Bacteria

Clostridium perfringens

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Clostridium perfringens, Gas Gangrene, Anaerobic Cellulitis, Clostridial Myonecrosis

  • See also
  1. Cellulitis
  2. Necrotizing Soft Tissue Infection
  3. Toxic Shock Syndrome
  4. Clostridium
  • Pathophysiology
  1. Clostridia are anaerobic, spore forming, non-motile Gram Positive Rods
    1. Germinate, mature, reproduce and release exotoxin under anaerobic conditions
  2. Tissue infection with gas-producing Anaerobic Bacteria (also occurs with Type I Necrotizing Fasciitis)
  3. Typically caused by penetrating Skin Injury with compromised soft tissue vascular supply and necrosis
    1. Resulting anaerobic environment allows for spore germination and Bacterial growth
  • Causes
  • Clostridial Myonecrosis (Gas Gangrene)
  1. Clostridium perfringens or Clostridium welchii (Traumatic source)
    1. Clostridium perfringens colonizes soil
  2. Clositridium septicum (spontaneous source without skin break)
  3. Clostridium sordellii (gynecologic source)
  4. Other organisms
    1. Clostridium species may also cause a more subacute anerobic Cellulitis
    2. Clostridium novyi
    3. Clostridium histolyticum
  • Types
  • Clostridium perfringens Infections
  1. Wound Infections
    1. Clostridium perfringens germinates and matures in necrotic, devitalized, anaerobic tissue
  2. Clostridial Myonecrosis
    1. Wound Infections may track along Muscles and subcutaneous tissue
    2. Results in Muscle breakdown (myonecrosis) and black fluid discharge
  3. Food Poisoning
    1. Among the most common causes of Food Poisoning in the U.S. with a typically benign course
      1. Incidence (U.S.): 970,000 cases with 440 hospitalizations and 26 deaths (0.0027% mortality) per year
    2. Ingested Clostridium perfringens causes watery Diarrhea (with fever, Headache) via in-vivo toxin production
    3. Most cases have onset 6-16 hours after ingestion and self-resolve by 24 hours
      1. However, a severe variant causes hemorrhagic necrosis of the jejunum
    4. Sources
      1. Pre-cooked meats
      2. Dried foods
      3. Meats or gravy
      4. Poultry
  • Findings
  1. See Necrotizing Soft Tissue Infection
  2. Skin Wound progression
    1. History of deep contaminated wound (Surgery, Trauma)
    2. Onset Sudden pain at wound site
    3. Local swelling and edema of wound site
    4. Thin hemorrhagic exudate
  3. Toxemia
  4. Severe Hypotension
  5. Renal Failure
  6. Fever
  7. Foul discharge from wound
  8. Subcutaneous crepitus
  • Labs
  1. See Necrotizing Soft Tissue Infection
  2. Complete Blood Count (CBC)
    1. Hemoconcentration
      1. Hematocrit may increase to 50-80%
    2. Marked Leukocytosis
      1. Leukemoid Reaction may occur with increased White Blood Cell Count to 50,000 to 150,000/mm3
  3. Wound smear
    1. Gram Positive encapsulated rods
  • Imaging
  1. See Necrotizing Soft Tissue Infection
  2. Gas in fascial plains
  • Differential Diagnosis
  1. See Necrotizing Soft Tissue Infection
  • Management
  1. See Necrotizing Fasciitis
  2. Extensive, early surgical Debridement
  3. Consider hyperbaric oxygen chamber
  4. Antibiotics are typically broader to start to cover Necrotizing Fasciitis in general
  5. Primary protocol for specific Clostridium coverage
    1. Clindamycin 900 mg IV every 8 hours (reduces toxin production) AND
    2. Penicillin G 24 Million Units daily divided every 4 to 6 hours
  6. Alternative Antibiotics for specific Clostridium coverage
    1. Ceftriaxone 2 g IV every 12 hours OR
    2. Erythromycin 1 gram every 6 hours IV infusion
  7. Other Antibiotics options (check sensitivity first)
    1. Chloramphenicol 4 g daily
    2. Metronidazole
  • References
  1. (2021) Sanford Guide, IOS, accessed 3/5/2021
  2. Khidir and Eyre (2021) Crit Dec Emerg Med 34(10): 12-3
  3. Stevens (2014) Clin INfect Dis 59(2): 147-59 +PMID:24947530 [PubMed]
  4. Stevens (2017) N Engl J Med 377(23):2253-65 +PMID:29211672 [PubMed]