Clostridium Species

Microbiology

 C perfringens: Anaerobic, gram positive “box-car shaped” rods

 Microscopically: rod shaped, pleomorphic, in short chains, as
clusters, or in pairs
 If with spores, club-shaped
 With peritrichous flagellae except C. perfringens
 C perfringens: catalase negative, oxidase negative, non H2S
reducer
 Produce neurotoxins, enterotoxins, collagenase, proteases, necrotoxins, lecithinase,
lipase, DNAse, neuraminidase

C. perfringens (Gas Gangrene)

 Traumatic injury that gets contaminated with spores

 Isolated from soil and sediment samples
 Myonecrosis due to exotoxins (lecithinase)

Pathogenesis

 Gas gangrene is most common following traumatic injuries that

result in lowered tissue oxygen tension (crushing/penetrating
injuries, foreign bodies (soil or objects causing penetrating
trauma)
 Contamination of lesions in which vascular insufficiency is
present (diabetic foot ulcers)

Diagnosis and Rx

 Myonecrosis occurs 24 to 72 hours after trauma/surgery

 Severe pain in the abscess of obvious physical findings
 Hemorrhagic bullae may form along with serosanguinous
discharge and “mousy odor”
 Fever minimal in early stages, but may progress to full blown
sepsis rapidly
 Rapid growth on blood agar plates within 12 to 16 hours of
inoculation
 Yellow to gray colonies, opaque, 4 to 8 mm with irregular borders
 Double zone hemolysis: Inner beta hemolysis, outer partial hemolysis
 Lecithinase detected on egg yolk agar – white precipitation surrounding colonies
 Important therapy – debridement of involved tissues
 Early antibiotic with penicillin (other meds: metronidazole, clindamycin, carbapenems)
 Ancillary Rx: hyperbaric oxygen, GCSF injections
Bacteroides Spp

 B fragilis: gram negative, pleomorphic, rods or coccobacilli

 Predominant gram neg anaerobic rods (GNAR) in polymicrobial infections
 B fragilis – circular, white or gray, 2 to 3 mm colonies that are shiny and smooth on
blood agar
 Liquid medium – with bipolar vacuoles showing characteristic “safety pin” appearance
 Vs other GNARs, B fragilis is bile tolerant thus growing in Bile Esculin Agar
 B fragilis – highly resistant to Kanamycin, Vancomycin, Colistin

Skin and Soft tissue infection

 Infection following intraabdominal or

gynecologic surgery
 Pilonidal cysts and sacral decubitus ulcers
contaminated by feces
 B fragilis, frequently cultured from decubitus
ulcers in both elderly and pediatric populations
as well as foot ulcers from patients with
peripheral vascular disease or diabetes
Treatment

 Beta lactamase with Beta lactamase inhibitors (ticarcillin-clavulanate or piperacillin-

tazobactam)
 Carbapenems (Imipenem, Ertapenem, Meropenem, Doripenem)
 Chloramphenicol – excellent in vitro activity but limited use due to toxicity
 Clindamycin 5-35% resistance among B fragilis
 Tigecycline – empiric therapy for complicated skin, soft tissue, intraabdominal infections
 Quinolones – Resistance for Levofloxacin and Ciprofloxacin as high as 50%
 Emerging resistance to metronidazole (nim gene expression)
Actinomyces
Etiologic Agents

 Actinomycoses most commonly caused by A. israelli

 most if not all actinomycotic infections are polymicrobial in nature
Epidemiology

 The agents of actinomycosis have been clearly established as members of the

endogenous flora of mucous membranes. The frequency of oral cavity colonization with
Actinomyces is nearly 100% by 2 years of age. It is also often cultured from the
gastrointestinal tract, bronchi, and female genital tract.
Pathogenesis and Pathology

 A pivotal step in the pathogenesis of actinomycosis is disruption of mucosal or epithelial

barriers enabling entry of colonizing Actinomyces or related genera
 An acute inflammatory phase manifesting with a painful cellulitic reaction is occasionally
observed with oral-cervicofacial disease or with soft tissue infection elsewhere in the
body
 “Classic” disease is characterized by a densely fibrotic lesion that undergoes slow,
contiguous spread that ignores tissue planes
 Lesions usually appear as either single or multiple indurated swellings. Over time,
central fluctuance and suppuration develop. The fibrous walls of the mass have been
characteristically described as “wooden” and, in the absence of suppuration, have been
frequently confused with neoplasms
 Given time, sinus tracts will often extend from the abscess to either the skin or adjacent
organs or bone, depending on the location of the lesion. Sinus tracts can spontaneously
close and then reform. Overlying skin may assume a red to bluish hue.
Microscopic

 Microscopically, lesions have an outer zone of granulation, consisting of collagen fibers

and fibroblasts. There is a central purulent loculation that contains neutrophils that
surround the sulfur granules present. Granules are conglomerations of organisms and
are virtually diagnostic of this disease. Bacterial biofilms may contribute to granule
formation
 Suppuration is a constant feature of active disease but may not be present in all areas of
the lesion.
Musculoskeletal Disease

 Blunt or penetrating trauma, injections, surgery, and hematogenous dissemination from

apparent or cryptic foci are initiating events
 Skin, subcutaneous tissue, muscle, and bone may be involved alone or in various
combinations. Cutaneous sinus tracts or abscesses are present in the majority of cases,
as is bony involvement in the form of periostitis or acute or chronic osteomyelitis
  A mycetoma (Madura foot) is an indolent soft tissue infection, usually of the foot, that
progresses over months to years. Bacteria or fungi are introduced from soil or vegetation
into the soft tissue by minor trauma
Diagnosis

 The single most helpful diagnostic maneuver for actinomycosis is the demonstration of
sulfur granules—a microscopic or macroscopic in vivo matrix of bacteria, calcium
phosphate, and host material—in pus via cytopathologic evaluation
 Microscopically, granules are round, oval, or horseshoe shaped. Although bacilli within
the granule are rarely visible with hematoxylin-eosin stain, the use of tissue Gram stains,
Gomori methenamine silver, and Giemsa stains will demonstrate gram-positive,
filamentous, branching bacteria at its periphery
 On hematoxylin-eosin stain the granules may be eosinophilic or variably surrounded by
a radiating fringe of eosinophilic clubs. This eosinophilic, proteinaceous coating around
organisms in tissue has been called the Splendore-Hoeppli phenomenon
Treatment