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Abstract
The objective of this study of a retrospective case series was to determine factors associated with survival after surgical intervention in pseudomembranous colitis (PMC). The study was conducted at a tertiary care medical center and comprised 36 patients who underwent colectomy for fulminant PMC from 1995 to 2006. Patients including 21 females ranged from 40 to 89 years of age (mean, 70 years). Comorbidities included diabetes (39%), cardiovascular disease (77%), chronic obstructive pulmonary disease (47%), and intake of immunosuppressive medications (45%). Seventy-two per cent received antibiotics in the previous 2 months. Only patients with a confirmation of PMC on pathology specimens were included in the study. All patients underwent colectomy. Patients were stratified into two groups: survivors and nonsurvivors. Various clinical factors/parameters used in the management of patients with PMC were studied in these two groups. Survival was correlated with mean white blood cell count (23,000 survivors versus 40,000 nonsurvivors, P < 0.01); multisystem organ failure (16 per cent survivors versus 47 per cent nonsurvivors, P < 0.05); and preoperative pressors (16 per cent survivors versus 47 per cent nonsurvivors, P < 0.05). Overall mortality for the study period was 47 per cent. Mortality rate analysis revealed a lower rate for the more recent years (32 per cent for 2000 to 2006 versus 65 per cent for 1995 to 1999, P < 0.05). In the more recent years, the time elapsing before colectomy was also lower (1.4 days versus 2.5 days, nonsignificant), and patients had less preoperative hemodynamic instability (70 per cent versus 31 per cent, P < 0.03). In one institution, survival after surgery for PMC was found to be associated with a mean white blood cell count (<37,000), nondependence on preoperative vasopressors, and surgical intervention before the onset of hemodynamic instability.
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Affiliation(s)
- Syed O. Ali
- University of Connecticut Integrated General Surgery Program, Farmington, Connecticut
| | - John P. Welch
- Connecticut Surgical Group, Hartford, Connecticut, Hartford Hospital, Hartford, Connecticut, the Department of Surgery, University of Connecticut School of Medicine, Farmington, Connecticut, and the Department of Surgery, Dartmouth Medical School, Hanover, New Hampshire; and
| | - Robert J. Dring
- North Shore University Hospital, Manhasset, New York, Long Island Jewish Hospital, New Hyde Park, New York, St. Francis Hospital, Roslyn, New York, and Winthrop University Hospital, Mineola, New York
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Clanton J, Fawley R, Haller N, Daley T, Porter J, Paranjape C, Bonilla H. Patience is a Virtue: An Argument for Delayed Surgical Intervention in Fulminant Clostridium difficile Colitis. Am Surg 2020. [DOI: 10.1177/000313481408000628] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Recently, the incidence and severity of Clostridium difficile infection (CDI) has increased. In cases of fulminant infection, surgery is a viable therapeutic option but associated with high mortality. We sought to examine factors associated with mortality in a large sample of patients with severe CDI that underwent surgery. A retrospective study was conducted in patients with severe CDI undergoing colectomy. Demographics, risk factors, comorbidities, clinical and laboratory data, and time between admission/diagnosis of CDI and colectomy were collected. Conventional markers of severity were evaluated as predictors of mortality. Sixty-four cases were included for analysis. The overall observed mortality rate was 45.3 per cent. Few conventional markers of severity were significantly associated with mortality. Risk factors that correlated with postsurgical mortality were vasopressor use (odds ratio, 3.08; 95% confidence interval, 1.00 to 9.92) and shorter time between diagnosis and surgery (median time, 2 vs 3 days, P = 0.009). This study suggests that a delay in surgery after diagnosis of severe CDI may improve overall outcomes. The finding regarding timing of surgery is contrary to traditional teaching and may be the result of improved medical treatment and stabilization before surgery. Consideration should be given to the importance of timing of colectomy in fulminant CDI, whereas prospective studies should be conducted to elucidate causal relationships.
