Gas gangrene is a life-threatening infection caused by Clostridium bacteria. It results in tissue death and gas formation in muscles. Common causes are traumatic wounds, surgery, or underlying conditions impairing the immune system. Symptoms include severe pain that spreads from the infection site. Signs include swelling, discoloration of the skin, gas-filled blisters, and a sweet smell. Treatment requires prompt antibiotic therapy with penicillin, sometimes plus clindamycin, as well as extensive surgical debridement of dead tissue. Adjuvant hyperbaric oxygen therapy may improve outcomes by enhancing antibiotic effects and tissue delineation for surgery. Without adequate treatment, gas gangrene can cause complications like organ failure and lead to

1. GAS GANGRENE
DR. B. BORTHAKUR (PROFESSOR)
SMCH,Assam

2. INTRODUCTION
• The term “gas gangrene” implies an infection
with Clostridium species of anaerobic
bacteria.
• Massive necrosis of tissue, superadded by
putrefaction.
• Myonecrosis - Bacterial infection - Necrotic
damage specific to muscle tissue - Gas tissues
in gangrene.
• Medical emergency

3. Organisms
• Anaerobic - Gram-positive - Spore-forming
bacillus
• Clostridium perfringens –
–Most common
–Alpha toxin – lecithinase – most important

4. • Other common clostridial species –
– Clostridium bifermentans
– Clostridium septicum
– Clostridium sporogenes
– Clostridium novyi
– Clostridium fallax
– Clostridium histolyticum
– Clostridium tertium

5. • Aerobic gram-negative bacteria
– Escherichia coli
– Proteus species
– Pseudomonas aeruginosa
– Klebsiella pneumoniae
• Incubation period - short (<24 h) -1 hour to 6
weeks.

6. PREDISPOSING FACTORS
• Contaminated wound
• Disrupted / necrotic tissue provides necessary
enzymes and low oxidation/reduction potential,
allowing for spore germination.
• Foreign bodies
• premature wound closure
• Local effects - necrosis of muscle, subcutaneous
fat & thrombosis of blood vessels.
• Marked edema - compromise blood supply.

7. • Fermentation of glucose - gas production
• Production of hydrogen sulfide and CO2 gas begins late and
dissects along muscle bellies & fascial planes.
• Local effects - rapid spread of the infection.
• Systemic effects - exotoxins - severe hemolysis.
• Hemoglobin levels - very low levels
• Hypotension- acute tubular necrosis and renal failure

8. Classification
 POST-TRAUMATIC
 POST-OPERATIVE
 SPONTANEOUS

9. POST TRAUMATIC
• Crush injuries
• Compound fractures
• Gunshot wounds
• Thermal
• Electrical burns
• Frostbite
• Farm or industrial injuries contaminated with soil
• Rare causes- IM or SC injections

10. POST OPERATIVE
 clostridial infections
– colon resection
– ruptured appendix
– bowel perforation
– biliary or other GI surgery, including laparoscopic
cholecystectomy and colonoscopy.
 Septic back-street abortions - uterine gas gangrene.

11. SPONATNEOUS
 Without external wound or injury - serious underlying
conditions.
 Colorectal adenocarcinoma
 Hematologic malignancy
 Children – Neutropenia
 Chemotherapy
 Spontaneous Clostridium septicum infections.
 Diabetes or neutropenic colitis
 Many cases - no predisposing condition
 Clostridium perfringens
 Clostridium septicum

12. SYMPTOMS
 Sudden onset of pain is usually the first
symptom
 Pain gradually worsens but spreads only as the
underlying infection spreads.
 Feeling of heaviness in the affected extremity.
 Low-grade fever and apathetic mental status.

13. SIGNS
Local swelling & serosanguineous exudate - onset of pain.
Skin - bronze color - blue-black color with skin blebs and
hemorrhagic bullae.
Within hours, entire region - markedly edematous.
Nonodorous or may have a sweet mousy odor.
Crepitus follows gas production
Crepitus may not be detected with palpation owing to
brawny edema.
Pain and tenderness to palpation disproportionate to
wound appearance
Tachycardia disproportionate to body temperature is
common, - feeling of impending doom.
Late signs - include hypotension, renal failure, and a
paradoxical heightening of mental acuity.

15. LABORATORY STUDIES
 Hemolytic anemia
 Increased lactate dehydrogenase (LDH)
 White blood cell – No leukocytosis.
 Toxic shock syndrome - C sordellii or C septicum
 Hemoconcentration & leukocytosis.
 Gram stain - exudate or infected tissues
• Box-car & large gram-positive bacilli without neutrophils
 < 1% of blood cultures - grow clostridial species.
 Metabolic abnormalities
• metabolic acidosis & renal failure
• with tissue injuries and hypotension.
 Rapid detection of alpha-toxin or sialidases – ELISA
 In vitro amplification of alpha-toxin or DNA - PCR

17. IMAGING STUDIES
Delineate the typical feathering pattern of gas
in soft tissue
Gas may not be present in patients
Gas in soft tissue does not confirm diagnosis

18. PROCEDURES
 Surgical exploration confirms diagnosis
• muscle appears pale
• No contractile function -incised or electrically stimulated
 Bedside biopsy with immediate frozen section under LA
 Develop massive hemolysis, shock, ARDS & R F
• Require invasive procedures
• Right-sided heart catheterization
• Mechanical ventilation
• Hemodialysis.

19. ANTIBIOTIC THERAPY
 DOC - penicillin G - 10-24 million U/d
 Combination of penicillin and clindamycin
 Protein synthesis inhibitors
– clindamycin, chloramphenicol, rifampin, tetracycline
– Inhibit synthesis of clostridial exotoxins
 Allergic to penicillin - Clindamycin & Metronidazole
 Combination of penicillin and metronidazole
– antagonistic and is not recommended.
 Daptomycin, linezolid, and tigecycline not be used as
primary antibiotics

20. ADJUVANT THERAPY
 Recombinant human activated protein C
– Drotrecogin alfa activated
– Adjuvant therapy for patients with severe sepsis
 Serious bleeding
– Drotrecogin alfa activated & repeated surgical
debridement
– Frequent interruption of the continuous infusion
– Not recommend this adjuvant therapy

21. HYPERBARIC OXYGEN
 Important adjunct to surgery and antimicrobial therapy
 Increased survival - treatment with surgery & antibiotics
 Direct bactericidal effect on most clostridial species
– inhibits alpha-toxin production
– enhance the demarcation of viable & nonviable tissue prior to surgery.
 100% oxygen at 2.5-3 absolute atmospheres for 90-120 minutes 3 times
 Potential risks
– Pressure-related trauma-barotraumatic otitis pneumothorax
– Oxygen toxicity (myopia, seizures)
– Claustrophobia.
– Most adverse effects - self-limiting & resolve after termination therapy

22. SURGICAL CARE
 Fasciotomy for compartment syndrome - not be delayed in patients
with extremity involvement.
 Perform daily debridement - necrotic tissue.
 Amputation of the extremity may be necessary and life-saving.
 Abdominal involvement requires excision of the body wall
musculature.
 Uterine gas gangrene following septic abortion usually necessitates
hysterectomy.

23. COMPLICATIONS
 Massive hemolysis - repeated blood transfusion
 DIC- Severe bleeding – Complicate aggressive surgical debridement
 Acute renal failure
 Acute respiratory distress syndrome
 Shock
 Prognosis –
– Failure to provide an early diagnose and inadequate surgical
intervention
– dictate the outcome.
– better if the incubation period is shorter than 30 hours
– Spontaneous gas gangrene worse prognosis than other forms of gas
gangrene.

24. THANK YOU