Hyperbaric oxygen therapy kills NSTI bacteria and saves threatened tissue alongside surgery
Hyperbaric oxygen therapy kills NSTI bacteria and saves threatened tissue alongside surgery
Understanding necrotizing soft tissue infections and how HBOT fights them
Necrotizing soft tissue infections (NSTIs) — including necrotizing fasciitis, Fournier's gangrene and clostridial myonecrosis — are among the most lethal bacterial infections in medicine. These polymicrobial infections spread along fascial planes at alarming speed, destroying muscle, fat and connective tissue and producing exotoxins that cause systemic toxemia, shock and multi-organ failure.
Mortality rates for NSTIs remain 20 to 40% even with aggressive treatment in hospital settings. The organisms responsible — including Group A Streptococcus, Staphylococcus aureus, Clostridium species and gram-negative enteric bacteria — thrive in the hypoxic, necrotic tissue environment created by the infection itself, creating a vicious cycle that surgical debridement alone cannot fully interrupt.
HBOT addresses this cycle directly. By raising tissue oxygen to levels lethal for anaerobic organisms, HBOT breaks the anaerobic bacterial advantage in necrotic tissue. It also restores the immune cell bactericidal activity impaired by tissue hypoxia, inhibits toxin production and helps demarcate viable from non-viable tissue to guide more precise surgical debridement.
Rapidly spreading skin redness, swelling and warmth disproportionate to the appearance
Severe pain followed paradoxically by numbness as nerves are destroyed
Crepitus — crackling under the skin from gas-producing organisms
Skin blistering, discoloration and tissue death progressing over hours
High fever, rapid heart rate and signs of septic shock
Mortality risk of 20 to 40% even with aggressive hospital treatment
How HBOT fights necrotizing soft tissue infections
NSTIs involve rapidly spreading bacterial destruction in a hypoxic tissue environment that disables the body's defenses. HBOT attacks the infection on multiple fronts simultaneously.
Directly kills and inhibits anaerobic bacteria
Restores immune cell killing power in infected tissue
Reduces toxin production and systemic toxemia
Demarcates viable from non-viable tissue
Potentiates antibiotic efficacy
Accelerates wound healing after debridement
For Providers
Clinical evidence for HBOT in necrotizing soft tissue infections
HBOT for necrotizing soft tissue infections is a Medicare-approved indication with clinical evidence from case series, retrospective studies and meta-analyses supporting its use as an adjunct to surgery and antibiotics.
Riseman et al. — retrospective comparative study (1990): Riseman and colleagues published a landmark retrospective study in Surgery comparing outcomes in 29 NSTI patients treated with surgery and antibiotics alone versus surgery, antibiotics and HBOT. Mortality in the HBOT group was 23% versus 66% in the non-HBOT group — a statistically significant reduction. The HBOT group also required fewer surgical debridements per patient. [Riseman JA et al. Surgery. 1990;108(5):847–850. PMID: 2237764]
Wilkinson and Doolette — systematic review (2004): Wilkinson and Doolette conducted a systematic review in ANZ Journal of Surgery of HBOT for NSTIs, examining multiple case series and the Riseman controlled study. They concluded that the evidence supports a clinically significant reduction in mortality with adjunctive HBOT, with a particularly strong signal for Fournier's gangrene cases. [Wilkinson D, Doolette D. ANZ J Surg. 2004;74(3):159–161. PMID: 15018383]
Korhonen et al. — Fournier's gangrene study (2000): Korhonen and colleagues published a study in Journal of Trauma evaluating HBOT in Fournier's gangrene patients, finding that adjunctive HBOT significantly reduced tissue loss and mortality compared to surgery and antibiotics alone, with the HBOT group requiring an average of 3.3 debridements versus 4.5 in the non-HBOT group. [Korhonen K et al. J Trauma. 2000;48(6):1031–1035. PMID: 10866247]
Tissue demarcation and surgical precision: Multiple surgical case series report that HBOT helps demarcate viable from non-viable tissue, enabling more precise debridement that reduces unnecessary tissue sacrifice. This effect — attributed to HBOT restoring perfusion in marginally viable tissue surrounding the necrotic zone — may reduce long-term reconstructive complexity and functional loss.
UHMS approval: NSTIs including necrotizing fasciitis and Fournier's gangrene are approved indications for HBOT by both the Undersea and Hyperbaric Medical Society and Medicare, reflecting the strength of the evidence base supporting adjunctive HBOT in these conditions.
Our NSTI treatment protocol at Bay Area Hyperbarics
HBOT is an adjunct to surgery and antibiotics in NSTIs — never a replacement. We coordinate care closely with your surgical and infectious disease teams and refer hemodynamically unstable patients to our hospital partners for emergency management.
Surgical and infectious disease team coordination
HBOT for NSTIs is initiated in close coordination with your surgical team. Our medical team assesses the infection extent, organism profile and current resuscitation status to confirm your case is appropriate for adjunctive HBOT at our clinic setting. Hemodynamically unstable patients are coordinated with our hospital partners.
High-pressure oxygen sessions to eliminate bacteria and control infection
You breathe 100% oxygen at 2.4 to 3.0 atmospheres absolute for approximately 90 minutes per session. Acute NSTIs typically require two to three sessions per day in the early post-surgical phase, transitioning to once daily as infection is controlled and wound healing progresses.
Wound healing support and reconstruction preparation
As infection control is achieved, HBOT transitions to supporting wound healing — stimulating granulation tissue formation and preparing the debridement wound for reconstruction or split-thickness skin grafting. Total treatment spans two to four weeks depending on wound extent and healing response.
Frequently Asked Questions
Answers to the questions patients and families most often ask about HBOT for necrotizing soft tissue infections.
Yes. NSTIs are true surgical emergencies with mortality rates of 20 to 40%. Every hour of delay in surgical debridement increases mortality significantly. If you suspect an NSTI, call 911 or go to the nearest emergency room immediately. Once the patient is surgically stabilized, contact us to discuss adjunctive HBOT as part of the post-operative care plan.
Recovering from an NSTI? Contact Bay Area Hyperbarics today
Bay Area Hyperbarics provides adjunctive HBOT for necrotizing soft tissue infections in coordination with your surgical and infectious disease teams. Severe or hemodynamically unstable cases are coordinated with our hospital partners. Call us to discuss your situation.
