Surgical infection
Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie in Bailey & Love's Short Practice of Surgery, 2018
Gas gangrene is caused by C. perfringens. These gram-positive, anaerobic, spore-bearing bacilli are widely found in nature, particularly in soil and faeces. This infection is particularly relevant to military and trauma surgery. Patients who are immunocompromised, diabetic or have malignant disease are at greater risk, particularly if they have wounds containing necrotic or foreign material, resulting in anaerobic conditions. Military wounds provide an ideal environment as the kinetic energy of high-velocity missiles or shrapnel causes extensive tissue damage. The cavitation which follows passage of a missile through the tissues causes a ‘sucking' entry wound, leaving clothing and environmental soiling in the wound in addition to devascularised tissue. Gas gangrene wound infections are associated with severe local wound pain and crepitus (gas in the tissues, which may also be visible on plain radiographs). The wound produces a thin, brown, sweet-smelling exudate, in which Gram staining will reveal bacteria. Oedema and spreading gangrene follow the release of collagenase, hyaluro- nidase, other proteases and alpha toxin. Early systemic complications with circulatory collapse and organ failure follow if prompt action is not taken.
Malignant Neoplasms of the Colon
Philip H. Gordon, Santhat Nivatvongs, Lee E. Smith, Scott Thorn Barrows, Carla Gunn, Gregory Blew, David Ehlert, Craig Kiefer, Kim Martens in Neoplasms of the Colon, Rectum, and Anus, 2007
Panwalker (328) found 55 patients with the dramatic clinical presentation of gas gangrene associated with colorectal carcinoma (16 of which were cecal). The gas gangrene was metastatic in 10 patients. Sites included the neck, chest wall, upper extremities, shoulders, and axilla. Kudsk (335) subsequently reported five cases of painful, rapidly spreading gas-producing infection of the lower extremity (three cases), upper extremity (one), and pelvis (one), which represented metastatic C. septicum infections in diabetic patients. All had occult carcinomas of the right colon. More recently, Lorimer and Eldus (336) reported three cases of invasive C. septicum infection associated with colorectal carcinoma. The authors cited a previous review of 162 cases of nontraumatic C. septicum infection identified-malignant disease in 81%, approximately half of which were colorectal. The carcinoma is typically right sided and always ulcerated, which can occur in three circumstances: occult carcinoma (80%), anastomotic recurrence, or carcinoma that is unresectable or has been bypassed. In summary, gas gangrene associated with colorectal carcinoma is a catastrophic illness that appears to be clostridial, affects diabetic patients disproportionately, and, in almost 50% of cases, is the result of an otherwise silent cecal carcinoma.
Orthopaedics
Roy Palmer, Diana Wetherill in Medicine for Lawyers, 2020
An open fracture is serious as it exposes the bone to the risk of infection; therefore, an exposed bone should be covered by a sterile dressing at the accident site, and antibiotics should be given to the patient as soon as possible. After the ATLS stabilization (see above) the patient should be taken to the main operating theatre and under anaesthetic and ideal circumstances the wound should be explored, thoroughly cleaned, and all dead tissue (such as skin and muscle) removed. This last procedure is essential because anaerobic bacteria, which live without oxygen, can grow in this tissue; the organism causing gas gangrene is such a bacterium. The surgeon knows when enough tissue has been removed as the cut edges of healthy tissue bleed. Once this stage is complete the fracture is reduced under direct vision and the skin is closed. Skin grafting may be required if debridement leaves a large defect. If the fracture is a closed fracture then the above procedures are unnecessary. If the fracture is displaced it should be reduced and returned to its normal alignment—this should be undertaken under appropriate anaesthesia, general or local, using an image intensifier.
Clostridium perfringens: a rare cause of spondylodiscitis case report and review of the literature
Published in British Journal of Neurosurgery, 2018
M. Seller, R.D. Burghardt, T. Rolling, N. Hansen-Algenstaedt, C. Schaefer
Clostridia are ubiquitous gram-positive anaerobic spore-forming rods found in human and animal gastrointestinal tracts and female genital tracts, as well as in water and soil. Clostridium perfringens is most commonly known as a cause of traumatic gas gangrene. But Clostridium species have also been shown to be an unusual cause of tissue infection and bacteremia. The most common source of infection appears to be the gastrointestinal tract – due to diverticulosis or other gastrointestinal pathologies.1 Furthermore, Clostridium bacteremia occur mainly in patients with multiple comorbidities, most commonly with diabetes or underlying malignancy.1 The prognosis of clostridial bacteremia is mainly determined by the severity of these underlying comorbidities.1 Up to now, no case of involvement of the vertebral body in a Clostridium perfringens infection has been described. Regarding the literature only six cases of a spondylodiscitis caused by Clostridium perfringens have been published.2 Two of them developed in course of a spinal surgical intervention. One case came along with a sever gastrointestinal infection with development of a paralytic ileus. In three cases the portal of entry was unknown only in one of these cases the patient suffered from a concomitant chronic hepatitis treated with 60 mg of Prednisolon.2,3 Despite the iatrogenic cases the remaining four2,3 were successfully treated by antimicrobial therapy alone, mostly with penicillin or a β-lactam-antibiotic for between 3 to 12 weeks.
Direct Gram staining and its various benefits in the diagnosis of bacterial infections
Published in Postgraduate Medicine, 2018
The DGS is of particular importance in cases of suspected gas gangrene that requires emergent surgical and empirical antibiotic treatment [30]. The most common causative agent of the rare but rapidly progressing and life-threatening infection, Clostridium perfringens, shows large boxcar-shaped square gram-positive rods without visible spores [30,40]. However, in contrast to other infections, in the case of gas gangrene, no PMNs are visible because of the powerful toxigenic and enzymatic activities of the clostridia [30,41].
Bacterial infection during wars, conflicts and post-natural disasters in Asia and the Middle East: a narrative review
Published in Expert Review of Anti-infective Therapy, 2020
Tania Nawfal Dagher, Charbel Al-Bayssari, Seydina M. Diene, Eid Azar, Jean-Marc Rolain
In a post-conflict situation, TB is considered the most important treat in refugee settings. Factors that increase the disease problem include the displacement of the population, poor access to healthcare facilities and disruption of on-going treatment or control programs. After the Earthquake of Great East Japan that occurred in 2011, several studies have reported the increasing frequency of TB [146–148], which was due to different factors, such as the overcrowded shelters, poor hygiene, and sanitation. Moreover, in 2008, the increasing rates of TB were described in China after the earthquake that hits Wenchuan [149]. Several other reports have described wound infections among patients who were still alive after that earthquake [150–152]. The most common isolated bacteria were A. baumannii, E. coli and S. aureus. During the Wenchuan earthquake, most patients have been covered under ruins with soil, stone or block. Following the rainstorm and high temperatures, the circumstances turned out to be far worse and most of the wounds reported were severely contaminated. On the other hand, the cases of patients affected with gas gangrene caused by earthquakes were rarely described, and no hospitals described the admission of patients suspected of having gangrene gas in the time following the earthquake. In the victims of the Wenchuan earthquake, a study was conducted to examine the clinical characteristics, appropriate treatment and successful control of the nosocomial cross-infection of gas gangrene [153]. The results showed that there were 67 suspected cases of gas gangrene, including 5 positive cases for the presence of Clostridium perfringens, due to the following factors such as serious and long-term injuries (which promote infection) and decreased hygiene in medical centers. The distribution of bacterial infections in countries affected by earthquakes is shown in (Figure 3(d)).