Although Clostridium spp. may colonise or contaminate wounds, no action is required unless there is evidences of spreading infection. Infection may be limited to tissue that is already damaged (anaerobic cellulitis) or involve healthy muscle (gas gangrene).
In anaerobic cellulitis, usually that due to C. perfringens or to other strains infecting devitalised tissue following a wound, gas forms locally and extends along tissue planes but bacteraemia does not occur. Prompt surgical debridement of devitalised tissue and therapy with penicillin or clindamycin is usually effective.
Gas gangrene (clostridial myonecrosis) is defined as acute invasion of healthy living muscle undamaged by previous trauma, and is most commonly caused by C. perfringens. In at least 70% of cases, it follows deep penetrating injury sufficient to create an anaerobic (ischaemic) environment and allow clostridial introduction and proliferation. Severe pain at the site of the injury progresses rapidly over 18–24 hours. Skin colour changes from pallor to bronze/purple discoloration and the skin is tense, swollen, oedematous and exquisitely tender.
Gas in tissues may be obvious, with crepitus on clinical examination, or visible on X-ray, CT or ultrasound. Signs of systemic toxicity develop rapidly, with high leucocytosis, multi-organ dysfunction, raised creatine kinase and evidence of disseminated intravascular coagulation and haemolysis. Antibiotic therapy with high-dose intravenous penicillin and clindamycin is recommended, coupled with aggressive surgical debridement of the affected tissues. Alternative agents include cephalosporins and metronidazole. Hyperbaric oxygen has a putative but controversial role.
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