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Affiliation(s)
- Jesse Clanton
- Department of Surgery, Summa Akron City Hospital, Akron, Ohio; the
| | - Ryan Fawley
- Department of Medicine, Naval Medical Center Portsmouth, Portsmouth, New Hampshire; the Departments of
| | | | - Timothy Daley
- Department of Mathematics, University of Southern California, Los Angeles, California
| | - Joel Porter
- Department of Surgery, Summa Akron City Hospital, Akron, Ohio; the
| | | | - Hector Bonilla
- Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Hrebinko K, Zuckerbraun BS. Clostridium difficile : What the surgeon needs to know. SEMINARS IN COLON AND RECTAL SURGERY 2018. [DOI: 10.1053/j.scrs.2017.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Carachi R, Grosfeld JL. Surgical Complications of Childhood Tumors. THE SURGERY OF CHILDHOOD TUMORS 2016. [PMCID: PMC7121030 DOI: 10.1007/978-3-662-48590-3_31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Robert Carachi
- Surgical Paediatrics, University of Glasgow, Glasgow, United Kingdom
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van der Wilden GM, Subramanian MP, Chang Y, Lottenberg L, Sawyer R, Davies SW, Ferrada P, Han J, Beekley A, Velmahos GC, de Moya MA. Antibiotic Regimen after a Total Abdominal Colectomy with Ileostomy for Fulminant Clostridium difficile Colitis: A Multi-Institutional Study. Surg Infect (Larchmt) 2015; 16:455-60. [PMID: 26069992 DOI: 10.1089/sur.2013.153] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Fulminant Clostridium difficile colitis (fCDC) is a highly lethal disease with mortality rates ranging between 12% and 80%. Although often these patients require a total abdominal colectomy (TAC) with ileostomy, there is no established management protocol for post-operative antibiotics. In this study we aim to make some recommendations for post-operative antibiotic usage, while describing the practice across different institutions. METHODS Multi-institutional retrospective case series including fCDC patients who underwent a TAC between January 1, 2007, and June 30, 2012. We first analyzed the complete cohort and consecutively performed a survivor analysis, comparing different antibiotic regimens. Additionally we stratified by time interval (antibiotics for ≤7 d, or ≥8 d). Primary outcome was in-hospital mortality. Additional secondary outcomes included hospital length of stay (HLOS), ICU LOS, number of ventilator-free days, and occurrence of intra-abdominal complications (proctitis, abscess, sepsis, etc.). RESULTS A total of 100 fCDC patients that underwent a TAC were included across five institutions. Four different antibiotic regimens were compared; A (metronidazole IV+vancomycin PO), B (metronidazole IV), C (metronidazole IV+vanco PO and PR), and D (metronidazole IV+vancomycin PR). The combination of IV metronidazole with or without PO vancomycin showed superior outcomes in terms of a shorter ICU length of stay and more ventilator-free days. However, when comparing metronidazole alone vs. metronidazole and any combination of vancomycin, no significant differences were found. Neither the addition of vancomycin enema, nor the time interval changed outcomes. CONCLUSION Patients, after a TAC for fCDC, may be placed on either IV metronidazole or PO vancomycin depending upon local antibiograms, and proctitis may be treated with the addition of a vancomycin enema (PR). There was no data to support routine treatment of more than 7 d.
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Affiliation(s)
- Gwendolyn M van der Wilden
- 1 Department of Surgery, Division of Trauma, Emergency Surgery & Critical Care, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts.,2 Department of Trauma Surgery, Leiden University Medical Center and Leiden University , Leiden, the Netherlands
| | - Melanie P Subramanian
- 1 Department of Surgery, Division of Trauma, Emergency Surgery & Critical Care, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
| | - Yuchiao Chang
- 3 Department of Medicine, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
| | - Lawrence Lottenberg
- 4 Department of Surgery, UF Health Science Center and University of Florida College of Medicine , Gainesville, Florida
| | - Robert Sawyer
- 5 Department of Surgery, University of Virginia Health System and University of Virginia School of Medicine , Charlottesville, Virginia
| | - Stephen W Davies
- 5 Department of Surgery, University of Virginia Health System and University of Virginia School of Medicine , Charlottesville, Virginia
| | - Paula Ferrada
- 6 Department of Surgery, VCU Medical Center and Virginia Commonwealth University School of Medicine , Richmond, Virginia
| | - Jinfeng Han
- 6 Department of Surgery, VCU Medical Center and Virginia Commonwealth University School of Medicine , Richmond, Virginia
| | - Alec Beekley
- 7 Department of Surgery, Thomas Jefferson University Hospital and Thomas Jefferson University , Philadelphia, Pennsylvania
| | - George C Velmahos
- 1 Department of Surgery, Division of Trauma, Emergency Surgery & Critical Care, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
| | - Marc A de Moya
- 1 Department of Surgery, Division of Trauma, Emergency Surgery & Critical Care, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
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Felder SI, Larson B, Balzer B, Wachsman A, Haker K, Fleshner P, Annamalai A, Margulies DR. Fulminant Clostridium difficile Colitis: Comparing Computed Tomography with Histopathology: Are They Concordant? Am Surg 2014. [DOI: 10.1177/000313481408001033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
A Total abdominal colectomy (TAC) is recommended for fulminant Clostridium difficile colitis (FCDC) because intraoperative assessment of diseased segments is inaccurate. To determine whether computerized tomography (CT) provides an accurate assessment of disease, we examined the concordance between CT and histopathologic colitis distribution in patients undergoing TAC for FCDC. The ileocolon was divided into seven distinct segments. Of 20 patients meeting criteria, the median interval between preoperative CT and TAC was 1.5 days (range, 0 to 23 days), and mortality was 65 per cent. The CT distribution of colitis was pancolitis in 12 patients and segmental in eight. Nine of the 12 patients with CT pancolitis had histologic pancolitis (75% concordance). Four of the eight patients with CT-diagnosed segmental disease had histologic segmental disease (50% concordance). For patients with FCDC, the distribution of colitis on CT agrees with the histopathologic extent of disease in the majority of patients. However, discordance between CT and histologic extent of disease was present in 25 to 50 per cent of patients. Therefore, the recommendation for TAC rather than segmental resection for FCDC remains justified.
