eMedicine Specialties > Emergency Medicine > Infectious Diseases
Gas Gangrene: Treatment & Medication
Updated: Jun 22, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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Treatment
Prehospital Care
Prehospital care for gas gangrene includes the following:
- Oxygenation
- Intravenous (IV) fluids
Emergency Department Care
Gas gangrene is a true emergency, and concurrent evaluation, treatment, and coordination of care should be carried out.1,2,3
Generally speaking, the treatment is a combination of antibiotics, surgery, and hyperbaric oxygen.
- Airway and breathing: Oxygen and airway management as necessitated by the clinical picture.
- Circulation: Good vascular access and liberal use of intravenous fluids is indicated. Frequent reassessment of the circulatory status is necessary. If pressors are necessitated, vasoconstrictors should only be used if absolutely necessary; they can decrease perfusion to already ischemic tissue.
- Administer tetanus toxoid if indicated.
- Administer antibiotics.
- Correct electrolyte abnormalities.
- Check compartment pressures if severe pain and evidence of compartment syndrome are present with minimal cutaneous evidence of infection.
- Wound care is indicated.
Consultations
- Surgery
- Obtain immediate surgical consultation.
- Definitive treatment of gas gangrene is wide debridement of necrotic muscle. This is identifiable because it does not bleed or contract when debrided.
- While laboratory studies and imaging studies may help make the diagnosis of gas gangrene, the criterion standard is tissue biopsy.
Medication
Antibiotics may not penetrate the ischemic muscle but are important adjuncts to surgery.
Antibiotics
Clostridial species are exquisitely sensitive to a combination of penicillin G and clindamycin. However, because it is difficult initially to distinguish gas gangrene from other soft tissue infections, such as necrotizing fasciitis, which is caused by a broad spectrum of pathogens, empiric first-line antibiotic therapy should be broad.1,2,3,14 Clindamycin, tetracycline, and other inhibitors of bacterial protein synthesis may, however, have some increased utility as they halt the production of bacterial toxin. Low-level clostridial resistance occurs to clindamycin, and, as such, this agent should not be used as monotherapy.
Antibiotic treatment should include gram-positive (penicillin or cephalosporin), gram-negative (aminoglycoside, third-generation cephalosporin, or ciprofloxacin), and anaerobic coverage (clindamycin or metronidazole). In addition, vancomycin or linezolid should be considered in those at risk for methicillin-resistant Staphylococcus aureus (MRSA). In some communities, MRSA infections are now being isolated even in those without risk factors (8-25%); the risk factors traditionally associated with MRSA are a history of hospitalization, surgery, dialysis, residence in a long-term care facility, presence of a permanent indwelling catheter or percutaneous medical device (eg, tracheostomy tube, gastrostomy tube, Foley catheter), or previous isolation of MRSA.1,2,3,14
Antibiotics should be administered IV since absorption by other routes is inconsistent given the hypotension and suboptimally performing gastrointestinal tract of seriously ill patients.
Penicillin G (Pfizerpen)
DOC for use with infections by clostridial species. Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms.
Adult
10-40 million U IV qd divided q4-6h
Pediatric
100,000-250,000 U/kg IV qd divided q4h
Probenecid can increase effects of penicillin; coadministration of tetracyclines can decrease effects of penicillin
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in impaired renal function
Clindamycin (Cleocin)
Lincosamide useful as treatment against serious skin and soft tissue infections caused by most staphylococcal strains. Also effective against aerobic and anaerobic streptococci, except enterococci. Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at bacterial ribosome where it preferentially binds to 50S ribosomal subunit, causing bacterial growth inhibition. Will also halt bacterial production of toxin.
Adult
600-1200 mg IV/IM qd divided q6-8h depending on degree of infection
Pediatric
16-20 mg/kg/d IV/IM divided tid/qid
Severe infections: May increase dose to 20-40 mg/kg/d IV/IM divided tid/qid
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin
Documented hypersensitivity; regional enteritis; ulcerative colitis; 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 colitis
Ceftriaxone (Rocephin)
Third-generation cephalosporin that has broad-spectrum activity against gram-negative organisms, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. Arrests bacterial cell wall synthesis and inhibits bacterial growth by binding to one or more penicillin-binding proteins.
