Clostridium Perfringens

In food poisoning and non-foodborne diarrheal disease, a history and physical can help to identify the causative agent and help to create a differential. The onset of symptoms is typically 8-16 hours after consuming raw or undercooked meat or poultry. The patient will often have a combination of diffuse abdominal pain, profuse watery non-bloody diarrhea, and vomiting.

Rarely, these patients can present with abdominal sepsis that may manifest with hypotension, tachycardia, and abnormal thermal homeostasis. In addition to hemodynamic instability, there will likely be signs of abdominal distention with tenderness, a rigid hypertympanic abdomen, and altered mental status. These signs are indicative of a medical and surgical emergency.

Clostridial myonecrosis (gas gangrene) typically occurs after an injury (traumatic) but can develop spontaneously in patients with ischemic vascular disease or diabetes(non-traumatic). The patients present with cellulitis at the site of infection, fever, and chills. The wound has edema, tenderness, and bullae that can have a discharge with a musty odor. Symptoms are disproportionately dominant compared to signs. Infection of the deeper tissues results in necrosis of subcutaneous fat, muscle, or nerves. Symptoms can rapidly progress to septic shock, disseminated intravascular coagulation, and acute respiratory distress syndrome, which is associated with very high mortality.[18][19]

In suspected C. perfringens infections, stool studies should be performed, which include stool culture and ELISA testing for CPA toxin. Often stools studies will also include WBCs, ova, and parasites to help rule out other etiologies. In more severe clostridial infections, imaging will be warranted to help identify the affected tissue.

An outbreak of foodborne disease is defined as the “occurrence of two or more cases of a similar illness from ingestion of a common food.”[4] Outbreak data, including the number of illnesses, hospitalizations, and mortality, should be reported to the local public health department and the Centers for Disease Control and Prevention.

In cases of clostridial myonecrosis, imaging such as an x-ray or CT scan of the affected area should be obtained in addition to blood tests, which include a CBC, CMP, blood culture, CK level, ABG, and lactic acid.

Since most C. perfringens-associated acute diarrheal disease is self-limiting, only supportive care is needed to maintain a euvolemic state. Antibiotics are generally not indicated.

The exception is clostridial sepsis, which is a medical emergency. Clostridial sepsis often presents in septic shock with possible intravascular hemolysis due to CPA-mediated destruction of red blood cells. In this situation, early antibiotic treatment with penicillin G and clindamycin, tetracycline, or metronidazole in combination with surgical debridement of necrotic tissue may help to prevent death.[20][21] These patients will likely be refractory to medical therapy unless source control is achieved.

A suspicion of clostridial myonecrosis warrants a surgical consultation. Consultation should not be delayed waiting for laboratory or imaging results. Broad-spectrum antibiotics should be promptly administered. In addition, hyperbaric oxygen is shown to improve outcomes in cases of severe infection.

Acute infectious diarrhea

• Norovirus
• Salmonella
• Campylobacter
• Staphylococcus aureus
• Escherichia coli producing Shiga toxin

Abdominal sepsis

• Appendicitis
• Infectious colitis
• Ischemic colitis
• Perforated peptic ulcer
• Pancreatitis

Clostridial cellulitis/myonecrosis

• Escherichia coli
• Klebsiella
• Streptococcus pyogenes
• Staphylococcus aureus
• Anaerobic bacteria: Bacteroides and Peptostreptococcus

The majority of cases of food poisoning and non-foodborne diarrheal disease are self-limiting. Those who are hospitalized need fluid resuscitation and advancing diet when tolerated. Generally, the prognosis is good. On the other hand, clostridial myonecrosis and sepsis are medical emergencies with a guarded prognosis. Early recognition and treatment, including surgical debridement, are vital. Even with appropriate treatment, the mortality rate is 20-30%, while without treatment, the mortality rate is 100%.[18]

The majority of cases from food poisoning and non-foodborne diarrheal disease have minimal to no complications if volume status is adequately managed. However, the bloodstream infection can result in toxin-mediated intravascular hemolysis and septic shock. Clostridial myonecrosis may require extensive debridement, amputation, and complications of severe sepsis, including shock, encephalopathy, acute respiratory distress syndrome, and death.

A consultation from general surgery and infectious disease specialists should be considered in the evaluation of C. perfringens associated infections.

Most of the food poisoning and non-foodborne diarrheal diseases from C. perfringens is due to undercooked meat or poultry. Therefore, patient education regarding food safety protocols is essential for preventing and limiting the spread of disease. Patients with risk factors such as diabetes or vascular disease must not delay seeking medical attention in the event of cellulitis or trauma due to an increased risk of severe infection and rapid progression.

Infection with C. perfringens is often a benign self-limiting disease that is treated with fluid resuscitation. However, patients can present with or develop septic shock with myonecrosis, which will require antibiotics, blood pressure support, and surgical intervention. It is essential to educate the healthcare team to be vigilant so that rapid diagnosis and treatment can be initiated. An interprofessional team of physicians, surgeons, radiologists, nurses, pharmacists, and physical therapists is needed to care for the patient. Also, the healthcare team can model effective communication to provide early detection of possible C. perfringens-mediated outbreaks and ensure that the necessary public health departments are aware to minimize spread. [Level 4]