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Affiliation(s)
- Seth I. Felder
- Departments of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Brent Larson
- Departments of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Bonnie Balzer
- Departments of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ashley Wachsman
- Radiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Katherine Haker
- Radiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Phillip Fleshner
- Departments of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Alagappan Annamalai
- Departments of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel R. Margulies
- Departments of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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Abstract
Clostridium difficile is an anaerobic, spore-forming, gram-positive bacillus that can produce severe colitis resulting in death. There has been an overall increase in the incidence of Clostridium difficile-associated disease and, particularly, an increase in the more virulent forms of the disease. Treatment of severe C difficile infection includes management of severe sepsis and shock, pathogen-directed antibiotic therapy, and, in selected cases, surgical intervention. Ultimately, prevention is the key to limiting the devastating effects of this microorganism.
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Markelov A, Livert D, Kohli H. Predictors of Fatal Outcome after Colectomy for Fulminant Clostridium difficile Colitis: A 10-Year Experience. Am Surg 2011; 77:977-80. [DOI: 10.1177/000313481107700813] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Surgical treatment of fulminant Clostridium difficile colitis has high mortality rates. Identification of a set of preoperative characteristics that could predict outcome after surgery is necessary to optimize clinical management and guide surgical timing. Data were retrospectively collected on patients operated on for C. difficile colitis between 2000 and 2010 at our institution. Statistical analysis was performed to identify predictors of mortality. We reviewed the records of 13 inpatients diagnosed as having C. difficile colitis and who underwent colectomy during the same admission. The in-hospital mortality rate for patients undergoing colectomy for colitis was 46.2 per cent. Independent predictors of mortality included the following: white blood cell count (34,600/μL or greater), hypoalbuminemia (1.5 g/dL or less), septic shock with requirements of vasopressors, and respiratory failure. Patients who underwent colectomy earlier (mean time from presentation to surgery 2.4 ± 1.5 days) had decreased mortality ( P = 0.019).). Longer length of hospital stay to the time of diagnosis was associated with higher rates of fatal outcome ( P = 0.031). Parameters without significant difference ( P > 0.05) included patient age, presenting symptoms, other comorbidities, creatinine levels, and CT scan findings. Identified factors can predict unfavorable outcomes after colectomy. Aggressive surgical intervention early in the course of the disease might be associated with improved survival.
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Affiliation(s)
- Alexey Markelov
- Easton Hospital, Easton, Pennsylvania; and Drexel University School of Medicine, Philadelphia, Pennsylvania
| | - David Livert
- Easton Hospital, Easton, Pennsylvania; and Drexel University School of Medicine, Philadelphia, Pennsylvania
| | - Harjeet Kohli
- Easton Hospital, Easton, Pennsylvania; and Drexel University School of Medicine, Philadelphia, Pennsylvania
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Butala P, Divino CM. Surgical aspects of fulminant Clostridium difficile colitis. Am J Surg 2010; 200:131-5. [PMID: 20409527 DOI: 10.1016/j.amjsurg.2009.07.040] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2009] [Revised: 07/09/2009] [Accepted: 07/10/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND Clostridium difficile-associated disease (CDAD) is responsible for the majority of nosocomial diarrhea, and fulminant C difficile colitis can have mortality upwards of 80%. Early identification and treatment of fulminant C difficile colitis is critical to patient care, but timing of surgical intervention remains difficult. This review summarizes the epidemiology, predictors of development, and management of fulminant C difficile colitis. METHODS A literature search was conducted between January 1989 and May 2009 using the keywords "clostridium difficile colitis" or "fulminant clostridium difficile colitis" and "surgery." Articles not in English, those not involving human subjects, and case reports were excluded. CONCLUSION Early diagnosis and treatment with subtotal colectomy and end ileostomy is critical in reducing the mortality associated with fulminant colitis. Patients who have a history of inflammatory bowel disease (IBD), recent surgery, prior treatment with intravenous immunoglobulin (IVIG), vasopressor requirements, leukocytosis, or increased lactate should have early surgical consultation and operative intervention.
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Affiliation(s)
- Parag Butala
- Department of Surgery, Mount Sinai School of Medicine, New York, NY, USA
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Affiliation(s)
- J. Daniel Stanley
- University of Tennessee College of Medicine, Chattanooga Department of Surgery, Chattanooga, Tennessee
| | - R. Phillip Burns
- University of Tennessee College of Medicine, Chattanooga Department of Surgery, Chattanooga, Tennessee
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Abstract
Clostridium difficile is the most common cause of infectious diarrhea in hospitalized patients. Its effects are mediated by C difficile toxins A and B. Recent outbreaks of severe colitis have been associated with a new strain of the bacterium that produces large amounts of the toxins. Although oral metronidazole and oral vancomycin can be used to treat C difficile-associated disease, intraluminal vancomycin is preferable for more severe C difficile colitis. Early surgical intervention can improve outcomes with fulminant colitis, although overall mortality remains high.
