II. Causes: Clostridial Myonecrosis (Gas Gangrene)

  1. Clostridium perfringens or Clostridium welchii (Traumatic source)
  2. Clositridium septicum (spontaneous source without skin break)
  3. Clostridium sordellii (gynecologic source)
  4. Other organisms
    1. Clostridium species may also cause a more subacute anerobic Cellulitis
    2. Clostridium novyi
    3. Clostridium histolyticum

III. Pathophysiology

  1. Tissue infection with gas-producing Anaerobic Bacteria (also occurs with Type I Necrotizing Fasciitis)
  2. Typically caused by penetrating Skin Injury with compromised soft tissue vascular supply
    1. Resulting anaerobic environment allows for spore germination and Bacterial growth

IV. Symptoms and Signs

  1. See Necrotizing Soft Tissue Infection
  2. Skin Wound progression
    1. History of deep contaminated wound (Surgery, Trauma)
    2. Onset Sudden pain at wound site
    3. Local swelling and edema of wound site
    4. Thin hemorrhagic exudate
  3. Toxemia
  4. Severe Hypotension
  5. Renal Failure
  6. Fever
  7. Foul discharge from wound
  8. Subcutaneous crepitus

V. Labs

  1. See Necrotizing Soft Tissue Infection
  2. Complete Blood Count (CBC)
    1. Hemoconcentration
      1. Hematocrit may increase to 50-80%
    2. Marked Leukocytosis
      1. Leukemoid Reaction may occur with increased White Blood Cell Count to 50,000 to 150,000/mm3
  3. Wound smear
    1. Gram Positive encapsulated rods

VI. Imaging

  1. See Necrotizing Soft Tissue Infection
  2. Gas in fascial plains

VII. Differential Diagnosis

VIII. Management

  1. See Necrotizing Fasciitis
  2. Extensive, early surgical Debridement
  3. Consider hyperbaric oxygen chamber
  4. Antibiotics are typically broader to start to cover Necrotizing Fasciitis in general
  5. Primary protocol for specific Clostridium coverage
    1. Clindamycin 900 mg IV every 8 hours (reduces toxin production) AND
    2. Penicillin G 24 Million Units daily divided every 4 to 6 hours
  6. Alternative antibiotics for specific Clostridium coverage
    1. Ceftriaxone 2 g IV every 12 hours OR
    2. Erythromycin 1 gram every 6 hours IV infusion
  7. Other antibiotics options (check sensitivity first)
    1. Chloramphenicol 4 g daily
    2. Metronidazole

IX. References

  1. (2021) Sanford Guide, IOS, accessed 3/5/2021
  2. Khidir and Eyre (2021) Crit Dec Emerg Med 34(10): 12-3
  3. Stevens (2014) Clin INfect Dis 59(2): 147-59 +PMID:24947530 [PubMed]
  4. Stevens (2017) N Engl J Med 377(23):2253-65 +PMID:29211672 [PubMed]

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