AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Background

Gas gangrene, a subset of necrotizing myositis, is an infectious disease emergency. Organisms in the spore-forming clostridial species including Clostridium perfringens, Clostridium septicum, and Clostridium novyi cause most of the cases. A nonclostridial form is caused by a mixed infection of aerobic and anaerobic organisms. The hallmarks of this disease are rapid onset of myonecrosis with muscle swelling, severe pain, gas production, and sepsis.

Pathophysiology

Clostridium species are gram-positive, spore-forming, anaerobic rods normally found in soil and the gastrointestinal tract of humans and animals. They most often cause disease in the setting of trauma or surgery but can also occur spontaneously in the absence of definite risk factors or exposures. Not all wounds contaminated with clostridia develop gas gangrene; the myonecrosis seems to only develop when sufficient devitalized tissue is present to support anaerobic metabolism.

Traumatic gas gangrene and surgical gas gangrene occur through direct inoculation of a wound. With a compromised blood supply, the wound has an anaerobic environment that is ideal for C perfringens, the cause of 80-95% of cases of gas gangrene.

Spontaneous gas gangrene is most often caused by hematogenous spread of C septicum from the gastrointestinal tract in patients with colon cancer. The organism enters the blood via a small break in the gastrointestinal mucosa and subsequently seeds muscle tissue. Unlike C perfringens, C septicum is aerotolerant and can infect normal tissues.

With C perfringens the local and systemic manifestations are due to the production of potent extracellular protein toxins by the bacteria. These are most notably alpha-toxin (a phospholipase C) and theta-toxin (a thiol-activated cytolysin). These toxins hydrolyze cell membranes, cause abnormal coagulation leading to microvascular thrombosis, and have direct cardiodepressive effects. Furthermore, the products of tissue breakdown, including creatine phosphokinase, myoglobin, and potassium, cause secondary toxicity.

Frequency

United States

Estimates of incidence of gas gangrene vary; however, cases are relatively rare. Data from 1975 estimate 900-1000 cases per year, or 0.03-5.2% of open wounds, depending on type of wound and treatment.

International

No data are published, but incidence is probably higher internationally than in the United States. Incidence is highest in areas with poor access to proper wound care.

Mortality/Morbidity

• Mortality from traumatic gas gangrene is greater than 25%.
• Mortality from nontraumatic gas gangrene caused by C septicum ranges from 67-100%.

Age

• Occurrence is not age specific.
• Diabetic peripheral vascular disease and other chronic immunocompromised states that can predispose individuals to gas gangrene are more prevalent in older populations.

CLINICAL

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

History

• The incubation period is usually less than 24 hours but has been described to be anywhere from 7 hours to 6 weeks, though when symptoms start, clinical deterioration can occur within hours.
• Muscle swelling and severe pain are prominent features. The pain is often out of proportion to physical findings, reflective of the hypoxic state of the muscle tissue, and is a key to distinguishing gas gangrene from simple cellulitis.
• Systemic toxicity may cause altered mental status, and the progression to toxemia and shock can be rapid.

Physical

• Vital signs: Unusually, fever is not a prominent feature of infection and may only be low grade throughout the clinical course. The degree of systemic involvement may produce a spectrum of changes from tachycardia through outright septic shock including hypotension and diaphoresis.
• Overlying skin: Initially, it may be normal and then progress through a yellowing or bronzing of the skin to bulla formation to patches of green/blue/grey/black necrosis. Serosanguineous drainage may be present, described classically as having a “mousy” or slightly sweet odor.
• Extremity examination: Most notable is extreme pain of the affected area with or without movement and with palpation, which may be out of proportion to the extent of the overlying skin changes. Tense edema with crepitance due to subcutaneous air may be noted and is proportional to the extent of underlying necrosis.
• Vascular examination: Distal pulses may be normal or diminished depending on the extent of local damage.
• Neurologic examination: Decreased pain or anesthesia at the site of infection can indicate that cutaneous nerve endings are being destroyed and that the disease is advanced.