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Affiliation(s)
- Philip A Efron
- Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
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Jaber MR, Olafsson S, Fung WL, Reeves ME. Clinical review of the management of fulminant clostridium difficile infection. Am J Gastroenterol 2008; 103:3195-203; quiz 3204. [PMID: 18853982 DOI: 10.1111/j.1572-0241.2008.02198.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is a frequent cause of morbidity and mortality among elderly hospitalized patients. A small but increasing number of patients have developed fulminant CDI, and a significant number of these patients require emergency colectomy. In this review, we discuss the risk factors, pathophysiology, diagnosis, and management of fulminant CDI. DATA SOURCES A literature search (Medline, Embase, Cochrane Library, Biosis, Science Citation Index, Ovid Journals) was performed from the period between January 1980 and June 2008 using the key words "Clostridium difficile,""pseudomembranous enterocolitis,""colectomy,""acute abdomen,""antibiotic-associated diarrhea," or "fulminant Clostridium difficile colitis." Articles not in English or not related to human subjects were excluded. For this review, we analyzed the articles identified in our original search and those articles cited in the original review articles. No randomized trials were found on the surgical management of fulminant CDI and only retrospective studies with a minimum of five patients were used in the review. With respect to medical treatment, we based our review on guideline articles, systematic reviews, and available randomized trials. CONCLUSION Both the incidence and severity of CDI are increasing. Fulminant CDI is underappreciated as a life-threatening disease because of a lack of awareness of its severity and its nonspecific clinical syndrome. Early diagnosis and treatment are essential for a good outcome, and early surgical intervention should be used in patients who are unresponsive to medical therapy. The surgical procedure of choice is a total abdominal colectomy with end ileostomy, although the mortality rate remains high.
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Affiliation(s)
- M Raffat Jaber
- Department of Surgery, Loma Linda University Medical Center, Loma, Linda, California 92354, USA
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Outcomes following colectomy for Clostridium difficile colitis. Int J Surg 2008; 7:78-81. [PMID: 19070558 DOI: 10.1016/j.ijsu.2008.11.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Revised: 11/12/2008] [Accepted: 11/18/2008] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Clostridium difficile associated diarrhoea has become an important health problem in UK hospitals but surgical intervention is rarely required. There is little evidence regarding best practice for patients requiring surgical intervention. The aim of this multicentre study was to review our experience in patients requiring surgery for C. difficile colitis. METHODS Patients who underwent surgery for C. difficile colitis in 5 hospitals in Southeast England over a 7-year period (1 teaching hospital and 4 district general hospitals) were identified from histopathology databases. Data were collected regarding the presentation, indication for surgery and post-operative outcomes. RESULTS 15 patients (9 males; mean age=71 years (range 35-84 years)) underwent surgery. 46% of patients (n=7) contracted C. difficile during their hospital admission for other medical reasons and 73% of patients were initially admitted under other medical specialties. Diagnosis was only made preoperatively in 8 patients (53%). Indications for surgery were peritonitis and systemic toxicity (n=12), failure of medical management (n=2) and unresolving large bowel dilatation (n=1). 12 patients underwent total colectomy and the rest underwent segmental resection. All patients were admitted to the intensive care unit post operatively with a mean stay of 6 days. 2 patients needed a second look laparotomy. Mortality rate was 67% (n=10), with all but 1 patient dying within the 30-day mortality period. The mean length of hospital stay of survivors was 30 days (range 17-72). CONCLUSIONS Surgical intervention for C. difficile colitis remains uncommon. Total colectomy and end ileostomy is the procedure of choice. The outlook for patients requiring surgery remains poor.
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Surgical Complications of Childhood Tumors. THE SURGERY OF CHILDHOOD TUMORS 2008. [PMCID: PMC7122594 DOI: 10.1007/978-3-540-29734-5_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Most childhood tumors will first present to a physician; some tumors will present in an atypical manner and may mimic a surgical condition. The diagnosis may be missed if the surgeon is not aware of the possibility of cancer. A very great number of rare presentations of childhood cancer have been described in the literature. It is important that the surgeon who is not experienced in the management of childhood cancer is aware that an apparently benign condition could be a manifestation of an underlying malignancy [71, 83] (Table 22.1).
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Hashimoto M, Sugawara Y, Tamura S, Kaneko J, Matsui Y, Togashi J, Makuuch M. Clostridium difficile-associated diarrhea after living donor liver transplantation. World J Gastroenterol 2007; 13:2072-6. [PMID: 17465450 PMCID: PMC4319127 DOI: 10.3748/wjg.v13.i14.2072] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the incidence and analyze the risk factors for Clostridium difficile-associated diarrhea (CDAD) after living donor liver transplantation (LDLT) in adult.
METHODS: The micobiological data and medical records of 242 adult recipients that underwent LDLT at the Tokyo University Hospital were analyzed retrospectively. The independent risk factors for postoperative CDAD were identified.
RESULTS: Postoperative CDAD occurred in 11 (5%) patients. Median onset of CDAD was postoperative d 19 (range, 5-54). In the multivariate analyses, male gender (odds ratio, 4.56) and serum creatinine (≥ 1.5 mg/dL, odds ratio, 16.0) independently predicted postoperative CDAD.
