- See Clostridium Dificile
- Tetanus Prone Wounds
- (see tetanus prophylaxis)
- greater than 8-24 hrs from injury to treatment
- barnyard contamination (bite wounds are considered moderate risk);
- devitalized tissue;
- Clostridium perfringes:
- is a non-motile gram positive, anaerobic bacillus without spores;
- it is the most important cause of gas gangrene
- it is an obligate anaerobe and cannot multiple in healthy tissues with high oxygen reduction potentials;
- factors required to establish a clostridial infection are ischemia, and necrosis of muscle tissue
- i.e., w/ decreased oxidation-reduction potential;
- Anaerobic cellulitis:
- due to clostridial species usually occurs in pts who have devitalized subcutaneous tissues;
- anaerobid cellulitis necrotizing fasciitis is a clostridial infection of ischemic tissue, usually occuring after several days, in an inadequately debrided wound;
- clostridium perfringens and other clostridial species thrive in dirty or inadequately debrided wounds;
- clostridial cellulitis occurs after inadequately debrided trauma when bacteria proliferate in already necrotic tissue;
- incubation period may be delayed for 1-2 days, however, once the infection begins it may spread rapidly;
- typically there will be crepitus caused by gas in the tissues, but systemic symptoms, local pain, and blebs are not seen;
- there is a thin foul discharge from flat blebs of the skin without systemic signs of toxicity;
- gas formation is foul smelling and abundant, but there remains no actual muscle invasion;
- diagnosis of clostridial myonecrosis has an unfavorable prognosis;
- gram-stained smear of discharge usually shows PMNs and numerous large, blunt gram-positive bacilli;
- diff dx:
- bacteroides infection:
- this type of cellulitic infection is distinguished from clostridial infection by presence of systemic toxicity and bullae, and by the presence of gram negative bacteria on the gram stain;
- Clostridial Myonecrosis / Gas Gangrene:
- caused by C.perfringens, novyi, and septicum, C. histolyticum, C. septicum, C. novyi, C. bifermentans
- gm pos spore forming bacilli that are found in the soil and can be part of the normal bowel flora;
- hence fecal contamination of a surgical wound can cause gas gangrene
- buttocks, thighs, and perineum are common sites of infection;
- also may follow septic abortion and in infected vascular dz;
- clostridia are obligate anaerobes surviving in environment as spores that are not readily killed by disinfectants;
- when innoculated into normal muscle they are not able to germinate because of the high oxygen tension;
- w/ divitalized tissue the spores germinate, and the bacteria produces toxins that create the high mortality from clostridial myonecrosis;
- clinical features: ecchymosis, necorsis, edematous skin, dark red serous fluid, and numerous gas filled vesicles and bullae;
- intense pain out of proportion to the wound is characteristic;
- within hours signs of systemic toxicity appear, including confusion, tachycardia, sweating, ect;
- infection may progress upto 10 cm per hour;
- gas gangrene is a clinical diagnosis: a gram stain does not establish dx, because the organism can be present without causing disease;
- alpha toxin of C. perfringes may cause shock and massive renal failure
- differential diagnosis: myonecrosis or necrotizing cellulitis;
- anaerobic streptococcal myositis, infected vascular gangrene, necrotizing fasciitis, and anaerobic cellulitis;
- culture: development of double zones of hemolysis when C. perfringes is grown on blood agar plates;
- gram stain may show huge numbers of large gram positive rods and virtually no neutrophils;
- check CPK levels as rising levels may prewarn of sepsis;
- radiographs: gas in the soft tissues;
- most of the species of clostridia produce large amounts of CO2 and hydrogen, and this accounts for crepitation of the wound and the radiologic appearance of gas in the soft tissues;
- Antibiotic Treatment:
- clindamycin, metronidazole, and rifampin;
- least effective: aqueous penicillin (IV) in a dosage of 10 to 20 million units/24hrs
Clostridium difficile infection in orthopaedic patients.
Nonclostridial gas gangrene. Report of 48 cases and review of the literature.
Gas gangrene and related infection: classification, clinical features and aetiology, management and mortality. A report of 88 cases.
Proceedings: Nonclostridial gas-forming infections. A collective review and report of seven cases.
Bacteriology of necrotizing fasciitis.
Susceptibility of Clostridium perfringens isolated from human infections to twenty antibiotics.
Effect of antibiotics on toxin production and viability of Clostridium perfringens.
Comparison of clindamycin, rifampin, tetracycline, metronidazole, and penicillin for efficacy in prevention of experimental gas gangrene due to Clostridium perfringens.