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Necrotising Soft Tissue Infections

Gas gangrene is a fulminating, soft-tissue infection with gram-positive anaerobic bacilli of the species Clostridium, notably Cl. Perfringens. The skin, subcutaneous fat and muscle may all be affected. The majority of cases are the consequence of contamination of traumatic wounds, where the initial cause of necrosis is not the Clostridium itself, but the fact that tissue damage has resulted in locally hypoxic tissue, so allowing Clostridium to thrive (Malerba F, Oriani G, Farnetti A. 1996. HBO in orthopaedic disorders. In: Oriani G, Marroni A, Wattel F eds. Handbook on Hyperbaric Medicine. Milano: Springer Verlag, 409-427).

Bacteria then produce an alpha-toxin, which causes the necrosis. The toxin is not only haemolytic but also has phospholipase activity, with consequent activation of inflammatory pathways causing increased vascular permeability. This results in oedema of the affected tissues (Sakurai J, Nagahama M, Oda M. 2004. Clostridium perfringens Alpha-Toxin: Characterization and Mode of Action. J Biochem, 136: 569–574), which in turn contributes to hypoxia, so facilitating the further multiplication of the bacteria.

Appropriate surgical management with antibiotic therapy should constitute the first line of management. At tissue oxygen tensions in excess of 250mmHg, alpha-toxin production is halted within minutes of commencing hyperbaric oxygen therapy (Bakker DJ. 1988. Clostridial Myonecrosis. In: Davis JC, Hunt TK eds. Problem Wounds: The Role of Oxygen. New York: Elsevier, 153-172).

The combination of hyperbaric oxygen (HBO) therapy and surgery has been demonstrated to be synergistic in reducing both mortality and morbidity, since the need for extensive debridement and amputation is significantly reduced, with viable and non-viable tissue being more strongly demarcated, thus making possible more accurate tissue debridement (Hart GB, Strauss MB. 1990. Gas gangrene – clostridial myonecrosis: a review. J Hyper Med, 5: 125-44). It has therefore been proposed that, where there is close contact between surgical and hyperbaric facilities, the initial surgical management should be limited to fasciotomy, with debridement of necrotic tissue performed later, after treatment with hyperbaric oxygen therapy (Cohn GH. 1986. Hyperbaric oxygen therapy; promoting healing in difficult cases. Postgrad Med, 79: 89-92). The extent of ablation may be reduced if early HBO treatment is used to halt progression of the infection.

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