Clostridial necrotising skin and soft tissue infection
Necrotising skin and soft tissue infection caused by Clostridium species can occur after a traumatic wound with associated vascular compromise.
Clostridial myonecrosis (gas gangrene) is diagnosed clinically (eg pain at the traumatic wound site, signs of systemic toxicity). The diagnosis is supported by identifying Clostridium species by culture and gas in the soft tissues (detected by palpation [skin and soft tissue crepitus] or radiography).
In people wounded in natural disasters, if evacuation and debridement is delayed, necrotising skin and soft tissue infection caused by Clostridium species should be considered.
In adults and children with clostridial necrotising skin and soft tissue infection, as a 2-drug regimen in combination with surgical debridement, useStevens, 2014:
benzylpenicillin 2.4 g (child: 60 mg/kg up to 2.4 g) intravenously, 4-hourly. For dosage adjustment in adults with kidney impairment, see benzylpenicillin dosage adjustment. See below for duration of therapy benzylpenicillin benzylpenicillin benzylpenicillin
PLUS
clindamycin 600 mg (child: 15 mg/kg up to 600 mg) intravenously, 8-hourly1. See below for duration of therapy. clindamycin clindamycin clindamycin
For patients who have had a hypersensitivity reaction to a penicillin, replace benzylpenicillin with metronidazole. Use:
metronidazole 500 mg (child: 12.5 mg/kg up to 500 mg) intravenously, 8-hourly. metronidazole metronidazole metronidazole
Clinical outcome data indicate that clindamycin is superior to benzylpenicillin; however, benzylpenicillin is included in the empirical regimen in case the infecting isolate is resistant to clindamycin.
Duration of therapy: switch to oral therapy when further debridement is no longer necessary, there has been clinical improvement, and the patient has been afebrile for 48 to 72 hours. The choice of oral antibiotic therapy should be guided by susceptibility results or expert advice. Continue oral therapy until the infection has resolved, but not necessarily until the wound has healed.