Cases Of Necrotic Enteritis Research Articles

Caracterização de coccidiose e avaliação de casos sugestivos de enterite necrótica subclínica em frangos de corte

ABSTRACT: This study performed the characterization of coccidiosis in broilers and evaluated the occurrence of suggestive cases of necrotic enteritis (NE), seeking if there is an association between the diseases in Brazilian flocks. Two hundred and fifty-six birds from 32 flocks were evaluated. Macroscopic and histopathological lesions were graduated for coccidiosis and NE. Intestinal content was investigated by polymerase chain reaction (PCR) for seven species of Eimeria and by selective anaerobic culture for Clostridium perfringens and identification of the NetB gene. Flocks positive for coccidiosis represented 93.8%. Macroscopic lesions of coccidiosis were Grade 1 for E. acervulina (27%); E. tenella (9.7%) and E. maxima (8.9%). Histopathological evaluation showed Grade 1 in duodenum (38.2%); jejunum (21.4%); cecum (9.3%) and ileum (5%). PCR demonstrated positivity for E. tenella (21.9%), E. maxima (18.8%), and E. acervulina (3.1%). Suggestive macroscopic lesions of necrotic enteritis ranged from Grade 1 (16%), 2 (23%) and 3 (10,9%). Histopathology indicated the absence of necrosis, showing only hemorrhage in the mucosa and submucosa, with the presence of Eimeria spp. Clostridium perfringens type A netB+ was not isolated, demonstrating that macroscopic lesions found mostly in the jejunum did not characterize NE, based on histopathology and negativity of the NetB gene. The study suggests that, due to the high occurrence of coccidiosis, many macroscopic findings suggestive of NE are, in fact, attributed to atypical lesions caused by the reproduction of Eimeria spp.

Case of necrotic enteritis associated with campylobacteriosis and coccidiosis in an adult Indian peacock (Pavo cristatus)

BackgroundTo date, Campylobacter jejuni has not been found to be pathogenic to peafowl. The available publications show that out of a total of 44 samples tested from peafowl, this bacterium was isolated only in two cases. Eimeria pavonina infestations in the peafowl have been described, but no fatal cases have been reported yet.Case presentationThe four-year-old peacock was presented with chronic diarrhea, emaciation and weakness. Post mortem examination revealed enlarged and pale kidneys, small intestinal mucosal necrosis and thickening of intestinal wall, and pericardial effusion. The histopathological examination revealed necrotic enteritis with marked mononuclear cells infiltration associated with the presence of coccidia, additionally there was histological evidence of septicemia in liver and kidneys. Bacteria identification was based on light microscopy of the small intestine sample, culture, and biochemical tests. Further identification was based on PCR. Antimicrobial susceptibility profile was created by determination of minimal inhibitory concentration (MIC) values for 6 antimicrobial agents from 5 different classes. PCR assays were performed to detect virulence factors genes responsible for motility, cytolethal distending toxin production, adhesion and internalization. Bacteriology of the small intestine sample showed abundant growth almost exclusively of Campylobacter jejuni, resistant to ciprofloxacin, gentamycin and ampicillin. Bacteria was sensitive to Amoxicillin + clavulanic acid, tetracycline, and erythromycin. All tested virulence factors genes have been detected. The parasitological examination was performed by microscopic examination of fresh faeces and intestinal content, and revealed the moderate number of Eimeria pavonina, Histomonas meleagridis, single Capillaria spp. eggs as well Heterakis spp. like parasites.ConclusionThe above case shows that a virulent isolate of Campylobacter jejuni in combination with a parasitic invasion may cause chronic enteritis in peafowl, which most likely led to extreme exhaustion of the host organism and death.