CONCLUSION: CDAD should be considered in the differential diagnosis of patients with postoperative diarrhea after LDLT.
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Affiliation(s)
- Masao Hashimoto
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
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Surowiec D, Kuyumjian AG, Wynd MA, Cicogna CE. Past, present, and future therapies for Clostridium difficile-associated disease. Ann Pharmacother 2006; 40:2155-63. [PMID: 17148650 DOI: 10.1345/aph.1h332] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE To describe and examine the past, present, and potential future treatment options for Clostridium difficile-associated disease (CDAD). DATA SOURCES A PubMed search, restricted to English-language articles concerning CDAD, was conducted (1965-October 2006) using the key words Clostridium difficile, diarrhea, vancomycin, metronidazole, immunoglobulin, and recurrence. Additional references were located through review of the bibliographies of cited articles and by visiting www.clinicaltrials.gov. STUDY SELECTION AND DATA EXTRACTION Articles related to the clinical manifestations, diagnosis, and treatment of CDAD, as well as articles addressing current issues related to CDAD, were included. DATA SYNTHESIS There have been many investigations into CDAD because of the recent increased incidence and morbidity and mortality of the disease. Various studies examining the changing epidemiology and pathogenicity of C. difficile, as well as new therapies for CDAD with agents such as tolevamer and nitazoxanide, are ongoing. In addition, researchers are investigating probiotics and vaccines to evaluate their effectiveness in preventing CDAD and/or preventing recurrences of CDAD. Studies assessing therapies for refractory CDAD are lacking, although case reports have been published citing treatment strategies using vancomycin enemas, intravenous metronidazole, colestipol and cholestyramine, fecal enemas, bowel irrigation, and immunoglobulin. Furthermore, judicious use of antimicrobials, contact precautions, and adequate environmental cleaning are being evaluated in healthcare institutions as methods for controlling and preventing the spread of C. difficile. CONCLUSIONS Oral metronidazole is the drug of choice for an initial CDAD episode. Oral vancomycin is an option for patients who cannot take or fail treatment with oral metronidazole. Clinical trials are necessary to define the therapy for initial CDAD that is most appropriate and produces lower recurrence rates compared with oral metronidazole or vancomycin treatment. Moreover, appropriate treatment for patients with multiple recurrences of or refractory CDAD needs to be determined. More studies are also needed assessing prevention of recurrences of CDAD.
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McFarland LV. Alternative treatments for Clostridium difficile disease: what really works? J Med Microbiol 2005; 54:101-111. [PMID: 15673502 DOI: 10.1099/jmm.0.45753-0] [Citation(s) in RCA: 128] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Vancomycin and metronidazole have been used for treating Clostridium difficile-associated disease (CDAD) for the past 25 years, but approximately 20 % of patients develop recurrent disease. The increasing incidence of nosocomial outbreaks, cases of recurrent CDAD and other complications (toxic megacolon, ileus, sepsis) has fuelled the search for different types of treatments. As the understanding of the pathogenesis of this disease has matured, newer treatment strategies that take advantage of these mechanisms have been developed. This review will describe such treatments and examine the evidence for each strategy.
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Affiliation(s)
- Lynne V McFarland
- University of Washington, HSR&D, 1100 Olive Street, #1400, Seattle, WA 98101, USA
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Longo WE, Mazuski JE, Virgo KS, Lee P, Bahadursingh AN, Johnson FE. Outcome after colectomy for Clostridium difficile colitis. Dis Colon Rectum 2004; 47:1620-6. [PMID: 15540290 DOI: 10.1007/s10350-004-0672-2] [Citation(s) in RCA: 150] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Clostridium difficile colitis is a relatively common entity, yet large series of patients with fulminant C. difficile colitis are infrequently reported. This study was designed to identify risk factors, clinical characteristics, and outcome of patients who required colectomy for fulminant C. difficile colitis. METHODS A population-based study on all patients in 159 hospitals of the Department of Veterans Affairs from 1997 to 2001 was performed. Data were compiled from several national computerized Department of Veterans Affairs data sets. Supplementary information including demographic information, discharge summaries, operative reports, and pathology reports were obtained from local medical records. Patient variables were entered into a computerized database and analyzed using the Pearson chi-squared and Fisher's exact tests. Statistical significance was designated as P < 0.05. RESULTS Sixty-seven patients (mean age, 69 (range, 40-86) years; 99 percent males) were identified. All 67 patients had C. difficile verified in the colectomy specimens. Thirty-six of 67 patients (54 percent) developed C. difficile colitis during a hospitalization for an unrelated illness, and 30 of 36 patients (87 percent) after a surgical procedure. Thirty-one of 67 (46 percent) developed C. difficile colitis at home. There was no history of diarrhea in 25 of 67 patients (37 percent). Thirty of 67 patients (45 percent) presented in shock (blood pressure, <90 mmHg). Forty-three of 67 patients (64 percent) presented with an acute surgical abdomen. Mean white blood cell count was 27.2; mean percent bands was 12. Twelve of 67 patients (18 percent) had a negative C difficile colitis stool assay. Abdominal computed tomography correctly diagnosed 45 of 46 patients (98 percent) who were imaged. Twenty-six of 67 patients (39 percent) underwent colonoscopy; all 26 were found to have severe inflammation or pseudomembranes. Fifty-three of 67 patients (80 percent) underwent total colectomy; 14 of 67 underwent segmental colonic resection. Perforation and infarction were found in 59 of 67 patients (58 percent) at surgery. Overall mortality was 48 percent (32/67). Mean hospitalization was 36 (range, 2-297) days. CONCLUSIONS Patients with fulminant C. difficile colitis often present with an unexplained abdominal illness with a marked leukocytosis that rapidly progresses to shock and peritonitis. Although frequently developed during a hospitalization and often after a surgical procedure, it may develop outside of a hospital setting. Diarrhea may be absent and stool cytology may be negative for C. difficile toxin. Perforation and infarction are frequently found at surgery. In those patients who survive, a prolonged hospitalization is common. Mortality from fulminant C. difficile colitis remains high despite surgical intervention.