Causes

• Risk factors for gas gangrene
• • Atherosclerosis
  • Burns
  • Chronic alcoholism
  • Corticosteroid use
  • Diabetes
  • Gastrointestinal malignancy
  • Hypoalbuminemia
  • Intravenous drug abuse
  • Malnutrition
  • Obesity
  • Peripheral vascular disease
  • Surgery
  • Trauma

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Other Problems to be Considered

Other causes of necrotizing myositis (group A streptococci, polymicrobial aerobic-anaerobic flora, and nonclostridial anaerobes)
Cutaneous anthrax
Vaccinia vaccination
Acute gout
Septic arthritis
Familial Mediterranean fever
Fixed drug reaction
Pyoderma gangrenosa
Sweet syndrome
Wells syndrome
Carcinoma erysipeloides
Pyomyositis
Water-borne skin infections (Vibrio vulnificus, Aeromonas hydrophila, Mycobacterium marinum)
Other causes of soft tissue gas (eg, pneumomediastinum, pneumothorax, fractured larynx, fractured trachea)

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Lab Studies

• Gram stain and culture of bullae fluid: The presence of gram-positive rods with few white blood cells is indicative of clostridial etiology, while the presence of many white cells is more suggestive of a mixed bacterial infection. While this information can be helpful, simple superficial wound swabs should not be obtained. Microorganisms that colonize the skin surface often do not contribute to the underlying infection.
• Complete blood count: CBC may reveal anemia, thrombocytopenia, and evidence of intravascular hemolysis on smear from destruction by the toxins.
• Electrolyte level: Hyperkalemia can result from cell breakdown. Hypocalcemia may result from subcutaneous fat necrosis.
• Renal panel: Kidney dysfunction may occur secondary to hypotension, hemoglobinuria, and myoglobinuria.
• Coagulation panel: Coagulopathy and thrombocytopenia can result.
• Liver function tests: Hyperbilirubinemia and liver dysfunction may result from release of toxins.
• Arterial blood gas determination: Gas gangrene can cause metabolic acidosis.
• Myoglobin level: Myoglobinemia and myoglobinuria can result from cellular breakdown.
• Blood cultures: This may help narrow antibiotic coverage.

Imaging Studies

• Gas in the soft tissues is neither sensitive nor specific for gas gangrene. Many different bacteria, trauma, and visceral perforation can cause soft tissue gas. Plain radiographs or ultrasonography can be used to look for the presence of gas.
• Computed tomography or magnetic resonance imaging can help to evaluate the depth of soft tissue inflammation.

Procedures

• Tissue biopsy is the criterion standard in helping make the diagnosis of gas gangrene.

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Prehospital Care

• Oxygenation
• Intravenous (IV) fluids

Emergency Department Care

Gas gangrene is a true emergency, and concurrent evaluation, treatment, and coordination of care should be carried out.

Generally speaking, the treatment is a combination of antibiotics, surgery, and hyperbaric oxygen.

• Airway and breathing: Oxygen and airway management as necessitated by the clinical picture.
• Circulation: Good vascular access and liberal use of intravenous fluids is indicated. Frequent reassessment of the circulatory status is necessary. If pressors are necessitated, vasoconstrictors should only be used if absolutely necessary; they can decrease perfusion to already ischemic tissue.
• Administer tetanus toxoid if indicated.
• Administer antibiotics.
• Correct electrolyte abnormalities.
• Check compartment pressures if severe pain and evidence of compartment syndrome are present with minimal cutaneous evidence of infection.

Consultations

• Surgery
• • Obtain immediate surgical consultation.
  • Definitive treatment of gas gangrene is wide debridement of necrotic muscle. This is identifiable because it does not bleed or contract when debrided.
  • While laboratory studies and imaging studies may help make the diagnosis of gas gangrene, the criterion standard is tissue biopsy.

MEDICATION

Section 7 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Antibiotics may not penetrate the ischemic muscle but are important adjuncts to surgery.

Drug Category: Antibiotics

Clostridial species are exquisitely sensitive to a combination of penicillin G and clindamycin. However, because it is difficult initially to distinguish gas gangrene from other soft tissue infections, such as necrotizing fasciitis, which is caused by a broad spectrum of pathogens, empiric first-line antibiotic therapy should be broad.

Antibiotic treatment should include gram-positive (penicillin or cephalosporin), gram-negative (aminoglycoside, third-generation cephalosporin, or ciprofloxacin), and anaerobic coverage (clindamycin or metronidazole). In addition, vancomycin or linezolid should be considered in those at risk for methicillin-resistant Staphylococcus aureus (MRSA). In some communities, MRSA infections are now being isolated even in those without risk factors (8-25%); the risk factors traditionally associated with MRSA are a history of hospitalization, surgery, dialysis, residence in a long-term care facility, presence of a permanent indwelling catheter or percutaneous medical device (eg, tracheostomy tube, gastrostomy tube, Foley catheter), or previous isolation of MRSA.

