Gas gangrene and related infection: Classification, clinical features and aetiology, management and mortality. A report of 88 cases

Abstract

The clinical features of gas gangrene and related infection seen in 88 patients over a 10-year period are described. It is suggested that clostridial infection could be simply classified as either 'gas-forming' or 'non-gas-forming'. The gas-forming group represents the more severe form of infection. Non-clostridial gas gangrene may present in a variety of forms. The anaerobic streptococcus was the organism most frequently responsible, but these cases were indistinguishable from clostridial infection on clinical grounds. The treatment of gas gangrene in this series of patients is reported. Emphasis is laid on the importance of adequate prophylaxis with penicillin in patients at risk. The value of antibiotics in established infection remains equivocal. The evidence supporting the value of hyperbaric oxygen therapy is assessed and an attempt made to quantify the response to this treatment. Benefit was apparent in only a proportion of patients. A favourable response indicated clostridial infection and guaranteed immediate survival. Extensive debridement or amputation is unnecessary in this group. No response following hyperbaric oxygen therapy indicated widespread mixed clostridial and non-clostridial infection, or infection due to organisms other than clostridia. Urgent and extensive debridement and amputation remain the predominant measures in this group.

Myonecrotic Gas Gangrene of the Extremities

“…Others have found that trauma patients developing gas gangrene have a better prognosis than patients developing gas gangrene after elective operations (Roding et al 1972). However, this difference could not be confirmed by Darke et al (1977), or by the present series. Thus the mortality rate after gas gangrene of the extremities seems to lie between 8 and 13 percent in reports from Holland et al (1975), Trippel et al (1967) and Darke et al (1977) all of whom used surgical measures, antibiotics and hyperbaric oxygen treatment.…”

“…However, this difference could not be confirmed by Darke et al (1977), or by the present series. Thus the mortality rate after gas gangrene of the extremities seems to lie between 8 and 13 percent in reports from Holland et al (1975), Trippel et al (1967) and Darke et al (1977) all of whom used surgical measures, antibiotics and hyperbaric oxygen treatment. In contrast to these reports Altemeier & Fullen (1971) avoided the use of hyperbaric oxygen treatment and presented a mortality rate of 15 per cent in 54 patients with myonecrotic gas gangrene.…”

“…Reports from the Second World War, where hyperbaric oxygen was not used, showed that surgery in combination with penicillin restricted mortality to between 14 per cent (Cutler & Sandusky 1944) and 25 per cent (Jeffrey & Thomson 1944). Thus one must agree with Darke et al (1977) that so far the beneficial effect of hyperbaric oxygen therapy has not been definitively proved. Surgery, which diminishes intracompartmental pressure and thereby reduces muscular necrosis, still stands as one of the most important measures.…”

“…Most materials available are concerned with the treatment of gas gangrene as one entity and do not distinquish between different groups or affections, though it has been shown that the localised form and the cellulitis form are mild infections compared to the m yonecrot ic gangrene (Altemeier & Fullen 1971, Darke et al 1977. Infections limited to the extremities run a milder course than if,the trunk is involved (Holland et al 1975).…”

“…Not everyone, however, is convinced on this point and some claim that the effect of hyperbaric oxygen is doubtful and that early and adequate surgical measures are still of utmost importance (Altemeier & Fullen 1971, Darke et al 1977. Another purpose of this paper is to discuss the possible influence that age, vascular status and toxic condition might have on the outcome of the infection and on the basis of the literature to discuss the beneficial effect of hyperbaric oxygen therapy.…”