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Affiliation(s)
- Walter E Longo
- Department of Surgery, St. Louis University School of Medicine, St. Louis, Missouri, USA.
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Apisarnthanarak A, Razavi B, Mundy LM. Adjunctive intracolonic vancomycin for severe Clostridium difficile colitis: case series and review of the literature. Clin Infect Dis 2002; 35:690-6. [PMID: 12203166 DOI: 10.1086/342334] [Citation(s) in RCA: 130] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2002] [Revised: 04/24/2002] [Indexed: 11/03/2022] Open
Abstract
Successful treatment of severe Clostridium difficile colitis has been reported with the use of adjunctive intracolonic vancomycin (ICV) therapy. We report a descriptive case series and review the literature on patients with C. difficile colitis who received adjunctive ICV therapy. Nine patients received antibiotics within 6 weeks prior to presentation. Complete resolution of the clinical presentation occurred in 8 patients (88.9%), and eradication of C. difficile cytotoxin production was documented in 3 (75%) of 4 patients who were tested after the completion of adjunctive ICV therapy. One patient (11.1%) died as a result of progressive multisystem organ failure. In the 6 weeks after the completion of treatment for C. difficile colitis, no patient had recurrent disease, required surgical intervention, or experienced complications from adjunctive ICV therapy. In this case series, administration of adjunctive ICV therapy appeared to be a safe, practical, and effective adjunctive therapy for severe C. difficile colitis.
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Affiliation(s)
- Anucha Apisarnthanarak
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, 63110, USA
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Alfa MJ, Swan B, VanDekerkhove B, Pang P, Harding GKM. The diagnosis of Clostridium difficile-associated diarrhea: comparison of Triage C. difficile panel, EIA for Tox A/B and cytotoxin assays. Diagn Microbiol Infect Dis 2002; 43:257-63. [PMID: 12151184 DOI: 10.1016/s0732-8893(02)00413-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
This study prospectively compared; Triage(R) C. difficile test (TCT), TechLab C. difficile toxin A-B enzyme immuno-assay (EIA), and cell-culture cytotoxin test (CT). Of the 400 stools tested, 99 were positive by any test with 92, 41 and 58 detected by TCT, EIA and CT, respectively. Culture of discordant samples indicated that 52 contained C. difficile (42 toxigenic, 10 non-toxigenic), 10 contained Clostridium species and 2 had no detectable clostridium isolates. There were 21/42 toxigenic C. difficile isolates from 17 patients whose stools were negative when originally tested by CT. Review of available patient charts indicated that 12/14 did not previously or currently have C. difficile associated diarrhea, whereas 2 patients developed disease within a few days. Compared to CT as the gold standard, the sensitivity and specificity were; 93%, 89% and 66%, 99% for TCT and EIA respectively. The 8 stool samples with Toxin A(-) Toxin B(+) isolates were detected in 8, 4, and 6 samples by TCT, EIA and CT, respectively. In summary, TCT as a screening test allowed reliable reporting for 85% of stools on the day of receipt. For the 15% of stools requiring further testing we recommend the use of CT.
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Affiliation(s)
- M J Alfa
- St. Boniface General Hospital, Winnipeg, MB, Canada.
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Abstract
Clostridium difficile is a major cause of antibiotic-associated diarrhea and colitis. The incidence of infection with this organism is increasing in hospitals worldwide, consequent to the widespread use of broad-spectrum antibiotics. Pathogenic strains of C. difficile produce two protein exotoxins, toxin A and toxin B, that cause colonic mucosal injury and inflammation. Many patients who are colonized are asymptomatic, and recent evidence indicates that diarrhea and colitis occur in those individuals who lack a protective antitoxin immune response. In patients who do develop symptoms, the spectrum of C. difficile disease ranges from mild diarrhea to fulminant pseudomembranous colitis. Prevention of nosocomial C. difficile infection involves judicious use of antibiotics and multidisciplinary infection control measures to reduce environmental contamination and patient cross-infection. Ultimately, active or passive immunization against C. difficile may be an effective means of controlling the growing problem of nosocomial C. difficile diarrhea and colitis.