Antibiotics should be administered IV since absorption by other routes is inconsistent given the hypotension and suboptimally performing gastrointestinal tract of seriously ill patients.

Drug Name	Clindamycin (Cleocin)
Description	Lincosamide useful as treatment against serious skin and soft tissue infections caused by most staphylococcal strains. Also effective against aerobic and anaerobic streptococci, except enterococci. Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at bacterial ribosome where it preferentially binds to 50S ribosomal subunit, causing bacterial growth inhibition.
Adult Dose	600-1200 mg IV/IM qd divided q6-8h depending on degree of infection
Pediatric Dose	16-20 mg/kg/d IV/IM divided tid/qid Severe infections: May increase dose to 20-40 mg/kg/d IV/IM divided tid/qid
Contraindications	Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis
Interactions	Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin
Pregnancy	B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions	Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe colitis

Drug Name	Ceftriaxone (Rocephin)
Description	Third-generation cephalosporin that has broad-spectrum activity against gram-negative organisms, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. Arrests bacterial cell wall synthesis and inhibits bacterial growth by binding to one or more penicillin-binding proteins.
Adult Dose	1-2 g IV qd or divided bid, depending on type and severity of infection; not to exceed 4 g/d
Pediatric Dose	Neonates >7 days: 25-50 mg/kg/d IV; not to exceed 125 mg/d Infants and children: 50-75 mg/kg/d IV divided q12h; not to exceed 2 g/d
Contraindications	Documented hypersensitivity
Interactions	Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Pregnancy	B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions	Adjust dose in renal impairment; caution in breastfeeding women and those with allergy to penicillin

Drug Name	Metronidazole (Flagyl)
Description	Active against various anaerobic bacteria and protozoa. Appears to be absorbed into cells; intermediate-metabolized compounds that are formed bind DNA and inhibit protein synthesis, causing cell death.
Adult Dose	Loading dose: Infuse 15 mg/kg IV over 1 h or 1 g for a 70-kg adult Maintenance dose: Following loading dose, infuse 7.5 mg/kg IV over 1 h q6-8h or 500 mg for a 70-kg adult; not to exceed 4 g/d
Pediatric Dose	Administer as in adults; not to exceed 2 g/d
Contraindications	Documented hypersensitivity
Interactions	May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity of metronidazole; disulfiram reaction may occur with orally ingested ethanol
Pregnancy	B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions	Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy

Drug Name	Linezolid (Zyvox)
Description	Prevents formation of functional 70S initiation complex, which is essential for bacterial translation process. Bacteriostatic against enterococci and staphylococci and bactericidal against most strains of streptococci. Used as alternative in patients allergic to vancomycin and for treatment of vancomycin-resistant enterococci.
Adult Dose	400-600 mg PO/IV q12h for 10-28 d
Pediatric Dose	Preterm neonate <7 days: 10 mg/kg PO/IV q12h Term neonates to 12 years: 10 mg/kg PO/IV q8h >12 years: Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	May cause hypertension when used concomitantly with adrenergic agents including pseudoephedrine, sympathomimetic agents, or vasopressor or dopaminergic agents (reduce dose of dopamine or epinephrine if concurrent use required); serotonin syndrome may occur if used concomitantly with serotonergic agents including tricyclic antidepressants, meperidine, dextromethorphan, trazodone, venlafaxine, and selective serotonin reuptake; may cause myelosuppression or pseudomembranous colitis inhibitors
Pregnancy	C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions	Has mild MAOI properties and has potential to have same interactions as other MAOIs; caution in uncontrolled hypertension, pheochromocytoma, carcinoid syndrome, or untreated hyperthyroidism, and in patients who are at increased risk for bleeding, have preexisting thrombocytopenia, are receiving concomitant medications that may decrease platelet count or function, or who may require >2 wk of therapy (monitor platelet counts); unnecessary use may lead to development of resistance to drug; may cause peripheral or optic neuropathy