Antibiotic resistance pattern of Clostridium perfringens isolated from necrotic enteritis cases of broiler chickens in Luxor city

Antibiotic resistance pattern of Clostridium perfringens isolated from necrotic enteritis cases of broiler chickens in Luxor city

Experimental induction of necrotic enteritis with or without predisposing factors using netB positive Clostridium perfringens strains

BackgroundPoultry necrotic enteritis (NE) is an economically important disease caused by C. perfringens. The disease causing ability of this bacterium is linked with the production of a wide variety of toxins. Among them, necrotic enteritis B-like (NetB) toxin is reported to be involved in the pathogenesis of NE; in addition there is some circumstantial evidence that tpeL toxin may enhance virulence, but this is yet to be definitely shown. The situation becomes more complicated in the presence of a number of predisposing factors like co-infection with coccidia, type of diet and use of high protein diet. These co-factors alter the intestinal environment, thereby favoring the production of more toxins, leading to a more severe disease. The objective of this study was to develop a successful animal model that would induce clinical signs and lesions of NE using C. perfringens type G strains obtained from field outbreaks. A separate trial was simultaneously considered to establish the role of dietary factor with coccidial co-infection in NE.ResultsThe results have shown that use of net-B positive C. perfringens without predisposing factors induce moderate to severe NE (Av. Lesion score 1.79 ± 1.50). In a separate trial, addition of fish meal to a feed of C. perfringens challenged birds produced higher number of NE cases (Av. Lesion score 2.17 ± 1.28). However, use of less virulent E. necatrix strain along with fish meal in conjunction with net-B positive strain did not alter the severity of NE lesions in specific pathogen free chicken (Av. Lesion score 2.21 ± 1.13).ConclusionsThis study suggests that virulent C. perfringens type G strains can induce NE lesions in the absence of other predisposing factors. Birds in the clostridia challenged group showed moderate to severe NE lesions. Use of less virulent coccidia strain contributed to a lesser extent in increasing the severity of disease. Maize based diet along with fishmeal (1:1) increased the severity of lesions but statistically it was non-significant. The NE lesions in all experimental groups were found to be present more frequently in the duodenum. In this way, this study provided an effective model for in vivo production of NE in poultry birds.

Isolation and Genotyping Study of Clostridium Perfringens From Broiler Farms Infected with Necrotic Enteritis in Sulaimania Province

The study is conducting to isolate and toxinotype the suspected cases of Clostridium perfringens infections of broiler farms in Sulaimania province. A total of 108 samples were collected from intestinal contents, mucosal scraping, and hemorrhagic lymphoid nodules from suspected cases of necrotic enteritis in broilers. The result of isolated and identified bacteria were revealed that 63 (58%) out of 108 samples were positive for C. perfringens. The results revealed that the isolates were only positive for alpha and beta2 toxin genes. Phylogenetic and DNA sequence analysis of cpa and cpb2 gene showed that cpa genes were highly identical to isolates from broiler in Iran, poultry stool and broiler in Brazil, and blue calves in Belgium. While cpb2 gene is closely related to the isolates of broiler in Iran, India and isolates of goat in Pakistan. The results indicated that the causative agent of necrotic enteritis in broiler farms in the region was mainly due to C. perfringens type A infection

The netB-positive Clostridium perfringens in the experimental induction of necrotic enteritis with or without predisposing factors

The netB-positive Clostridium perfringens has been considered as the requisite to consistently induce necrotic enteritis (NE). However, use of a netB-positive strain did not guarantee consistent NE reproduction unless high protein diets or Eimeria, conceived as 2 major predisposing factors, was incorporated. To establish a refined model, the roles of dietary fishmeal inclusion, Eimeria inoculation, and netB-positive C. perfringens challenge in NE induction and the confounding effects of Eimeria infection on NE were examined. The results showed that the use of netB-positive C. perfringens without a predisposing factor failed to induce NE. Fishmeal incorporation promoted the occurrence of NE but did not significantly affect the incidence of the disease in conjunction with challenge of netB-positive C. perfringens. However, the additional participation of Eimeria infection in the same induction procedure produced significantly higher numbers of NE cases and promoted more severe lesions in chickens (P < 0.05). Inoculation of Eimeria resulted in a significant higher incidence of NE compared to the non-Eimeria treated group (P < 0.05). The results demonstrated that both netB-positive C. perfringens and predisposing factors were required for the reproduction of disease. Mild-to-moderate coccidial infection (coccidial lesion score ≤ 2) was noted in NE cases in this model but severe coccidial infection did not correlate with the occurrence of NE, indicating mild coccidial infection may be beneficial for the development of NE. If multiple species infection of Eimeria precedes the challenge of C. perfringens, days 19 to 21 (1 to 3 D after the last clostridial challenge) was the time period favorable for observations of NE lesions. The time after this period may be subject to bias of severity, incidence, or mortality of NE owing to the profound coccidial lesions in the intestinal region. This study demonstrated that the co-infection with netB-positive C. perfringens and Eimeria species under fishmeal incorporation produced a desirable NE model, being of value in studying the effectiveness of novel feed additives and alternative mitigation strategies to prevent NE.

