Clostridium hathewayi bacteraemia and surgical site infection after uterine myomectomy

Background

Clostridium species are anaerobic, endospore-forming, rod-shaped bacteria that are widely distributed and frequently a part of normal gastrointestinal tract flora. Most of these are Gram-positive rods. However, Clostridium hathewayi is a newly described gut commensal that stains Gram-negative. It is a rare cause of human infection and we report the first case of surgical site infection and bacteraemia with this organism.

Case presentation

A 42-year-old woman, with a medical history significant for sickle cell trait and uterine fibroids, underwent an extensive abdominal myomectomy and myolysis for management of infertility and iron-deficiency anaemia. The patient received cefazolin for perioperative prophylaxis. Her intraoperative course was complicated by blood loss for which she received two units of packed red blood cells. Her postoperative course was complicated by fever of 38.5°C on postoperative day (POD) 1 and 38.7°C on POD 2. A CT scan of the abdomen and pelvis was performed on POD 1, which revealed multiple small haematomas at the myomectomy site ( figure 1 A). The patient was initially started on empiric therapy with piperacillin/tazobactam intravenously. Her blood cultures that were obtained on second POD grew Chathewayi in anaerobic culture bottles only. The organisms were resistant to penicillin on in vitro testing but susceptible to the rest of the panel that included piperacillin/tazobactam, ertapenem, clindamycin and metronidazole. The patient's fever curve improved while on piperacillin/tazobactam and she was discharged on POD 3 on oral levofloxacin. The patient continued to take levofloxacin but began to experience fevers as high as 38.5°C that were associated with back pain for which she was readmitted to the hospital on POD 8.

Investigations

The patient was haemodynamically stable with a temperature of 37.9°C on admission. Her abdominal incision was clean with no erythema, purulence or drainage and she had no rebound or guarding on abdominal palpation. Abnormal laboratory findings included a leucocyte count of 17.7x10⁹ /L (normal 3.5 to 10.5x10⁹ /L) with 89% neutrophils. Haemoglobin was 10.3 g/dL (normal 13.5 to 17.5 g/dL) and potassium 5.1 (normal 3.5 to 5.3 mmol/L).

A repeat CT scan of the abdomen and pelvis performed at the time of admission on POD 8 showed new gas formation throughout the previously seen haematoma ( figure 1 B,C). Blood cultures from the time of...