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Affiliation(s)
- L Kyne
- Harvard Medical School, Gerontology Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Abstract
Treatment of C. difficile diarrhea with metronidazole or vancomycin is highly effective at relieving symptoms. The high rate of diarrhea recurrence is concerning, but fortunately most patients respond to a second course of treatment. The problem of vancomycin resistance in hospital organisms has markedly reduced usage of this agent as a first-line treatment for C. difficile diarrhea, leaving metronidazole as the mainstay of treatment in the United States where teicoplanin and fusidic acid are not marketed. It is likely that any new antimicrobial agent used to treat C. difficile will be similarly plagued by a high rate of recurrence, presumably incurred as a result of disruption of normal bowel flora. There is a need for improved treatment and prevention of this increasingly frequent and debilitating nosocomial infection. Treatments that utilize passive antibodies, immunization, nontoxigenic C. difficile, or other forms of biotherapy may hold the key to improved treatment and prevention of C. difficile disease in the future. In the meantime, it behooves all practitioners to use antimicrobials judiciously in order to prevent as many cases of C. difficile diarrhea as possible.
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Affiliation(s)
- D N Gerding
- Department of Medicine, Northwestern University Medical School, Chicago, IL, USA
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García-Osogobio S, Takahashi T, Gamboa-Domínguez A, Medina H, Arch J, Mass W, Sierra-Madero J, Uscanga L. Toxic pseudomembranous colitis in a patient with ulcerative colitis. Inflamm Bowel Dis 2000; 6:188-90. [PMID: 10961591 DOI: 10.1097/00054725-200008000-00005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
UNLABELLED Toxic colitis is a severe disease that may be caused by several inflammatory and/or infectious diseases. Ulcerative colitis is one of the most frequent causes of toxic colitis in the United States. Toxic megacolon complicating Clostridium difficile colitis is a rare occurrence with significant morbidity and mortality. CASE REPORT A 52-year-old male presented with rectal bleeding and tenesmus. He had been treated for amebiasis with metronidazole, and had improved. Two weeks later, symptoms recurred, and he was referred to our hospital. A sigmoidoscopy and biopsies demonstrated mucosal ulcerative colitis. He underwent treatment with systemic prednisone, mesalamine, and hydrocortisone enemas with adequate response. He was asymptomatic for 2 months, but later presented with a tender abdomen and rectal bleeding. Plain abdominal and thorax films showed colonic distention and free intraperitoneal air. Emergency laparotomy was performed, and an inflamed and distended colon, with free inflammatory liquid in the peritoneum, was found. A total abdominal colectomy with temporary ileostomy and Hartmann's pouch was performed. The histopathology analysis demonstrated a Clostridium difficile pseudomembranous colitis. CONCLUSION The presence of toxic megacolon due to Clostridium difficile in patients with ulcerative colitis is a rare complication that may be suspected in patients with initial relapse who are on antibiotics.
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Affiliation(s)
- S García-Osogobio
- Service of Colon and Rectal Surgery, Department of Surgery, Instituto Nacional de la Nutricion Salvador Zubiran, Mexico City, Mexico
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Surawicz CM, McFarland LV. Pseudomembranous Colitis Caused by C. difficile. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2000; 3:203-210. [PMID: 11097737 DOI: 10.1007/s11938-000-0023-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
Pseudomembranous colitis (PMC) is a considerable clinical concern for several reasons, including disease severity, increasing frequency, complications, and development of antibiotic-resistant organisms. C. difficile infection should be considered in anyone who develops diarrhea during or after antibiotic therapy; PMC is the most serious manifestation of C. difficile disease. PMC is effectively treated with either metronidazole or vancomycin. Metronidazole should be first-line therapy, reserving vancomycin for those who are very ill or who do not respond to metronidazole or cannot take it (ie, first trimester pregnancy, side effects). Recurrent C. difficile disease (which occurs in approximately 20% of C. difficile cases) is best treated with an antibiotic in combination with a biotherapeutic agent. Prevention of epidemics of C. difficile requires careful hand washing and cleaning of environmental surfaces. Antibiotic restriction may be necessary in some cases.
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Affiliation(s)
- CM Surawicz
- Division of Gastroenterology, Box 359773, Harborview Medical Center, 325 9th Avenue, Seattle, WA 98104, USA
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Crabtree TD, Pelletier SJ, Gleason TG, Pruett TL, Sawyer RG. Winner of the Best Paper Award from the Gold Medal Forum: Clinical Characteristics and Antibiotic Utilization in Surgical Patients with Clostridium difficile-Associated Diarrhea. Am Surg 1999. [DOI: 10.1177/000313489906500603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Clostridium difficile-associated diarrhea (CDAD) remains a significant problem in surgical patients. To address this, we prospectively studied all episodes of treated CDAD in surgical inpatients at the University of Virginia hospital from December 1996 through March 1998. CDAD accounted for 3.2 per cent (32) of 1000 total infections. Compared with a randomly selected control group with other nosocomial infections, patients with CDAD had a longer period from the time of admission to diagnosis of infection (19 ± 4 versus 9 ± 1; P = 0.01), were more likely to be female (66% versus 37%; P = 0.009), and had a higher overall crude mortality (31% versus 11%; P = 0.01), although there were no deaths directly attributable to CDAD. Ciprofloxacin (19%) and cefoxitin (16%) were the most common individual antibiotics prescribed before the diagnosis of CDAD. The average time from completion of antibiotic therapy to diagnosis of CDAD was 7 ± 2 days (range, 0-58). Sixteen per cent (5 of 32) developed CDAD after administration of prophylactic perioperative antibiotics only. The high crude mortality rate associated with CDAD suggests that this may be a significant predictor of poor outcome among infected surgical patients. Antibiotics used commonly but not classically associated with CDAD frequently precipitate this infection. Finally, the use of prophylactic antibiotics is not without risk, as demonstrated by the significant percentage of CDAD occurring after routine administration of these agents.