Molecular Characterization and Virulent Gene Detection of Clostridium perfringens from Necrotic Enteritis Cases in Kadaknath Fowl

Enteric diseases are one of the most important problems in the poultry industry leading to production losses, high mortality and risk of contamination of poultry products for human consumption. Necrotic enteritis (NE) is one of the most clinically associated bacterial enteric disease of poultry caused by Clostridium perfringens, which is an anaerobic, gram-positive bacteria. In present study, 08 Kadaknath birds, which showed signs of inappetence and diarrhea, were presented for necropsy. Gross examination of the fowls revealed necrotic to ulcerative lesions in intestine. Clostridium perfringens organisms were isolated from intestine after anaerobic incubation. Initial enrichment of intestinal samples were done in Robertson’s cooked meat media (RCMM) and streaked on perfringens agar base with T.S.C supplements and for further confirmation, these colonies were streaked on egg yolk agar for lecithinase activity. The isolates were confirmed by 16S rRNA gene specific PCR and further processed for necrotic enteritis B like toxin (NetB) gene. Out of 08 intestinal samples processed, 04 were found positive for C. perfringens by phenotypic and genotypic confirmation. All confirmed C. perfringens isolates were processed for NetB gene and out of 4 samples, 01 was positive for NetB gene. This study further pointed out that C. perfringens NetB toxin is a one of the new key virulent factor for the development of NE in poultry birds.

Isolation and Characterization of Clostridium perfringens from Suspected Cases of Necrotic Enteritis (NE) in Broiler Chicken

Considering necrotic enteritis (NE) as an economically important problem of broiler industry, a study was undertaken to establish the association of Clostridium perfringens with the disease. Screening of 35 fecal samples/intestinal scrapping of broiler chicken, either clinically affected or died due to the suspected form of NE revealed isolation of C. perfringens from 13 (37.14%) samples. Among the isolates, 10 were identified as toxin type A, while remaining three as toxin type C. One of the toxin type A revealed the presence of additional virulence-associated genes, netB and tpeL. Irrespective of toxin types, C. perfringens isolates showed resistance towards Ciprofloxacin (76.92%), followed by Norfloxacin (53.85%), Tetracycline (46.15%), Colistin (23.07%) and Levofloxacin (15.38%), of which eight could exhibit resistance towards multiple antimicrobial agents. The release of C. perfringens toxins was found to be more, during the 6-8 hrs of incubation with 13 distinct protein bands including of cpa, netB and tpeL protein. The toxin type A with additional virulence-associated genes was found to be more pathogenic in mice pathogenicity test.

Update on the emergence and pathogenesis of necrotic enteritis in broiler chickens

Necrotic enteritis (NE) is a disease of broiler chickens, which is caused by Clostridiumperfringens type A or C and is characterized by high mortality and severe intestinal lesions. NE is described as a disease of high economical importance which affects health and welfare of broilers and also may pose a threat to public health. Although NE was known as a disease since 1930, it did not cause serious problems to the poultry industry. The emergence of the disease occurred after 1986 in Scandinavia and 2000 in the European Union and was related with the ban of in-feed antimicrobial growth promoter. Furthermore, the ban of meat meal and bone meal from the feed of broiler chickens and their replacement by fishmeal increased further the occurrence of NE. NE breaks the Koch's postulate, which supports that "a disease-causing organism should not be present in healthy individuals", because C perfringens may be detected in high populations in the gut of birds with no visible signs of NE. Moreover, challenge of birds with C perfringens does not \eadperse to the development of the disease. It is very well accepted that NE is a multi-factorialdisease in which a number of co-factors are usually required for the proliferation and toxinogenesis of C. perfringens and manifestation of the disease. Toxin -a, since 2006, has been proposed to be the main virulence factor for NE in poultry. The origin of this assumption seems to lie to observation that crude supernatant from C perfringens type A cultures induced necrotic lesions in broilers. Moreover, the development of NE lesions prevented partially by antibodies against C. perfringens toxin -a. The interpretation of these early studies is not clear, because they used crude supernatant and the assumption was made that the effects were caused by the dominant protein present (i.e. toxin -a). However, many other proteins are also present in the supernatant ofC perfringens cultures. The most convincing evidence, that toxin -a is not essential virulence factor for the pathogenesis of NE, comes from studies using a toxin -a negative mutant (epa mutant) of a C perfringens strain from NE outbreak, which was able to produce characteristic NE lesions. Recently, netB, a novel toxin that is associated with broiler NE, has been described. A netB mutant of C perfringens was unable to cause necrotic lesions in the gut of experimentally infected broilers, but a complemented netB mutant was virulent, like the wild-type strain. However, netB per se, might not be an essential component of virulence factor for the pathogenesis of NE, because not all strains isolated from diseased birds carry the netB gene. The presence of the toxin -β2, although it has been linked with increased incidence of bovine enterotoxaemia, intestinal disorders in human, horses and diarrhea in piglets, does not seem to be involved in the pathogenesis of NE in broiler. Most C. perfringens strains isolated from cases of NE do not carry the gene (cpb2) which is responsible for the production of toxin -β2. The efficacy of antitoxin -a toxoid vaccines, the high concentration of toxin-a at the supernatant of C. perfringens culture and feces of diseased birds, as well as the high titer of antibodies against toxin-a in birds with NE, indicate that toxin -a definitely play a role, major or minor, on the pathogenesis of NE in broilers.

