Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point-of-care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors and editors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

Choose from the list below to learn more about subscriptions for a:


Subscribers log in here


Toxic shock syndrome due to Clostridium sordellii

INTRODUCTION

Clostridium sordellii is part of the normal flora of the vagina and may gain entry to the uterus via the cervix during spontaneous or induced abortion, childbirth, or menstruation. C. sordellii is a cause of toxic shock syndrome associated with gynecologic procedures, childbirth, and abortion (including spontaneous, surgical, and medical abortion) [1-6]. C. sordellii toxic shock (CSTS) is an uncommonly reported condition with a limited number of case reports and small case series.

The epidemiology, microbiology, pathogenesis, clinical manifestations, diagnosis, and management of CSTS syndrome will be reviewed here. Other issues related to clostridial myonecrosis are discussed separately. (See "Clostridial myonecrosis".)

EPIDEMIOLOGY

C. sordellii can be found in soil, sewage, and the gastrointestinal tracts of humans and animals [7]. C sordellii has been identified in the gastrointestinal tracts of 0.5 percent of humans [8].

Healthy women can harbor clostridial species in the vagina. Clostridium perfringens is the most common clostridial species (4 to 18 percent of healthy women); C. sordellii is less common (0.5 to 10 percent of healthy women) [8-10]. Clostridial vaginal colonization following abortion has been observed in up to 29 percent of women [10]. Similarly, fecal vaginal contamination during or after childbirth could be the source of C. sordelli infection [8].

The incidence of C. sordellii toxic shock (CSTS) is unknown; one review of death certificates suggested that CSTS was the cause of 1 in 200 deaths among young women of childbearing age [6].

                  

