediatr Emerg Care. 2004 Jul. 20(7):457-9. [Medline].