Prevalence and Predisposing Factors in Spontaneous Cases of Necrotic Enteritis in Cage Reared Commercial Layer Chicken

Prevalence and Predisposing Factors in Spontaneous Cases of Necrotic Enteritis in Cage Reared Commercial Layer Chicken

Necrotic enteritis in a captive mute swan (Cygnus olor) in the breeding season

Abstract A captive mute swan ( Cygnus olor ) in the brooding period was found dead without any specific signs. On necropsy, the entire digestive tract was severely necrotized with loosely adherent pseudomembranes, and Clostridium perfringens (CP) colonies isolated from the intestinal contents were identified as CP type A by polymerase chain reaction. Microscopically, the intestine and the liver were necrotized and intralesional bacterial clusters were observed. In this case, there were no other mortalities, so the con-dition of a single bird, in particular, stress from incubation effort, could act as the predisposing factor for necrotic enteritis. In this study, we report a unique case of necrotic enteritis associated with in-cubation in a captive mute swan. Key words : Cygnus olor , Incubation effort, Mute swan, Necrotic enteritis, Stress factor INTRODUCTION Necrotic enteritis (NE) is a clinically dramatic enteric disease afflicting birds which is characterized by an in-testinal necrotic fibrinous pseudomembrane with a “Turkish towel” appearance (Opengart and Songer, 2013). NE occurs in the presence of predisposing fac-tors, such as feed ingredients, stress or intestinal para-sites (Timbermont et al, 2011) that cause a microbial imbalance favorable for the overgrowth of the causal agent,

Molecular Characterization and Toxinotyping of a Clostridium perfringens Isolate from a Case of Necrotic Enteritis in Indian Kadaknath Fowl

Molecular Characterization and Toxinotyping of a Clostridium perfringens Isolate from a Case of Necrotic Enteritis in Indian Kadaknath Fowl

Use of a Multiplex PCR for the Detection of Toxin-Encoding Genes netB and tpeL in Strains of Clostridium perfringens

Some studies have shown that the NetB toxin may be an important virulence factor of Clostridium perfringens associated necrotic enteritis in poultry. Additionally, research has shown that strains of C. perfringens positive for both the netB gene and a second toxin-encoding gene, tpeL, appear to be more virulent than strains with only netB. In the past, detection of these genes has been performed relatively inefficiently using two single locus PCRs. This report describes a novel multiplex PCR developed to detect netB and tpeL simultaneously in C. perfringens strains isolated from cases of necrotic enteritis in broilers, providing a more efficient diagnostic tool in the screening of strains for these genes.

