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Overview of Clostridial Infections

By Joseph R. Lentino, MD, PhD, Loyola University Stritch School of Medicine;Hines VA Hospital

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Clostridia are spore-forming, gram-positive bacilli present widely in dust, soil, and vegetation and as normal flora in mammalian GI tracts.

Nearly 100 Clostridium sp have been identified, but only 25 to 30 commonly cause human or animal disease.

Pathophysiology

The pathogenic species produce tissue-destructive and neural exotoxins that are responsible for disease manifestations. Clostridia may become pathogenic when tissue O2 tension and pH are low. Such an anaerobic environment may develop in ischemic or devitalized tissue, as occurs in primary arterial insufficiency or after severe penetrating or crushing injuries. The deeper and more severe the wound, the more prone the patient is to clostridial infection, especially if there is even minimal contamination by foreign matter.

Clostridial disease can also occur after injection of street drugs.

Serious noninfectious disease can occur after ingestion of home-canned foods in which clostridia have produced toxins.

Diseases Caused by Clostridia

Diseases caused by clostridia (see Table: Selected Conditions Associated With Clostridial Infections) include

Selected Conditions Associated With Clostridial Infections

Condition

Agent

Toxin

Soft-tissue infection

Crepitant cellulitis, myositis, clostridial myonecrosis, hemolysis

C. perfringens

α-Toxin (phospholipase C), θ-toxin, others

Gas gangrene, tissue necrosis, hemolysis

C. septicum

α-Toxin, β-toxin, hyaluronidase γ-toxin, septicolysin δ-toxin

Enteric diseases

Food poisoning

C. perfringens type A

Enterotoxin

Enteritis necroticans

C. perfringens type C

β-Toxin

Antibiotic-associated colitis

C. difficile

Toxin A or B or C. difficile binary toxin (CDT)

Neutropenic enterocolitis

C. septicum, others

Unknown, possibly β-toxin

Colorectal cancer

C. septicum

Abdominal infections: Cholecystitis, peritonitis, ruptured appendix, bowel perforation

C. perfringens , C. ramosum, many others

β-Toxin*

Neurologic syndromes

Tetanus

C. tetani

Tetanospasmin

Botulism

C. botulinum

Botulinal toxins A–H

*β-Toxin is produced by C. perfringens type C, but most of these infections are caused by C. perfringens type A, which does not produce β-toxin.

The most frequent clostridial infection is minor, self-limited gastroenteritis, typically due to C. perfringens type A. Serious clostridial diseases are relatively rare but can be fatal.

Abdominal disorders, such as cholecystitis, peritonitis, ruptured appendix, and bowel perforation can involve C. perfringens, C. ramosum, and many others.

Muscle necrosis and soft-tissue infection, which is characterized by crepitant cellulitis, myositis, and clostridial myonecrosis, can be caused by C. perfringens.

Skin and tissue necrosis can be caused by bloodborne C. septicum from the colon.

Clostridia also appear as components of mixed flora in common mild wound infections; their role in such infections is unclear.

Hospital-acquired clostridial infection is increasing, particularly in postoperative and immunocompromised patients. Severe clostridial sepsis may complicate intestinal perforation and obstruction.

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