Adult
1-2 g IV qd or divided bid, depending on type and severity of infection; not to exceed 4 g/d
Pediatric
Neonates >7 days: 25-50 mg/kg/d IV; not to exceed 125 mg/d
Infants and children: 50-75 mg/kg/d IV divided q12h; not to exceed 2 g/d
Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; caution in breastfeeding women and those with allergy to penicillin
Metronidazole (Flagyl)
Active against various anaerobic bacteria and protozoa. Appears to be absorbed into cells; intermediate-metabolized compounds that are formed bind DNA and inhibit protein synthesis, causing cell death.
Adult
Loading dose: Infuse 15 mg/kg IV over 1 h or 1 g for a 70-kg adult
Maintenance dose: Following loading dose, infuse 7.5 mg/kg IV over 1 h q6-8h or 500 mg for a 70-kg adult; not to exceed 4 g/d
Pediatric
Administer as in adults; not to exceed 2 g/d
May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity of metronidazole; disulfiram reaction may occur with orally ingested ethanol
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy
Linezolid (Zyvox)
Prevents formation of functional 70S initiation complex, which is essential for bacterial translation process. Bacteriostatic against enterococci and staphylococci and bactericidal against most strains of streptococci. Used as alternative in patients allergic to vancomycin and for treatment of vancomycin-resistant enterococci.
Adult
400-600 mg PO/IV q12h for 10-28 d
Pediatric
Preterm neonate <7 days: 10 mg/kg PO/IV q12h
Term neonates to 12 years: 10 mg/kg PO/IV q8h
>12 years: Administer as in adults
May cause hypertension when used concomitantly with adrenergic agents including pseudoephedrine, sympathomimetic agents, or vasopressor or dopaminergic agents (reduce dose of dopamine or epinephrine if concurrent use required); serotonin syndrome may occur if used concomitantly with serotonergic agents including tricyclic antidepressants, meperidine, dextromethorphan, trazodone, venlafaxine, and selective serotonin reuptake; may cause myelosuppression or pseudomembranous colitis inhibitors
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
Has mild MAOI properties and has potential to have same interactions as other MAOIs; caution in uncontrolled hypertension, pheochromocytoma, carcinoid syndrome, or untreated hyperthyroidism, and in patients who are at increased risk for bleeding, have preexisting thrombocytopenia, are receiving concomitant medications that may decrease platelet count or function, or who may require >2 wk of therapy (monitor platelet counts); unnecessary use may lead to development of resistance to drug; may cause peripheral or optic neuropathy
Gentamicin (Gentacidin, Garamycin)
Aminoglycoside antibiotic used for gram-negative bacterial coverage. Commonly used in combination with an agent with activity against gram-positive organisms and one that covers anaerobes.
Not antibiotic of first choice. Consider using when penicillins or other less toxic drugs are contraindicated, when bacterial susceptibility tests and clinical judgment indicate its use and in mixed infections caused by susceptible strains of staphylococci and gram-negative organisms.
Dosing regimens are numerous and are adjusted based on CrCl and changes in volume of distribution. Gentamicin may be administered IV/IM.
Adult
Serious infections and normal renal function: 3 mg/kg/d IV/IM q8h
Life-threatening infections: 5 mg/kg/d IV/IM q6-8h
Each regimen must be followed by at least a trough level drawn on third or fourth dose, 0.5 h before dosing; may draw a peak level 0.5 h after 30-min infusion
Dose may need adjustment in patients with renal impairment
Pediatric
<5 years with normal renal function: 2.5 mg/kg/dose IV/IM q8h
>5 years: 1.5-2.5 mg/kg/dose IV/IM q8h or 6-7.5 mg/kg/d IV/IM divided q8h; not to exceed 300 mg/d with adjustments for renal function prn (monitor levels as in adults)
Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; because aminoglycosides enhance effects of neuromuscular blocking agents, prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)
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
Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment
Vancomycin (Vancocin)
Potent antibiotic directed against gram-positive organisms and active against enterococci species. Useful to treat septicemia and skin structure infections. Indicated for patients who cannot receive or have failed to respond to penicillins and cephalosporins or for those who have infections with resistant staphylococci. For abdominal penetrating injuries, combine with an agent active against enteric flora and/or anaerobes.
To avoid toxicity, assay of vancomycin trough levels after the third dose drawn 0.5 h prior to next dosing currently is recommended. May need to adjust dose in patients diagnosed with renal impairment (use CrCl).
