Clostridial sepsis: unusual clinical presentations.

We present four cases exhibiting the widely diverse nature of clinical infections due to anaerobic Clostridium perfringens. These cases exemplify the need for a thorough initial physical examination, immediate Gram staining of fluid from involved tissue, and recognition of the severity of the disease in any patient who has early septic deterioration after elective or emergency surgical procedures. Management of these infections includes both high-dose parenteral penicillin therapy and aggressive initial surgical debridement of all involved tissues.

Contaminated street heroin. Relationship to clinical infections.

Thirty-one samples of street heroin were analyzed bacteriologically and chemically as to their microbial burden and chemical adulterants (fillers). Sixty-one percent of the samples were positive for microbial growth. Many species were isolated from the positive samples with Bacillus sp (79%) and Aspergillus sp (10%) predominating. The level of contamination ranged from 1.6 X 10(2) to 3.7 X 10(4) organisms per gram. We obtained cultures from 16 addicts from the Chicago area and 21 from the New Orleans area who had soft-tissue infections related to their habit. Infections in this group of patients were usually polymicrobial; however, there was no correlation between the organisms recovered from street heroin and the addicts' infections. Most drug-related infections appear to be related to the addicts' own oral and dermal microflora. No correlation was observed between the chemical fillers and the bacteria recovered from the heroin.

Severe systemic sepsis resulting from neglected perineal infections.

Eleven patients with severe necrotizing fasciitis involving the soft tissues and muscles of the perineum, abdominal wall, buttocks, and thighs were treated on the Tulane Surgical Service in New Orleans between 1979 and 1981. The etiologic factor in ten of these patients was a neglected or inadequately drained perirectal abscess. Three of the 11 patients died of the disease and ensuing multiple organ failure, for a mortality of 27%. All of the patients had signs of systemic sepsis. Initial radical debridement of all involved tissues, diverting colostomy, and aggressive medical support of the multisystem failure that ensues from sepsis are essential for successful management. To decrease the prohibitive mortality, early treatment is essential. A preventive measure appears to be operative drainage under adequate anesthesia of all perirectal abscesses.

Intra-abdominal sepsis.

Initially, intra-abdominal contamination with endogenous bacteria produces peritonitis and septicemia. If the infection is localized and the patient survives, the late phase is usually abscess formation. Treatment consists of prompt, thorough surgical drainage, with repair of the diseased or traumatized viscera, as well as the use of preoperative, intraoperative and postoperative antibiotics aimed at both aerobic and anaerobic infecting microflora.