Medical Care
Successful therapy requires rapid diagnosis and aggressive early treatment. [7] The physician must maintain a high index of suspicion for this uncommon but potentially fatal process. Clinical distinction in early stages between necrotizing fasciitis and necrotizing soft tissue infection is undetectable. [14] 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.
Antibiotic therapy
Broad-spectrum empiric antibiotic treatment is warranted to cover group A Streptococcus, Clostridium species, and mixed aerobes and anaerobes.
Definitive antibiotic therapy should consist of the combination of penicillin plus clindamycin or tetracycline. Optimal duration of therapy has not been defined, and it should be continued until no further debridement is planned and hemodynamic stability has been achieved.
Antibiotics against C septicum in animal models demonstrated higher susceptibility to penicillin, clindamycin, and tetracycline, but considerably lower susceptibility to vancomycin. [15]
Hyperbaric oxygen therapy
The role of hyperbaric oxygen (HBO) treatment as adjunctive therapy remains controversial. Some nonrandomized studies have reported good results with HBO therapy when combined with antibiotics and surgical debridement. [16]
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 also therapy may 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.
Future management
Future treatment strategies may include attenuation of toxin-induced vascular leukostasis and resultant tissue injury by targeting endogenous proadhesive molecules and reducing duration and severity of shock via anti-cytokine molecules.
Treatment guidelines
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). [17]
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).
Consultations
Consultations are as follows:
-
Infectious disease specialists
-
General, trauma, or burn surgeon
-
Plastic surgeon
Diet
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.
Activity
Once patients have survived the critical period of illness, they may benefit from occupational or physical therapy to restore preinjury function.
Further Inpatient Care
If patients survive, they typically are hospitalized for several weeks.
Transfer
Transfer is required infrequently and may be detrimental to the patient.
As long as the treating facility has the capability and experience to provide adequate surgical and intensive care, no transfer is necessary.
Transfer merely to obtain access to hyperbaric oxygen therapy is not indicated.
