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* This is the Professional Version. *

Clostridial Intra-abdominal and Pelvic Infections

By Joseph R. Lentino, MD, PhD

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Patient Education

Clostridia, primarily Clostridium perfringens, are common in mixed intra-abdominal infections due to a ruptured viscus or pelvic inflammatory disease.

Clostridial infections of the abdomen and pelvis are serious and sometimes fatal.

Clostridium sp are common residents of the GI tract and are present in many abdominal infections, generally mixed with other enteric organisms. Clostridia are often the primary agents in the following:

  • Emphysematous cholecystitis

  • Gas gangrene of the uterus (which may occur after delivery and was previously common in patients who had a septic abortion)

  • Certain other female genital tract infections (tubo-ovarian, pelvic, and uterine abscesses)

  • Infection after perforation in colon carcinoma

The primary organisms are C. perfringens and, in the case of colon carcinoma, C. septicum. The organism produces exotoxins (lecithinases, hemolysins, collagenases, proteases, lipases) that can cause suppuration. Gas formation is common. Clostridial septicemia may cause hemolytic anemia because lecithinase (α-toxin) disrupts RBC membranes. With severe hemolysis and coexisting toxicity, acute renal failure can occur.

Symptoms and Signs

Symptoms are similar to those of other abdominal infections (eg, pain, fever, abdominal tenderness, a toxic appearance). Patients with a uterine infection may have a foul-smelling, bloody vaginal discharge, and gas sometimes escape through the cervix. Rarely, acute tubular necrosis develops.

Sepsis

Sepsis may be a complication of intra-abdominal or uterine clostridial infections. Initial symptoms can include fever, chills, vomiting, diarrhea, abdominal pain, hypotension, tachycardia, jaundice, cyanosis, and oliguria.

In 7 to 15% of patients with sepsis due to C. perfringens, acute massive intravascular hemolysis occurs. These patients have jaundice and red-tinged serum and urine. Spherocytes, ghost cells, and sometimes C. perfringens can be seen in a stained blood smear. Blood cultures are positive for C. perfringens.

Clostridial sepsis may result in multiorgan failure, which is frequently fatal, often within 24 h of hospital admission.

Diagnosis

  • Gram stain and culture

Early diagnosis requires a high index of suspicion. Early and repeated Gram stains and cultures of the site, pus, lochia, and blood are indicated. Because C. perfringens can occasionally be isolated from healthy vagina and lochia, cultures are not specific.

X-rays may show local gas production (eg, in the biliary tree, gallbladder wall, or uterus).

Treatment

  • Surgical debridement

  • High-dose penicillin

Treatment is surgical debridement and penicillin G 5 million units IV q 6 h for at least 1 wk. Organ removal (eg, hysterectomy) may be necessary and can be lifesaving if debridement is insufficient.

If acute tubular necrosis develops, dialysis is needed.

The usefulness of hyperbaric O2 has not been established.

* This is the Professional Version. *