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Clostridial Intra-abdominal Infections
Clostridia, primarily Clostridium perfringens, are common in mixed intra-abdominal infections due to a ruptured viscus or pelvic inflammatory disease.
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 emphysematous cholecystitis, gas gangrene of the uterus (previously common with septic abortion), certain other female genital tract infections (tubo-ovarian, pelvic, and uterine abscesses), and 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 disrupts RBC membranes. With severe hemolysis and coexisting toxicity, acute renal failure can occur.
Symptoms are similar to those of other abdominal infections (eg, pain, fever, abdominal tenderness, a toxic appearance). In uterine infection, gas sometimes escapes through the cervix. Rarely, acute tubular necrosis develops.
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 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 O 2 has not been established.
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