Classification of Histotoxic Clostridial Disease
The technique (Clark et al., 1969). Smears and cultures from the exudate around the wound surface may be misleading. Tables 1 and 2 summarize the most important findings for the differential diagnosis Treatment. Treatment must be prompt and vigorous. Most important is thorough debridement and excision of all devitalized tissue and dead muscle. Hopelessly involved extremities usually need to be amputated except perhaps under the Clostridial Disease of hyperbaric oxygen. It is said that if any infected muscle is left behind, it will prevent cure. General supportive measures should include intravenous fluids and blood, other measures to combat vascular collapse and shock, and peritoneal dialysis when necessary.
Antimicrobial treatment is given to prevent bloodstream invasion and to suppress the further spread of infection. Penicillin is the drug of choice given in large doses of 10 to 20 million units per day intravenously. Erythromycin may be substituted in patients allergic to penicillin. In a recent study, it was found that 11 percent of clostridial strains were resistant to tetra.
TABLE 1. CLASSIFICATION OF HISTOTOXIC CLOSTRIDIAL DISEASE
A. Wound infection (war and civilian)
1. Simple contamination
2. Localized (purulent or “gas abscess”)
3. Gas-forming cellulitis
B. Uterine infection (postabortion and postpartum)
C. Burns, panophthalmitis, brain abscess, etc.
A. Postoperative (abdominal, amputation).
1. Localized (pneumonia, empyema, cholecystitis, myonecrosis)
2. Septicemic (malignant disease, intestinal lesion) D. Bacteremia without hemolysis or sepsis (from decubitus ulcer, gangrenous extremity, uterus)
Onset Toxemia Pain Swelling Skin color Exudate Gas
Antitoxin is recommended in neutralizing any free toxin in the body although its usefulness is doubtful because toxins are very rapidly bound to cells. The mended dose is 40 thousand units of trivaiest pentavalent antitoxin intravenously at once 20 to 40 thousand units repeated at four to six intervals. The usual precautions for horse use must be observed. Hyperbaric oxygen at 3 atmospheres has been recommended by some as a dramatically successful mode of therapy that should take precedence over immediate surgical treatment and antitoxin. It is said that debridement may be deferred until systemic toxicity has been relieved and demarcation between necrotic and viable tissue is clear.
In this way loss of tissue may be minimized and amputation sometimes avoided. If a suitable chamber is not available locally, it is probably unwise to delay surgical extirpation in favor of a long journey. Treatment of “anaerobic” cellulitis and streptococcal myonecrosis need not be so radical. Usually, wide excision and debridement along with supportive measures and appropriate antimicrobials will suffice. A Gram-stained smear of wound exudate and muscle aspirate will help one to decide, whether penicillin alone should be given (for pure Clostridium or Streptococcus) or whether anti-staphylococcal or anticoliform agents should be added or substituted.
For the former, one should use semisynthetic penicillinase-resistant penicillins (methicillin, nafcillin, or cephalothin) to initiate treatment; for the gram-negative bacilli, one can add tetracycline, gentamicin, or kanamycin. Prevention. The prophylactic use of antitoxin and antimicrobials at the time of injury does not prevent gas gangrene. Careful attention to good surgical technique is most important. All devitalized tissue must be excised and vascular supply left intact. Care must be taken with tourniquets and casts to prevent undue ischemia. Plaster of Paris itself may be contaminated with clostridia.
TABLE 2.• GAS-FORMING SOFT TISSUE INFECTIONS
Sudden Extreme May be severe Marked Bronze Thin, brown Little, in muscle
“Anaerobic” Cellulitis Streptococcal Myositis Dead, “cooked,” healthy muscle invaded Mixed flora from exudate or open wound; from muscle aspirate pure gram-positive rods Prognosis Serious Treatment Radical surgery, penicillin, anti-toxin, hyperbaric oxygen Gradual Slight Slight Slight No change Thin, bloody; later purulent Profuse, large bubbles in fascial planes Not involved Maybe pure clostridia or mixed flora from exudate or subcutaneous tissue; no organisms in muscle aspirate Good Surgical drainage and debridement, appropriate antimicrobials Gradual Slight Gradually increasing Marked Erythematous Profuse, thin seropurulent Little, in muscle Initially edematous, then hemorrhagic Anaerobic streptococci, along with Group A Streptococcus, Staph. aureus, etc., from exudate and muscle
Good Surgical drainage and debridenmssit penicillin