Effects of virginiamycin against experimentally induced necrotic enteritis in broiler chickens vaccinated or not with an attenuated coccidial vaccine

SUMMARY Necrotic enteritis (NE) is a deadly poultry disease caused by Clostridium perfringens. Infeed antibiotics such as virginiamycin (Vm) are commonly used in many countries to control NE. A ban on in-feed antibiotics usage in some European Union countries has caused an increase in the incidence of NE. In the present investigation, first, the effects of a live attenuated coccidial vaccine on the severity of experimentally induced NE in broilers and the role of Vm in prevention of disease were assessed. Second, we studied whether Vm, salinomycin (Sm), or both would help to reduce the severity of NE. The results of the first study showed that although the administration of a double dose of an attenuated coccidial vaccine led to a higher morbidity and mortality among C. perfringens-challenged birds, Vm prevented mortalities and improved the performance parameters among the vaccinated birds. In the second study, administration of Vm and Sm for 30 d were efficacious in preventing NE induced by C. perfringens which had been previously isolated from acute cases of NE in broiler farms. However, the short-term effects of in-feed Vm against NE, although evident in reducing the mortalities, were not satisfactory. This study provides further evidence that in-feed Vm benefits the poultry industry by prevention of NE.

Antibiotic resistance of Clostridium perfringens isolates from broiler chickens in Egypt.

The use of antibiotic feed additives in broiler chickens results in a high prevalence of resistance among their enteric bacteria, with a consequent emergence of antibiotic resistance in zoonotic enteropathogens. Despite growing concerns about the emergence of antibiotic-resistant strains, which show varying prevalences in different geographic regions, little work has been done to investigate this issue in the Middle East. This study provides insight into one of the world's most common and financially crippling poultry diseases, necrotic enteritis caused by Clostridium perfringens. The study was designed to determine the prevalence of antibiotic resistance in C. perfringens isolates from clinical cases of necrotic enteritis in broiler chickens in Egypt. A total of 125 isolates were obtained from broiler flocks in 35 chicken coops on 17 farms and were tested using the disc diffusion method. All 125 isolates were resistant to gentamicin, streptomycin, oxolinic acid, lincomycin, erythromycin and spiramycin. The prevalence of resistance to other antibiotics was also high: rifampicin (34%), chloramphenicol (46%), spectinomycin (50%), tylosin-fosfomycin (52%), ciprofloxacin (58%), norfloxacin (67%), oxytetracycline (71%), flumequine (78%), enrofloxacin (82%), neomycin (93%), colistin (94%), pefloxacin (94%), doxycycline (98%) and trimethoprim-sulfamethoxazole (98%). It is recommended that C. perfringens infections in Egypt should be treated with antibiotics for which resistant isolates are rare at present; namely, amoxicillin, ampicillin, cephradine, fosfomycin and florfenicol.

Alpha toxin specific PCR for detection of toxigenic strains of Clostridium perfringens in Poultry

Aim : Isolation of Clostridium perfringens from necrotic enteritis cases in poultry and confirmation by alpha toxin specific PCR Materials and methods: Robertson cooked meat medium with Brain Heart Infusion broth was used for isolation of C. perfringens from intestinal contents of necrotic enteritis suspected birds. Positive cultures from perfringens agar were further confirmed by biochemical tests and subjected to alpha toxin specific PCR. Results and Discussion: Twenty Clostridium perfringens isolates were isolated from intestinal contents of thirty five NE suspected birds. Out of the twenty isolates, fourteen were isolated from commercial broilers of 2 to 6 wk of age and six from commercial layers of 9 to 15 wk of age. Frequency of isolation of C. perfringens was more with Robertson cooked meat medium with BHI broth than thioglycollate broth alone. When positive cultures were streaked on to clostridial agar appreciable luxuriant growths were obtained and the selective streaking of these colonies on perfringens agar with supplements revealed rough and black colonies with sulphate reduction. The isolates produced rough and black colonies with sulphate reduction on perfringens agar, double zone haemolysis on sheep blood agar, stormy clot fermentation on milk medium and opalescence on egg yolk medium. The isolates were found negative for oxidase, catalase, liquefied gelatin, fermented glucose, maltose, lactose and sucrose except mannitol. All the fourteen isolates obtained from commercial broilers proved the alpha toxin producing strains of C. perfringens when they were subjected to alpha toxin specific PCR. Conclusion : This study revealed alpha toxin specific PCR is highly useful for detection of toxigenic strains of Clostridium perfringens in poultry

TpeL-producing strains of Clostridium perfringens type A are highly virulent for broiler chicks