Adult
500-2000 mg/d IV divided tid/qid for 7-10 d
Pediatric
40 mg/kg/d IV divided tid/qid for 7-10 d
Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants
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
Caution in renal failure and neutropenia
Medicinal gas
Hyperbaric oxygen (HBO) produces a tissue level of 300 mm Hg of oxygen. This is approximately 50 mm Hg greater than the partial pressure necessary to induce bacteriostasis and halt toxin production. This then decreases the extent of debridement and possible amputation needed to control infection.15
Hyperbaric oxygen (HBO)
Use is controversial but can be used to supplement surgical debridement and antibiotics. This modality may be particularly helpful in areas where complete surgical resection of necrotic tissue is difficult such as the paraspinal muscles or abdominal wall. Potential benefits include improved neutrophil-mediated killing of bacteria, direct bactericidal effect on anaerobes, improved activity of some antibiotics, and enhanced wound healing. Given its aerotolerance, gas gangrene caused by C septicum may be less amenable to HBO therapy.
Adult
Typical therapy is 100% oxygen at 3 atm of pressure for 90 min with 2-3 dives in first 24 h, followed by 2-3 dives/d for a total of 7-10 dives
Pediatric
Administer as in adults
None reported
None reported
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Barotrauma can cause rupture of the middle ear, cranial sinuses, teeth, or lungs
Prophylactic myringotomy should be considered; oxygen toxicity can cause reversible myopia, a lower seizure threshold, and pulmonary toxicity
Toxoids
Toxoids are used to induce active immunity.
Tetanus toxoid
Used to induce active immunity against tetanus in selected patients. Immunizing agents of choice for most adults and children >7 y are tetanus and diphtheria toxoids. Necessary to administer booster doses to maintain tetanus immunity throughout life.
Pregnant patients should receive only tetanus toxoid not a diphtheria antigen-containing product.
In children and adults, may administer into deltoid or midlateral thigh muscles. In infants, preferred site of administration is mid thigh laterally.
Adult
Primary immunization: 0.5 mL IM; administer 2 injections 4-8 wk apart; third dose 6-12 mo after second injection
Booster dose: 0.5 mL IM q10y
Pediatric
Administer as in adults
Patients receiving immunosuppressants, including corticosteroids or radiation therapy, may remain susceptible despite immunization due to poor immune response; cimetidine may enhance or augment delayed-hypersensitivity responses to skin-test antigens; avoid concurrent use of medication with systemic chloramphenicol because it may impair amnestic response to tetanus toxoid; concurrent use of tetanus immune globulin may delay development of active immunity by several days (interaction is nevertheless clinically insignificant and does not preclude concurrent use)
Documented hypersensitivity; history of any type of neurologic symptoms or signs following administration of this product; FDA recommends that elective tetanus immunization be deferred during any outbreak of poliomyelitis because tetanus toxoid injections are an important cause of provocative poliomyelitis
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
Do not use to treat actual tetanus infections or for immediate prophylaxis of unimmunized individuals (instead use tetanus antitoxin, preferably human tetanus immune globulin); diminished antibody response to active immunization may be observed in patients receiving immunosuppressive therapy; better to defer primary diphtheria immunization until immunosuppressive therapy discontinued; routine immunization of symptomatic and asymptomatic HIV-infected persons is recommended
Immunoglobulins
Immunoglobulins are used to induce passive immunity.
Tetanus immune globulin (Hyper-Tet)
Used for passive immunization of any person with a wound that may be contaminated with tetanus spores.
Adult
Prophylaxis: 250-500 U IM in opposite extremity to tetanus toxoid lesion
Clinical tetanus: 3,000-10,000 U IM
Pediatric
Prophylaxis: 250 U IM in opposite extremity to tetanus toxoid
Clinical tetanus: 3,000-10,000 U IM
None reported
Documented hypersensitivity; because antibodies in globulin preparation may interfere with immune response to vaccination, do not administer within 3 mo of live-virus immune globulin administration; may be necessary to revaccinate persons who received immune globulin shortly after live-virus vaccination
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
Persons with isolated IgA deficiency have potential for developing antibodies to IgA and could have anaphylactic reactions to subsequent administration of blood products that contain IgA; do not perform skin testing since intradermal injection of concentrated gamma globulin may cause localized area of inflammation and can be misinterpreted, causing medication to be withheld from a patient not allergic to this material; true allergic responses to human gamma globulin administered in prescribed IM manner are extremely rare; do not admix with other medications since usually incompatible
Analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma or have sustained injuries.
