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