(See also Overview of Anaerobic Bacteria and Overview of Clostridial Infections.)
Clostridial infections of the abdomen and pelvis are serious and sometimes fatal.
Clostridium species are common residents of the gastrointestinal tract and are present in many abdominal infections, generally mixed with other enteric organisms. Clostridia are often the primary agents in the following:
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 necrosis. Gas formation is common. Clostridial septicemia may cause hemolytic anemia because lecithinase (alpha-toxin) disrupts red blood cell membranes. With severe hemolysis, muscle necrosis, and coexisting toxicity, acute renal failure can occur.
Symptoms and Signs
Symptoms of clostridial infections 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 escapes 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 hours of hospital admission.
Diagnosis
Early diagnosis of clostridial infections requires a high index of suspicion. Early and repeated Gram stains and cultures of the site, pus, lochia, and blood are indicated. Gram stain of the wound discharge shows gram-positive rods; polymorphonuclear cells are absent.
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
Treatment of clostridial abdominal and pelvic infections is surgical debridement and penicillin G 5 million units IV every 6 hours for at least 1 week. Alternatively, carbapenems, beta-lactam/beta-lactamase inhibitors, metronidazole, or clindamycin may be used. 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 oxygen has not been established.
Key Points
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Clostridial intra-abdominal and pelvic infections are serious and sometimes fatal.
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Like other abdominal infections, clostridial abdominal infections cause pain, fever, and abdominal tenderness, and patients have a toxic appearance.
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Patients with a clostridial uterine infection may have a foul-smelling, bloody vaginal discharge; gas sometimes escapes through the cervix.
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Early diagnosis of clostridial infections requires a high index of suspicion and early and repeated Gram staining and cultures of the samples from the site and samples of pus, lochia, and blood.
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Treat with surgical debridement and high-dose penicillin or other antibiotics (carbapenems, beta-lactam/beta-lactamase inhibitors, metronidazole, clindamycin).
