What is the role of hyperbaric oxygen therapy (HBOT) in the treatment of necrotizing infections?

Answer

These infections may be single aerobic or anaerobic but are more often mixed infections that often occur as a result of trauma, surgical wounds, or foreign bodies, including subcutaneous and muscular injection of contaminated street drugs. They are often seen in compromised hosts who have diabetes or a vasculopathy of another type. These infections are named based on their clinical presentation and include necrotizing fasciitis, clostridial and nonclostridial myonecrosis, and Fournier gangrene.

Regardless of the depth of the tissue invasion, these infections have similar pathophysiology that includes local tissue hypoxia, which is exacerbated by a secondary occlusive endarteritis.^[69]Intravascular sequestration of leukocytes is common in these types of infections, mediated by toxins from specific organisms.^[70]Clostridial theta toxin appears to be one such mediator. All of these factors together foster an environment for facultative organisms to continue to consume remaining oxygen, and this promotes growth of anaerobes.

The cornerstones of therapy are wide surgical debridement and aggressive antibiotic therapy. Hyperbaric oxygen therapy (HBOT) is used adjunctively with these measures, as it offers several mechanisms of action to control the infection and reduce tissue loss. First, HBOT is toxic to anaerobic bacteria.^[71]Next, HBOT improves polymorphonuclear function and bacterial clearance.^{[14, 72]}Based on results of work related to CO poisoning, HBOT may decrease neutrophil adherence based on inhibition of beta-2 integrin function.^{[19, 18]}Further investigation is needed to see if this mechanism is at work in necrotizing infections as well. In the case of clostridial myonecrosis, HBOT can stop the production of the alpha toxin.^{[21, 73]}Finally, limited evidence indicates that HBOT may facilitate antibiotic penetration or action in several classes of antibiotics, including aminoglycosides,^[22]cephalosporins,^[24]sulfonamides^[23]and amphotericin.^[25]

Multiple clinical studies suggest that HBOT is efficacious in the treatment of necrotizing soft tissue infections. These include case series, retrospective and prospective studies, and non-randomized clinical trials. They suggest significant reductions in mortality and morbidity. The reduction in mortality was remarkably similar in two studies: 34% (untreated) vs. 11.9% (treated) in one study;^[74]38% (untreated) vs. 12.5% (treated) in the other.^[75]In another study,^[76]the treated group had more patients with diabetes and more patients in shock and still had significantly less mortality (23%) than the untreated group (66%). Clinical studies involving patients with Fournier gangrene treated with HBOT bear similar results.

Initial HBOT is aggressively performed at least twice per day in coordination with surgical debridement. Typically, a treatment pressure ranging from 2.0-2.5 ATA is adequate. However, in the specific case of clostridial myonecrosis, 3 ATA is often used to ensure adequate tissue oxygen tensions to stop alpha toxin production. For the same reason, HBOT should be initiated as quickly as possible in this circumstance and performed 3 times in the first 24 h if at all feasible.

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Media Gallery

Rectangular hyperbaric chamber.
Interior of rectangular chamber.
Cylindrical multiplace chamber.
Monoplace chamber.

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Author

Emi Latham, MD, FACEP, FAAEM, UHM Assistant Clinical Professor of Emergency Medicine, Hyperbaric Medicine Physician, University of California, San Diego, School of Medicine

Emi Latham, MD, FACEP, FAAEM, UHM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Undersea and Hyperbaric Medical Society, Wilderness Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Marc A Hare, MD Assistant Clinical Professor, Department of Emergency Medicine, University of California San Diego Medical Center

Marc A Hare, MD is a member of the following medical societies: American College of Emergency Physicians, Undersea and Hyperbaric Medical Society

Disclosure: Nothing to disclose.

Michael Neumeister, MD, FRCSC, FACS Chairman, Professor, Division of Plastic Surgery, Director of Hand/Microsurgery Fellowship Program, Chief of Microsurgery and Research, Institute of Plastic and Reconstructive Surgery, Southern Illinois University School of Medicine

Michael Neumeister, MD, FRCSC, FACS is a member of the following medical societies: American Association for Hand Surgery, American Burn Association, American College of Surgeons, American Medical Association, American Society for Surgery of the Hand, American Society of Plastic Surgeons, American Society for Reconstructive Microsurgery, Canadian Society of Plastic Surgeons, Illinois State Medical Society, Illinois State Medical Society, Ontario Medical Association, Plastic Surgery Research Council, Royal College of Physicians and Surgeons of Canada, Society of University Surgeons, American Council of Academic Plastic Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD, FACP, FCCP Geri and Richard Brawerman Chair in Pulmonary and Critical Care Medicine, Professor and Executive Vice Chairman, Department of Medicine, Medical Director, Women's Guild Lung Institute, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD, FACP, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic Society

Disclosure: Nothing to disclose.

Additional Contributors

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Acknowledgements

Multiplace hyperbaric chamber photos courtesy of OxyHeal Health Group, Inc.

Monoplace hyperbaric chamber photos courtesy of Sechrist Industries, Inc.

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