Drug Name	Gentamicin (Gentacidin, Garamycin)
Description	Aminoglycoside antibiotic used for gram-negative bacterial coverage. Commonly used in combination with an agent with activity against gram-positive organisms and one that covers anaerobes. Not antibiotic of first choice. Consider using when penicillins or other less toxic drugs are contraindicated, when bacterial susceptibility tests and clinical judgment indicate its use and in mixed infections caused by susceptible strains of staphylococci and gram-negative organisms. Dosing regimens are numerous and are adjusted based on CrCl and changes in volume of distribution. Gentamicin may be administered IV/IM.
Adult Dose	Serious infections and normal renal function: 3 mg/kg/d IV/IM q8h Life-threatening infections: 5 mg/kg/d IV/IM q6-8h Each regimen must be followed by at least a trough level drawn on third or fourth dose, 0.5 h before dosing; may draw a peak level 0.5 h after 30-min infusion Dose may need adjustment in patients with renal impairment
Pediatric Dose	<5 years with normal renal function: 2.5 mg/kg/dose IV/IM q8h >5 years: 1.5-2.5 mg/kg/dose IV/IM q8h or 6-7.5 mg/kg/d IV/IM divided q8h; not to exceed 300 mg/d with adjustments for renal function prn (monitor levels as in adults)
Contraindications	Documented hypersensitivity
Interactions	Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; because aminoglycosides enhance effects of neuromuscular blocking agents, prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)
Pregnancy	C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions	Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment

Drug Name	Vancomycin (Vancocin)
Description	Potent antibiotic directed against gram-positive organisms and active against enterococci species. Useful to treat septicemia and skin structure infections. Indicated for patients who cannot receive or have failed to respond to penicillins and cephalosporins or for those who have infections with resistant staphylococci. For abdominal penetrating injuries, combine with an agent active against enteric flora and/or anaerobes. To avoid toxicity, assay of vancomycin trough levels after the third dose drawn 0.5 h prior to next dosing currently is recommended. May need to adjust dose in patients diagnosed with renal impairment (use CrCl).
Adult Dose	500-2000 mg/d IV divided tid/qid for 7-10 d
Pediatric Dose	40 mg/kg/d IV divided tid/qid for 7-10 d
Contraindications	Documented hypersensitivity
Interactions	Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants
Pregnancy	C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions	Caution in renal failure and neutropenia

Drug Category: Medicinal gas

Hyperbaric oxygen (HBO) produces a tissue level of 300 mm Hg of oxygen. This is approximately 50 mm Hg greater than the partial pressure necessary to induce bacteriostasis and halt toxin production. This then decreases the extent of debridement and possible amputation needed to control infection.

Drug Category: Toxoids

Toxoids are used to induce active immunity.

Drug Category: Immunoglobulins

Immunoglobulins are used to induce passive immunity.

Drug Category: Analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma or have sustained injuries.

Drug Name	Fentanyl citrate (Duragesic, Sublimaze)
Description	A synthetic opioid that is 75-200 times more potent and has a much shorter half-life than morphine sulfate. Has less hypotensive effects and is safer in patients with hyperactive airway disease than morphine because of minimal-to-no associated histamine release. By itself, it causes little cardiovascular compromise, although addition of benzodiazepines or other sedatives may result in decreased cardiac output and blood pressure. Highly lipophilic and protein-bound. Prolonged exposure leads to accumulation in fat and delays weaning process. Consider continuous infusion because of the short half-life of fentanyl. Parenteral form is DOC for conscious sedation analgesia. Ideal for analgesic action of short duration during anesthesia and immediate postoperative period. Excellent choice for pain management and sedation with short duration (30-60 min) and easy to titrate. Easily and quickly reversed by naloxone. After initial parenteral dose, subsequent parenteral doses should not be titrated more frequently than q3h or q6h thereafter. Transdermal form is used only for chronic pain conditions in patients with tolerance to opioids. When using transdermal dosage form, most patients are controlled with 72-h dosing intervals; however, some patients require dosing intervals of 48 h. Easily and quickly reversed by naloxone.
Adult Dose	Emergency: 0.5-2 mcg/kg/dose IM/IV Analgesia: 0.5-1 mcg/kg/dose IM/IV q30-60min Transdermal: Apply a 25 mcg/h system q48-72h
Pediatric Dose	<2 years: 2-3 mcg/kg/dose IM/IV q60min 2-12 years: 1-2 mcg/kg/dose IM/IV q60min >12 years: Administer as in adults
Contraindications	Documented hypersensitivity; hypotension or potentially compromised airway where it would be difficult to establish rapid airway control
Interactions	Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants may potentiate adverse effects of fentanyl when both drugs are used concurrently
Pregnancy	C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions	Caution in hypotension, respiratory depression, constipation, nausea, emesis, and urinary retention; idiosyncratic reaction, known as chest wall rigidity syndrome, may require neuromuscular blockade in order to increase ventilation

FOLLOW-UP

Section 8 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Further Inpatient Care

• Urgent surgical debridement may be indicated.
• Admit the patient to an ICU with invasive monitoring as necessary.

In/Out Patient Meds

• Inpatient medications include intravenous antibiotics and analgesics.

