Clostridium subterminale - Infection Secondary to an Open Fracture

Clostridia are anaerobic, spore-forming, gram-positive bacilli that are ubiquitious in nature. They can be isolated from soil and the GI tract of animals and humans.1 These organisms are responsible for a vast variety of human diseases, such as tetanus, botulism, sepsis, and severe soft tissue infections. Generally, infection occurs after inoculation of environmental spores into the host and subsequent germination in an anaerobic wound milieu. Some strains of Clostridium perfringens, Clostridium histolyticum, Clostridium novyi, and Clostridium septicum are highly pathogenic; possess necrotizing toxins; and may cause life-threatening diseases, such as clostridial myonecrosis (gas gangrene) and sepsis.1 Clostridial infections are therefore recognized as serious complications of open fractures contaminated with soil.2 Case report During an outdoor soccer game, an 18-year-old man fell to the ground and fractured his right forearm. A radiograph revealed a complete fracture of both the proximal ulna and the radius. Soft tissue injury was minimal, and a grade 1 open fracture was diagnosed. The wound was cleaned, and a local iodine-containing antiseptic was applied. An open reposition and implantation of 2 titanium-coated metal plates was performed, and 2 Robinson drains were placed near the plates. The patient received oral sultamicillin (ampicillin/sulbactam) 375 mg bid postoperatively for 2 days. The drains were removed 3 days later. Fourteen days after the operation, a purulent discharge was observed at the site of the former access to the ulna. A sample of the discharge was sent for examination for bacteria, and antibiotic treatment with sultamicillin was restarted. Two days later, the former wound was surgically reopened and inspected. The osteosynthesis was stable, but parts of the fascia were inflamed and therefore were resected. A swab specimen was taken and sent for bacterial culture. The wound was cleaned and a Robinson drain and a carrier system were inserted into the cavity of the wound. The drain was removed after 2 days, and the carrier was removed 1 week lat-er. At that time, the condition of the wound was unremarkable. However, after another 11 days, the patient noticed a painful red swelling and a purulent discharge at the distal wound margin. The antibiotic treatment was switched to oral clindamycin 300 mg qid but was discontinued after 48 hours because a rash developed.