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Affiliation(s)
- Traves D. Crabtree
- Surgical Infectious Disease Laboratory, University of Virginia Department of Surgery, Charlottesville, Virginia
| | - Shawn J. Pelletier
- Surgical Infectious Disease Laboratory, University of Virginia Department of Surgery, Charlottesville, Virginia
| | - Thomas G. Gleason
- Surgical Infectious Disease Laboratory, University of Virginia Department of Surgery, Charlottesville, Virginia
| | - Timothy L. Pruett
- Surgical Infectious Disease Laboratory, University of Virginia Department of Surgery, Charlottesville, Virginia
| | - Robert G. Sawyer
- Surgical Infectious Disease Laboratory, University of Virginia Department of Surgery, Charlottesville, Virginia
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Cleary RK. Clostridium difficile-associated diarrhea and colitis: clinical manifestations, diagnosis, and treatment. Dis Colon Rectum 1998; 41:1435-49. [PMID: 9823813 DOI: 10.1007/bf02237064] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This review examines the pathogenesis, clinical manifestations, diagnosis, and current medical and operative strategies in the treatment of Clostridium difficile diarrhea and colitis. Prevention and future avenues of research are also investigated. METHODS A review of the literature was conducted with the use of MEDLINE. RESULTS C. difficile is a gram-positive, spore-forming bacterium capable of causing toxigenic colitis in susceptible patients, usually those receiving antibiotics. Overgrowth of toxigenic strains may result in a spectrum of disease, including becoming an asymptomatic carrier, diarrhea, self-limited colitis, fulminant colitis, and toxic megacolon. Diagnosis requires a high index of suspicion and depends on clinical data, laboratory stool studies (enzyme-linked immunoabsorbent assay and cytotoxin test), and endoscopy in selected cases. Protocols for treatment of primary and relapsing infections are provided in algorithm format. Discontinuation of antibiotics may be enough to resolve symptoms. Medical management with oral metronidazole or vancomycin is the first-line therapy for those with symptomatic colitis. Teicoplanin, Saccharomyces spp. and Lactobacillus spp., and intravenous IgG antitoxin are reserved for more recalcitrant cases. Refractory or relapsing infections may require vancomycin given orally or other newer modalities. Fulminant colitis and toxic megacolon warrant subtotal colectomy. Cost, in terms of extended hospital stay, medical and surgical management, and, in some cases, ward closure, is thought to be formidable. Review of perioperative antibiotic policies and analysis of hospital formularies may contribute to prevention and decreased costs. CONCLUSION C. difficile diarrhea and colitis is a nosocomial infection that may result in significant morbidity, mortality, and medical costs. Standard laboratory studies and endoscopic evaluation assist in the diagnosis of clinically suspicious cases. Appropriate perioperative antibiotic dosing, narrowing the antibiotic spectrum when treating infections, and discontinuing antibiotics at appropriate intervals prevent toxic sequelae.
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Affiliation(s)
- R K Cleary
- St. Joseph Mercy Hospital, Ann Arbor, Michigan, USA
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Mistry B, Longo W, Solomon H, Garvin P. Clostridium difficile colitis requiring subtotal colectomy in a renal transplant recipient: a case report and review of literature. Transplant Proc 1998; 30:3914. [PMID: 9838712 DOI: 10.1016/s0041-1345(98)01287-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- B Mistry
- Department of Surgery, Saint Louis University Health Sciences Center, St Louis, MO 63110-0250, USA
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Abstract
Pseudomembranous enterocolitis is an inflammatory bowel disorder caused by Clostridium difficile toxins. Classical presentation includes abdominal pain, pyrexia, diarrhoea and leucocytes. The management is mainly conservative but in extreme cases surgery is necessary. Resectional procedures (colectomy) carry a better prognosis than diversion procedures (colostomy). A careful history, a high index of suspicion, and early diagnosis and treatment would reduce the associated morbidity and mortality of this condition. The aetiopathogenesis, pathology, clinical presentation, diagnosis, differential diagnosis, complications, medical and surgical management are reviewed, and three case reports briefly discussed. A management algorithm is also suggested.
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Affiliation(s)
- Y K Viswanath
- Department of Surgery, General Hospital, Newcastle upon Tyne, UK
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