Massive intravascular hemolysis from Clostridium perfringens septicemia: a review

We describe the case of a patient with hemolysis-associated Clostridium perfringens septicemia and review all similar cases published in the literature since 1990, with specific focus on the relationship between treatment strategy and survival. We searched PubMed for all published cases of C. perfringens-associated hemolysis, using the medical subject terms "clostridia," "clostridial sepsis," and/or "hemolysis." All case reports, case series, review articles, and other relevant references published in the English literature since 1990 were included in this study. There were no exclusion criteria. Each case was examined with respect to presenting features of illness, antibiotic regimen, time-to-antibiotic therapy, additional interventions, complications, and patient survival. These variables were entered into a data set and then systematically analyzed with the aid of a statistician, using serial t tests and chi-square analyses. Since 1990, 50 patients of C. perfringens septicemia with hemolysis have been reported. Median age was 61 years (range 31-84), and 58% were male. Mortality was 74%, with a median time to death of 9.7 hours (range 0-96 hours). Of the patients, 35 (70%) were treated medically, while 15 (30%) received antibiotics and surgery. Surgical intervention was associated with significantly improved survival (risk ratio [RR] 0.23, 95% confidence interval [CI] 0.10, 0.53) as was the use of a combination of penicillin and clindamycin (RR of death 0.46, 95% CI 0.25, 0.83). Four patients utilizing hyperbaric oxygen therapy (HBOT) have been reported, and all patients survived. In cases of clostridial sepsis with hemolysis, strong predictors of survival include early initiation of appropriate antibiotics as well as surgical removal of infected foci. The HBOT may also be associated with survival. The disease often progresses rapidly to death, so rapid recognition is critical for the patient survival.