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. A combination of penicillin and clindamycin is widely used. [22]
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. [35]
In spite of increasing clindamycin resistance among anaerobes, cases of clindamycin-resistant C perfringens are exceptional. [36, 37]
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. Similarly, new antibiotics such as tedizolid, dalbavancin, and oritavancin have been approved for the treatment of complicated skin and soft tissue infections; however, they have not been evaluated for the treatment of gas gangrene or necrotizing fasciitis; 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.
Serum calcium monitoring
Monitoring serum calcium may need special attention when large areas of necrotic fat may lead to its deposition. [33]
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). [38, 39] 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. [40]
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, [41, 42] although a 2014 study reported that HBO therapy increased survival rates in necrotizing soft-tissue infections. [43]
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. [44]
In 2023, a systematic review and meta-analysis study that consisted of 23 retrospective cohort and case-control studies of the efficacy of hyperbaric oxygen therapy (HBO) in the treatment of necrotizing soft tissue infections (NSTI), showed the mortality rate in the HBO group was significantly lower than that in the non-HBO group (RR = 0.522). However, the authors recognized that the evidence is weak in view of the retrospective studies. [56]
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.
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.
Uterine gas gangrene following septic abortion usually necessitates hysterectomy.
Urgent surgical interventions such as hysterectomy can be life-saving in obstetric-gynecological necrotizing infections; however, an obstetrician/gynecologist may be reluctant to consider hysterectomy in young nulliparous patients with these life-threatening infections. [45]
Patients with obstetric/gynecological necrotizing infections must be monitored closely in the ICU and under the care of a multidisciplinary team including an obstetrician/gynecologist, an intensivist, an infectious disease specialist, and a general surgeon. Broad-spectrum antibiotics should be initiated immediately after collection of body fluid from multiple sources, including blood, cervical and vaginal swabs, urine, and uterine aspirate (postpartum or postabortion), for aerobic and anaerobic cultures. Surgical intervention, which often is crucial to preserve the patient’s life, should be performed within the first 24 hours in cases of failing aggressive medical therapy, worsening laboratory results, or clinical signs of worsening sepsis despite appropriate antibiotic therapy. The indications for surgical intervention in serious obstetric/gynecological infections are discussed below. [45]
Major indications for hysterectomy include the following:
-
Failure to respond to antimicrobial therapy alone in the first 24 hours
-
Rapid deterioration of clinical status despite medical therapy intervention
-
Evidence of necrotizing soft tissue infection
-
Evidence of intraabdominal or pelvic fluid collection suggestive of abscess collection
-
Evidence of gas within the uterine myometrial tissue suggestive of necrotizing soft tissue infection with clostridial species
The following circumstances suggest the source to be the uterus:
-
Postpartum (cesarean or vaginal delivery)
-
Postabortal or septic abortion
The following are worsening laboratory signs suggestive of toxic shock syndrome and/or tissue necrosis despite medical therapy:
-
WBC counts generally are more than 25,000/µL or less than 4,000/µL
-
Marked bandemia (>10%) independent of the total WBC count
-
Hemolysis: Hemoglobin level < 11 mg/dL
-
Massive hemoconcentration (hematocrit >45%) due to fluid pouring into necrotic areas, resulting in third-spacing and edema and an intravascular fluid depletion
-
Thrombocytopenia due to disseminated intravascular coagulopathy (DIC)
-
Serum sodium level less than 135 mEq/L
-
Creatinine level more than 1.6 mg/dL
-
Glucose level more than 180 mg/dL
-
Anion gap metabolic acidosis
-
Bicarbonate level less than 15 mg/dL
-
Lactic acid level more than 2.2 mmol/L
Systemic signs of severe sepsis include the following:
-
Septic shock
-
Adult respiratory distress syndrome
-
Disseminated intravascular coagulation
-
Hemolysis
Consultations
Consultations may include the following:
-
General surgeon
-
Orthopedic surgeon [46]
-
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
Prevention
Avoid suturing wounds due to a crush injury or open fractures with devitalized muscle and soil contamination.
Provide warnings and instructions of wound care to rescuers and health care workers about clostridial infections, including tetanus and gas gangrene, in injured victims of natural disasters such as earthquake or tsunami.
Further Outpatient Care
Gas gangrene is one of the most devastating infections. Patients who survive the infection often sustain extremity amputation or massive loss of muscles, skin, and soft tissues, requiring extensive reconstructive surgery and physical rehabilitation.
Patients with spontaneous gas gangrene may have occult malignancies of the GI tract. Carefully instruct these patients and monitor their cases appropriately.
Further Inpatient Care
Further inpatient care may include the following:
-
Daily or repeated surgical debridement
-
Daily or repeated HBO therapy, if available
-
Intensive supportive care
-
Hemodialysis for renal failure, if indicated
Transfer
Aggressive surgical debridement and intensive medical therapy are the mainstays of treatment in gas gangrene; however, HBO therapy has become an important adjunctive therapy, especially in patients with truncal involvement.
Patients transferred for HBO therapy must be in stable condition. If compartment syndrome develops, do not delay fasciotomy to perform HBO therapy.
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A patient developed gas gangrene after injecting cocaine. Clostridium septicum was isolated in both blood and wound cultures.
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Gas feathering in the arm soft tissue of a patient with gas gangrene.
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Extension of gas gangrene to the chest wall despite initial debridement.
Tables
Variable |
Score |
|---|---|
C-reactive protein level |
|
< 150 mg/L |
0 |
≥150 mg/L |
4 |
Total WBC count |
|
< 15 cells/µL |
0 |
15-25 cells/µL |
1 |
>25 cells/µL |
2 |
Sodium level |
|
≥135 mmol/L |
0 |
< 135 mmol/L |
2 |
Hemoglobin level |
|
>13.5 g/dL |
0 |
11-13.5 g/dL |
1 |
< 11 g/dL |
2 |
Creatinine level |
|
≤ 141 mmol/L |
0 |
>141 mmol/L |
2 |
Glucose level |
|
≤10 mmol/L |
0 |
>10 mmol/L |
1 |
Variable on Admission |
Points |
||
|---|---|---|---|
Heart rate >110 bpm |
1 |
||
Temperature < 36°C |
1 |
||
Serum creatinine level >1.5 mg/dL |
1 |
||
Age >50 years |
3 |
||
WBC count >40,000/µL |
3 |
||
Hematocrit >50% |
3 |
||
Group category |
Number of points |
Mortality risk (%) |
|
1 |
0-2 |
6 |
|
2 |
3-5 |
24 |
|
3 |
≥6 |
88 |
|