Morphine sulfate (Astramorph, MS Contin, MSIR, Oramorph)
DOC for analgesia due to reliable and predictable effects, safety profile, and ease of reversibility with naloxone.
Various IV doses are used; commonly titrated until desired effect obtained.
Adult
Starting dose: 0.1 mg/kg IV/IM/SC
Maintenance dose: 5-20 mg/70 kg IV/IM/SC q4h
Relatively hypovolemic patients: Start with 2 mg IV/IM/SC; reassess hemodynamic effects of dose
Pediatric
Infants and children:
0.1-0.2 mg/kg dose IM/SC q4h prn; not to exceed 15 mg/dose; may initiate at 0.05 mg/kg/dose
<6 months: 0.03-0.05 mg/kg IV
>6 months: 0.05-0.1 mg/kg IV
Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate adverse effects of morphine
Documented hypersensitivity; hypotension; potentially compromised airway where establishing rapid airway control would be difficult
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
Caution in hypotension, respiratory depression, nausea, emesis, constipation, urinary retention, atrial flutter, and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate
Fentanyl citrate (Duragesic, Sublimaze)
A synthetic opioid that is 75-200 times more potent and has a much shorter half-life than morphine sulfate. Has less hypotensive effects and is safer in patients with hyperactive airway disease than morphine because of minimal-to-no associated histamine release. By itself, it causes little cardiovascular compromise, although addition of benzodiazepines or other sedatives may result in decreased cardiac output and blood pressure.
Highly lipophilic and protein-bound. Prolonged exposure leads to accumulation in fat and delays weaning process.
Consider continuous infusion because of the short half-life of fentanyl.
Parenteral form is DOC for conscious sedation analgesia. Ideal for analgesic action of short duration during anesthesia and immediate postoperative period.
Excellent choice for pain management and sedation with short duration (30-60 min) and easy to titrate. Easily and quickly reversed by naloxone.
After initial parenteral dose, subsequent parenteral doses should not be titrated more frequently than q3h or q6h thereafter.
Transdermal form is used only for chronic pain conditions in patients with tolerance to opioids. When using transdermal dosage form, most patients are controlled with 72-h dosing intervals; however, some patients require dosing intervals of 48 h.
Easily and quickly reversed by naloxone.
Adult
Emergency: 0.5-2 mcg/kg/dose IM/IV
Analgesia: 0.5-1 mcg/kg/dose IM/IV q30-60min
Transdermal: Apply a 25 mcg/h system q48-72h
Pediatric
<2 years: 2-3 mcg/kg/dose IM/IV q60min
2-12 years: 1-2 mcg/kg/dose IM/IV q60min
>12 years: Administer as in adults
Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants may potentiate adverse effects of fentanyl when both drugs are used concurrently
Documented hypersensitivity; hypotension or potentially compromised airway where it would be difficult to establish rapid airway control
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
Caution in hypotension, respiratory depression, constipation, nausea, emesis, and urinary retention; idiosyncratic reaction, known as chest wall rigidity syndrome, may require neuromuscular blockade in order to increase ventilation
Antibiotic, Miscellaneous
Tetracycline
Semisynthetic antibacterial agent derived from Streptomyces cultures. Treats gram-positive and gram-negative organisms and mycoplasmal, chlamydial, and rickettsial infections. Inhibits bacterial protein synthesis by binding with 30S and, possibly, 50S ribosomal subunit(s).
Adult
500 mg IV q6h
Pediatric
<8 years: Not recommended
>8 years: Not established
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one-half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
More on Gas Gangrene |
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| Differential Diagnoses & Workup: Gas Gangrene |
 Treatment & Medication: Gas Gangrene |
| Follow-up: Gas Gangrene |
| Multimedia: Gas Gangrene |
| References |
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References
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Further Reading
Keywords
gas gangrene , Clostridium perfringens, C perfringens, Clostridium septicum, C septicum, clostridial myonecrosis, tissue infection, clostridial infection of tissues, emphysematous gangrene, gangrenous emphysema, progressive emphysematous necrosis, gas production, sepsis, myonecrosis, necrotizing myositis, muscle swelling, colon cancer, diabetic peripheral vascular disease, chronic immunosuppression