Transfer

• Transfer the patient if appropriate surgical specialist and ICU setting are unavailable.

Deterrence/Prevention

• Appropriate wound care at time of injury (eg, debridement of crushed or dead tissue, copious irrigation) may deter infection.
• Prophylactic antibiotics may prevent subsequent infection in selected circumstances.

Complications

• Disease may progress rapidly; patients often become septic.

Prognosis

• Early diagnosis and aggressive treatment are the keys to decreasing mortality.

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Medical/Legal Pitfalls

• Gas gangrene and necrotizing myositis in general can present with very subtle signs early in its course. A high index of suspicion is necessary to avoid catastrophes. Once the diagnosis is established, timely intervention with aggressive resuscitation, appropriate antibiotics, and surgical intervention is indicated.

ACKNOWLEDGMENTS

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Wende R Reenstra-Buras, MD, PhD, and N Ewen Wang, MD, for the development and writing of this article.

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

• Anesti E, Brooks P, Majumder S. Images in emergency medicine. Gas gangrene. Ann Emerg Med. Jul 2007;50(1):14, 33. [Medline].
• Arteta-Bulos R, Karim SM. Images in clinical medicine. Nontraumatic Clostridium septicum myonecrosis. N Engl J Med. Oct 21 2004;351(17):e15. [Medline].
• Brook I. Recovery of anaerobic bacteria from wounds after lawn-mower injuries. Pediatr Emerg Care. Feb 2005;21(2):109-10. [Medline].
• Bryant AE. Biology and pathogenesis of thrombosis and procoagulant activity in invasive infections caused by group A streptococci and Clostridium perfringens. Clin Microbiol Rev. Jul 2003;16(3):451-62. [Medline].
• Folstad SG. Soft tissue infections. In: Tintinalli JE, et al, eds. Emergency Medicine: A Comprehensive Study Guide. 6^th ed. McGraw Hill; 2004:979-986.
• Frazee BW, Lynn J, Charlebois ED, Lambert L, Lowery D, Perdreau-Remington F. High prevalence of methicillin-resistant Staphylococcus aureus in emergency department skin and soft tissue infections. Ann Emerg Med. Mar 2005;45(3):311-20. [Medline].
• Fridkin SK, Hageman JC, Morrison M, Sanza LT, Como-Sabetti K, Jernigan JA, et al. Methicillin-resistant Staphylococcus aureus disease in three communities. N Engl J Med. Apr 7 2005;352(14):1436-44. [Medline].
• Headley AJ. Necrotizing soft tissue infections: a primary care review. Am Fam Physician. Jul 15 2003;68(2):323-8. [Medline].
• Meislin HW, Guisto JA. Soft tissue infections. In: Marx JA, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 5^th ed. Mosby-Year Book; 2002:1944-1955.
• Miller LG, Perdreau-Remington F, Rieg G, Mehdi S, Perlroth J, Bayer AS, et al. Necrotizing fasciitis caused by community-associated methicillin-resistant Staphylococcus aureus in Los Angeles. N Engl J Med. Apr 7 2005;352(14):1445-53. [Medline].
• Schneider DJ, Reid JS. Images in clinical medicine. Gas gangrene associated with occult cancer. N Engl J Med. Nov 30 2000;343(22):1615. [Medline].
• Smith-Slatas CL, Bourque M, Salazar JC. Clostridium septicum infections in children: a case report and review of the literature. Pediatrics. Apr 2006;117(4):e796-805. [Medline].
• Stevens DL. The pathogenesis of clostridial myonecrosis. Int J Med Microbiol. Oct 2000;290(4-5):497-502. [Medline].
• Swartz MN. Clinical practice. Cellulitis. N Engl J Med. Feb 26 2004;350(9):904-12. [Medline].
• Temple AM, Thomas NJ. Gas gangrene secondary to Clostridium perfringens in pediatric oncology patients. Pediatr Emerg Care. Jul 2004;20(7):457-9. [Medline].
• Trott AT. Skin and Soft-tissue Infections. In: Wolfson AB, et al, eds. Harwood-Nuss' Clinical Practice of Emergency Medicine. 4th. Lippincott Williams & Wilkins; 2005:715-717.
• Wang C, Schwaitzberg S, Berliner E, Zarin DA, Lau J. Hyperbaric oxygen for treating wounds: a systematic review of the literature. Arch Surg. Mar 2003;138(3):272-9; discussion 280. [Medline].

Article Last Updated: Dec 4, 2007