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Aug 2014. | This topic last updated: Sep 18, 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
References
Top
  1. Smith LDS. Clostridium sordelli. In: The pathogenic anaerobic bacteria, 2, Charles C Thomas Publishing, Springfield 1975. p.291.
  2. McGregor JA, Soper DE, Lovell G, Todd JK. Maternal deaths associated with Clostridium sordellii infection. Am J Obstet Gynecol 1989; 161:987.
  3. Centers for Disease Control and Prevention (CDC). Clostridium sordellii toxic shock syndrome after medical abortion with mifepristone and intravaginal misoprostol--United States and Canada, 2001-2005. MMWR Morb Mortal Wkly Rep 2005; 54:724.
  4. Fischer M, Bhatnagar J, Guarner J, et al. Fatal toxic shock syndrome associated with Clostridium sordellii after medical abortion. N Engl J Med 2005; 353:2352.
  5. Sinave C, Le Templier G, Blouin D, et al. Toxic shock syndrome due to Clostridium sordellii: a dramatic postpartum and postabortion disease. Clin Infect Dis 2002; 35:1441.
  6. Ho CS, Bhatnagar J, Cohen AL, et al. Undiagnosed cases of fatal Clostridium-associated toxic shock in Californian women of childbearing age. Am J Obstet Gynecol 2009; 201:459.e1.
  7. Foroulis CN, Gerogianni I, Kouritas VK, et al. Direct detection of Clostridium sordellii in pleural fluid of a patient with pneumonic empyema by a broad-range 16S rRNA PCR. Scand J Infect Dis 2007; 39:617.
  8. Aldape MJ, Bryant AE, Stevens DL. Clostridium sordellii infection: epidemiology, clinical findings, and current perspectives on diagnosis and treatment. Clin Infect Dis 2006; 43:1436.
  9. Goplerud CP, Ohm MJ, Galask RP. Aerobic and anaerobic flora of the cervix during pregnancy and the puerperium. Am J Obstet Gynecol 1976; 126:858.
  10. Bartlett JG, Onderdonk AB, Drude E, et al. Quantitative bacteriology of the vaginal flora. J Infect Dis 1977; 136:271.
  11. FDA Advisory http://www.fda.gov/drugs/drugsafety/publichealthadvisories/ucm051298.html (Accessed on April 19, 2010).
  12. Greene MF. Fatal infections associated with mifepristone-induced abortion. N Engl J Med 2005; 353:2317.
  13. Soper DE. Abortion and clostridial toxic shock syndrome. Obstet Gynecol 2007; 110:970.
  14. Fjerstad M, Trussell J, Sivin I, et al. Rates of serious infection after changes in regimens for medical abortion. N Engl J Med 2009; 361:145.
  15. Cohen AL, Bhatnagar J, Reagan S, et al. Toxic shock associated with Clostridium sordellii and Clostridium perfringens after medical and spontaneous abortion. Obstet Gynecol 2007; 110:1027.
  16. Bangsberg DR, Rosen JI, Aragón T, et al. Clostridial myonecrosis cluster among injection drug users: a molecular epidemiology investigation. Arch Intern Med 2002; 162:517.
  17. Brett MM, Hood J, Brazier JS, et al. Soft tissue infections caused by spore-forming bacteria in injecting drug users in the United Kingdom. Epidemiol Infect 2005; 133:575.
  18. Sosolik RC, Savage BA, Vaccarello L. Clostridium sordellii toxic shock syndrome: a case report and review of the literature. Infect Dis Obstet Gynecol 1996; 4:31.
  19. Wiebe E, Guilbert E, Jacot F, et al. A fatal case of Clostridium sordellii septic shock syndrome associated with medical abortion. Obstet Gynecol 2004; 104:1142.
  20. Hogan SF, Ireland K. Fatal acute spontaneous endometritis resulting from Clostridium sordelli. Am J Clin Pathol 1989; 91:104.
  21. Soper DE. Clostridial myonecrosis arising from an episiotomy. Obstet Gynecol 1986; 68:26S.
  22. Spera RV Jr, Kaplan MH, Allen SL. Clostridium sordellii bacteremia: case report and review. Clin Infect Dis 1992; 15:950.
  23. Bhatnagar J, Deleon-Carnes M, Kellar KL, et al. Rapid, simultaneous detection of Clostridium sordellii and Clostridium perfringens in archived tissues by a novel PCR-based microsphere assay: diagnostic implications for pregnancy-associated toxic shock syndrome cases. Infect Dis Obstet Gynecol 2012; 2012:972845.
  24. Nakamura S, Yamakawa K, Nishida S. Antibacterial susceptibility of Clostridium sordellii strains. Zentralbl Bakteriol Mikrobiol Hyg A 1986; 261:345.
  25. Martinez RD, Wilkins TD. Purification and characterization of Clostridium sordellii hemorrhagic toxin and cross-reactivity with Clostridium difficile toxin A (enterotoxin). Infect Immun 1988; 56:1215.
  26. Tait AS, Dalton M, Geny B, et al. The large clostridial toxins from Clostridium sordellii and C. difficile repress glucocorticoid receptor activity. Infect Immun 2007; 75:3935.
  27. Aldape MJ, Bryant AE, Ma Y, Stevens DL. The leukemoid reaction in Clostridium sordellii infection: neuraminidase induction of promyelocytic cell proliferation. J Infect Dis 2007; 195:1838.
  28. Voth DE, Martinez OV, Ballard JD. Variations in lethal toxin and cholesterol-dependent cytolysin production correspond to differences in cytotoxicity among strains of Clostridium sordellii. FEMS Microbiol Lett 2006; 259:295.
  29. Walk ST, Jain R, Trivedi I, et al. Non-toxigenic Clostridium sordellii: clinical and microbiological features of a case of cholangitis-associated bacteremia. Anaerobe 2011; 17:252.
  30. Buchman AL, Ponsillo M, Nagami PH. Empyema caused by Clostridium sordellii, a rare form of pleuropulmonary disease. J Infect 1991; 22:171.
  31. File TM Jr, Fass RJ, Perkins RL. Pneumonia and empyema caused by Clostridium sordellii. Am J Med Sci 1977; 274:211.
  32. Barnes P, Leedom JM. Infective endocarditis due to Clostridium sordellii. Am J Med 1987; 83:605.
  33. Spindler AJ, Musa H. Clostridium sordelli septic arthritis. J Rheumatol 1987; 14:635.
  34. Matten J, Buechner V, Schwarz R. A rare case of Clostridium sordellii bacteremia in an immunocompromised patient. Infection 2009; 37:368.
  35. Smith C, Goslin B. Clostridium sordellii surgical site infection after breast mass excision: case report. Surg Infect (Larchmt) 2013; 14:160.
  36. Lorber B. Gas gangrene and other Clostridium-associated diseases. In: Principles and Practice of Infectious Diseases, 6th ed, Mandell GL, Bennett JE, Dolin R (Eds), Churchill Livingstone, Philadelphia 2005. p.2828.
  37. Bitti A, Mastrantonio P, Spigaglia P, et al. A fatal postpartum Clostridium sordellii associated toxic shock syndrome. J Clin Pathol 1997; 50:259.
  38. Stevens DL. Clostridial infections. In: Stevens DL, Mandell GL, Atlas of Infectious Diseases (Ed), Churchill Livingstone, Philadelphia 1995. p.13.1.
  39. Beyers R, Baldwin M, Dalabih S, Dalabih A. Clostridium sordellii as a Cause of Fatal Septic Shock in a Child with Hemolytic Uremic Syndrome. Case Rep Pediatr 2014; 2014:237674.
  40. Rørbye C, Petersen IS, Nilas L. Postpartum Clostridium sordellii infection associated with fatal toxic shock syndrome. Acta Obstet Gynecol Scand 2000; 79:1134.
  41. Grimwood K, Evans GA, Govender ST, Woods DE. Clostridium sordellii infection and toxin neutralization. Pediatr Infect Dis J 1990; 9:582.