A number of types of infections of soft tissue may benefit from adjunct treatment with hyperbaric oxygen and are included in the category of “necrotizing soft tissue infections.” Names of such clinical syndromes include crepitant anaerobic cellulitis, progressive bacterial gangrene, necrotizing fasciitis, and nonclostridial myonecrosis. Gas gangrene (Clostridial myositis and myonecrosis) is a separate entity and is reviewed elsewhere in this site.
Necrotizing soft tissue infections may result from either a single strain or a mixed population of bacteria, typically occurring after trauma, surgery, and/or around foreign bodies. The individual affected by such infections is frequently compromised by conditions such as diabetes or vascular disease.
In addition to pre-existing host compromise, necrotizing soft tissue infections themselves may induce conditions adverse to control of the infection by normal host defense mechanisms. The infections commonly lower tissue oxygen levels, impairing the ability of the white blood cells (neutrophils) to fight infection. Toxins produced by bacteria involved may also inhibit neutrophil activity.
The primary treatments for necrotizing soft tissue infection are surgical excision of infected tissue and administration of appropriate antibiotics. In selected cases, addition of hyperbaric oxygen therapy may be both lifesaving and cost effective. Hyperbaric oxygen may be beneficial in several ways. Some of the bacteria involved in necrotizing soft tissue infections are “anaerobic,” growing most rapidly in a low oxygen environment. In the hyperbaric chamber, tissue oxygen levels may be raised sufficiently to inhibit bacterial growth. In addition, hyperbaric oxygen treatment may enhance the ability of neutrophils to kill bacteria, by a number of different mechanisms.
The use of hyperbaric oxygen for treatment of necrotizing soft tissue infections should be individualized. In specific instances where risk of morbidity and mortality are high, adjunct hyperbaric oxygen therapy should be considered.
Effect of Hyperbaric Oxygen on Vibrio vulnificus and Its Infection.
Hyperbaric oxygen therapy as an anti-infective agent.
- Mader JT, Adams KR, Sutton TE. Infectious diseases: Pathophysiology and mechanisms of hyperbaric oxygen. J Hyperbaric Med 1987;2:133-140.
- Knighton DR, Fiegel VD, Halverson T, Schneider S, Brown T, Wells CL. Oxygen as an antibiotic: The effect of inspired oxygen on bacterial clearance. Arch Surg 1990;125:97-100.
- Brogan TV, Nizet V, Waldhausen JHT, Rubens CE, Clarke WR. Group A Streptococcal necrotizing fasciitis complicating primary varicella: A series of fourteen patients. Pediatr Infect Dis Jour 1995;14:588-594.
- Riseman JA, Zamboni WA, Curtis A, Graham DR, Konrad HR, Ross DS. Hyperbaric oxygen therapy for necrotizing fasciitis reduces mortality and the need for debridements. Surgery 1990;108-847-850.
- Hollabaugh RS, Dmochowski RR, Hickerson WL Cox CE. Fournier’s Gangrene: Therapeutic impact of hyperbaric oxygen. Plast Reconstruct Surg 1998;101:94-100.
Other references on Necrotizing Soft Tissue Infections:
PROGRESSIVE NECROTIZING INFECTIONS
- Green RJ, Dafoe DC, Raffin TA: Necrotizing fasciitis. Chest 1996;110(1)219-229.
A recent review of necrotizing fasciitis, published in CHEST. With regard to hyperbaric oxygen, the authors conclude that where available, "it should be considered as a treatment adjunct in patients with necrotizing fasciitis".
- Knighton DR, Halliday B, Hunt TK: Oxygen as an antibiotic: the effect of inspired oxygen on infection. Arch Surg 1984;119:199-204.
This reference is included to emphasize an important feature of HBO therapy in infectious diseases. Hyperbaric doses of oxygen take on antibiotic-like properties. The paper stresses the importance of sufficient local oxygen tension in order that bacterial killing by leukocytes can be accomplished.
- Knighton DR, Halliday B, Hunt TK: Oxygen as an antibiotic: a comparison of the effects of inspired oxygen concentration and antibiotic administration on in vivo bacterial clearance. Arch Surg 1986;121:191-195.
The same authors cited in the previous paper demonstrate an additive effect when elevated oxygen tensions are combined with antibiotics.
- Mader JT, Guckian JC, Glass DL, et al: Therapy with hyperbaric oxygen for experimental osteomyelitis due to staphylococcus aureus in rabbits. The Journal of Infectious Diseases 1978;138(3):312-318.
The third of three papers that provide important mechanistic support for HBO therapy in infected tissue. In this case, HBO improves leukocyte antimicrobial function.
- Bakker DJ: Pure and mixed aerobic and anaerobic soft tissue infections. Hyperbaric Oxygen Review 1985;6(2):65-96.
A review article, with emphasis on the role of hyperbaric oxygen therapy. The author further presents 50 cases from his institution.
- Hirn M: Hyperbaric oxygen in the treatment of gas gangrene and perineal necrotizing fasciitis. Eur J Surg 1993;(570):1-36.
A monograph; it describes an experimental model of both necrotizing fasciitis and gas gangrene, a clinical series, and a literature review. HBO therapy decreases mortality, clarifies the demarcation of necrotic vs. potentially viable tissue (improved limb salvage), and enhances wound healing.
- Riseman JA, Zamboni WA, Curtis A, et al: Hyperbaric oxygen therapy for necrotizing fasciitis reduces mortality and the need for debridements. Surgery 1990;108:847-850.
A clinical study of 29 patients, in which outcome was compared between a surgery and antibiotics group and a surgery, antibiotics, and HBO therapy group. The addition of HBO "… significantly reduced mortality and wound morbidity/number of treatments".
- Gozal D, Ziser A, Shupak A, et al: Necrotizing fasciitis. Arch Surg 1986;121:233-235.
A small clinical series in which the combined approach of surgery, antibiotics and HBO therapy resulted in a mortality of 12.5%. This compared with mortality rates as high as 72.7% noted in the paper’s review of the disease treated without HBO.
- Pizzorno R, Bonini F, Donelli A, et al: Hyperbaric oxygen therapy in the treatment of Fournier’s disease in 11 male patients. The Journal of Urology 1997;158:837-840.
A clinical series of the "Fournier’s Disease" aspect of necrotizing soft tissue infections. The authors, while recognizing their small number of patients, felt that their results "underline the importance of hyperbaric oxygen therapy …"
- Hollabaugh RS, Dmochowski RR, Hickerson EL, et al: Fournier’s gangrene: therapeutic impact of hyperbaric oxygen. Plast. Reconstr. Surg. 1998;101(1):94-100.
A very recent clinical series involving two largely equal groups, with HBO therapy as the variable. Mortality was 7% in the HBO group compared to 42% in those not receiving HBO (statistical significance at the 0.05 level).
- McHenry CR, Piotrowski JJ, Petrinic D, et al: Determinants of mortality for necrotizing soft-tissue infections. Ann. Surg. 1995;221(5):558-565.
Contrast the previous papers with that presented in this oft-quoted paper that reported improved mortality (29%!) vs. previous literature. The authors discounted HBO therapy’s efficacy and suggested that its use will delay debridement. Typically, HBO therapy does not precede surgery, therefore, such delays do not occur