II. Causes: Clostridial Myonecrosis (Gas Gangrene)
- Clostridium perfringens or Clostridium welchii (Traumatic source)
- Clositridium septicum (spontaneous source without skin break)
- Clostridium sordellii (gynecologic source)
- Other organisms
- Clostridium species may also cause a more subacute anerobic Cellulitis
- Clostridium novyi
- Clostridium histolyticum
III. Pathophysiology
- Tissue infection with gas-producing Anaerobic Bacteria (also occurs with Type I Necrotizing Fasciitis)
- Typically caused by penetrating Skin Injury with compromised soft tissue vascular supply
- Resulting anaerobic environment allows for spore germination and Bacterial growth
IV. Symptoms and Signs
- See Necrotizing Soft Tissue Infection
-
Skin Wound progression
- History of deep contaminated wound (Surgery, Trauma)
- Onset Sudden pain at wound site
- Local swelling and edema of wound site
- Thin hemorrhagic exudate
- Toxemia
- Severe Hypotension
- Renal Failure
- Fever
- Foul discharge from wound
- Subcutaneous crepitus
V. Labs
- See Necrotizing Soft Tissue Infection
-
Complete Blood Count (CBC)
- Hemoconcentration
- Hematocrit may increase to 50-80%
- Marked Leukocytosis
- Leukemoid Reaction may occur with increased White Blood Cell Count to 50,000 to 150,000/mm3
- Hemoconcentration
-
Wound smear
- Gram Positive encapsulated rods
VI. Imaging
- See Necrotizing Soft Tissue Infection
- Gas in fascial plains
VII. Differential Diagnosis
VIII. Management
- See Necrotizing Fasciitis
- Extensive, early surgical Debridement
- Consider hyperbaric oxygen chamber
- Antibiotics are typically broader to start to cover Necrotizing Fasciitis in general
- Primary protocol for specific Clostridium coverage
- Clindamycin 900 mg IV every 8 hours (reduces toxin production) AND
- Penicillin G 24 Million Units daily divided every 4 to 6 hours
- Alternative antibiotics for specific Clostridium coverage
- Ceftriaxone 2 g IV every 12 hours OR
- Erythromycin 1 gram every 6 hours IV infusion
- Other antibiotics options (check sensitivity first)
- Chloramphenicol 4 g daily
- Metronidazole
IX. References
- (2021) Sanford Guide, IOS, accessed 3/5/2021
- Khidir and Eyre (2021) Crit Dec Emerg Med 34(10): 12-3
- Stevens (2014) Clin INfect Dis 59(2): 147-59 +PMID:24947530 [PubMed]
- Stevens (2017) N Engl J Med 377(23):2253-65 +PMID:29211672 [PubMed]