Clostridium perfringens type A and type C are causative agents of necrotic enteritis (NE) in poultry. TpeL, a recently-described novel member of the family of large clostridial cytotoxins, was found in C. perfringens type C. Others have since reported TpeL in type A isolates from NE outbreaks, suggesting that it may contribute to the pathogenesis of NE. The virulence of TpeL-positive and -negative C. perfringens strains from cases of NE was examined by challenge of broiler chicks. Gross lesions typical of NE were observed in all challenged birds, and those inoculated with TpeLpos strains had higher average macroscopic lesion scores than those inoculated with a TpeLneg strain. Infection with TpeLpos strains may yield disease with a more rapid course and higher case fatality rate. Thus, TpeL may potentiate the effect of other virulence attributes of NE strains of C. perfringens. However, TpeLpos and Tpelneg strains compared here were not isogenic, and definitive results await the production and testing of specific TpeL mutants.

Multilocus Sequence Typing Subtypes of Poultry Clostridium perfringens Isolates Demonstrate Disease Niche Partitioning

Clostridium perfringens is a ubiquitous and versatile pathogenic bacterium and is implicated in the etiology of the poultry diseases necrotic enteritis (NE) and poultry gangrene (PG). In this study, multilocus sequence typing was used to investigate genotypic relationships among 139 C. perfringens isolates from 74 flocks. These isolates had multiple disease, host, and environmental origins. The results indicated a polymorphic yet highly clonal population, with 79.6% of all isolates partitioning into one of six clonal complexes or two dominant sequence types, ST-9 and ST-31. The most prolific clonal complex, CC-1, contained 27.3% of all isolates and was not clearly associated with one particular disease. The subtypes CC-4 and ST-31 were highly associated with NE and represented 9.4% and 7.2% of the total isolates, respectively. No PG-associated and NE-associated C. perfringens isolates shared the same sequence type or clonal complex. NE-associated subtypes were more clonal and appeared more evolutionarily divergent than PG-associated subtypes, which tended to cluster in the more ancestral lineages alongside isolates from asymptomatic chickens and turkeys. Toxin gene screening identified cpb2 throughout these isolates and correlated the presence of netB with NE pathology. Previous investigations into the genetic basis of C. perfringens pathogenicity have focused on toxins and other variable genetic elements. This study presents the first sequence-based comparison of C. perfringens isolates recovered in clinical cases of PG and NE and demonstrates that niche specialization is observable in the core genomes of poultry-associated C. perfringens isolates, a concept with both epidemiological and evolutionary significance.

Virulence for chickens of Clostridium perfringens isolated from poultry and other sources

Clostridium perfringens type A is the most common cause of poultry necrotic enteritis (NE). Of the four “major” toxins, type A strains produce only alpha toxin (CPA), which has long been considered a major factor in pathogenesis of NE. We investigated the virulence for poultry of type A strains from a variety of enteric sources. Newly-hatched Cornish × Rock chicks were fed a low protein diet for one week, a high protein diet for a second week, and then challenged with log-phase cultures of C. perfringens, mixed 3:4 (v/v) with high protein feed. Strain JGS4143 [genotype A, beta2 positive ( cpb2 pos), from a field case of NE] produced gross lesions compatible with NE in >85% of challenged birds. However, strains JGS1714 (enterotoxigenic genotype A, cpb2 pos, human food poisoning), JGS1936 (genotype A, cpb2 neg, bovine neonatal enteritis), JGS4142 (genotype A, cpb2 pos, bovine jejunal hemorrhage syndrome), JGS1473 (genotype A, cpb2 pos, chicken normal flora), JGS1070 (genotype C, cpb2 pos, porcine hemorrhagic enteritis), JGS1882 (genotype A, cpb2 pos, porcine neonatal enteritis), JGS1120 (ATCC 13124, genotype A, cpb2 neg, gas gangrene), JGS4151 (strain 13, genotype A, cpb2 pos, canine), and JGS4303 (SM101, enterotoxigenic genotype A, cpb2 neg, human food poisoning) failed to produce disease. In vivo passage failed to increase virulence of the non-NE strains. NE strains must have specific poultry-associated virulence attributes, such as the recently identified NetB and other factors, which allow for the development of disease.

A Case of Necrotic Enteritis with Hepatic Portal Venous Gas Probably Caused by Clostridium Infection

A Case of Necrotic Enteritis with Hepatic Portal Venous Gas Probably Caused by Clostridium Infection