Cefazolin-induced pseudomembranous colitis resulting in perforation of the sigmoid colon

Vancomycin (Rectal): Clostridium difficile Infection (Severe/Complicated)

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Is It Clostridium difficile Infection or Something Else? A Case-control Study of 352 Hospitalized Patients With New-onset Diarrhea

BACKGROUND

Clostridium difficile-associated diarrhea (CDAD) is a leading cause of nosocomial diarrhea in the United States, and may be associated with significant morbidity and occasional mortality. Diarrhea is also very common among hospitalized patients and is often related to a variety of factors not related to C difficile infection.

METHODS

We performed a retrospective case-control study at a tertiary care community medical center to delineate factors that are predictive of CDAD among hospitalized patients with new-onset diarrhea (ie, not present at the time of admission). Controls were selected based on negative C difficile toxin test(s) (CDTTs) (> 95% by cytotoxic assay), presence on the same ward as the patients with first positive CDTT, and hospitalization around the same period as the positive cases.

RESULTS

The study involved 352 patients (88 cases and 264 controls). In univariate analysis, age 75 years or greater, exposure to cefazolin or levofloxacin during the 4-week period preceding CDTT, and hospitalization for 7 days or greater before CDTT were significantly associated with a positive test; male gender and prior ceftriaxone exposure nearly reached statistical significance. Multivariate logistic regression analysis revealed age 75 years or greater (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.3-3.7), hospitalization for 7 days or more (OR 2.3, 95% CI 1.3-3.8], and prior exposure to cefazolin (OR 3.5, 95% CI 1.6-7.5) or levofloxacin (OR 2.1, 95% CI 1.2-3.7) as independent predictors of a positive CDTT; male gender nearly achieved statistical significance (OR 1.6, 95% CI 0.9-2.7).

CONCLUSIONS

Among hospitalized patients with diarrhea who underwent testing for C difficile toxin, age 75 years or older, hospitalization for 7 days or greater, and recent exposure to cefazolin or levofloxacin were important predictors of a positive CDTT. These findings may help in the initiation of early presumptive treatment for CDAD, and appropriate isolation of higher risk patients before results become available. In addition, consideration of these risk factors may help in deciding whether a CDTT should be repeated when the first test is negative. Our study also supports more judicious use of antibiotics, particularly cefazolin and levofloxacin, in reducing the risk of CDAD in hospitalized patients.

Adjunctive intracolonic vancomycin for severe Clostridium difficile colitis: case series and review of the literature

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.

The role of surgery in pseudomembranous enterocolitis

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.

Clostridium difficile colitis in the critically ill

Morbidity and treatment of Clostridium difficile colitis (CDC) continue to be controversial. Some claim minimum morbidity, which may be a function of differences in patient population and/or bacterial virulence.

METHODS

To evaluate the effect of CDC in the critically ill, we retrospectively reviewed the records of 59 intensive care unit patients with CDC who were diagnosed by fecal toxin assays or clinical evidence of pseudomembranous colitis from January 1991 to October 1994. Symptoms, signs, antibiotic regimens, diagnostic tests, Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, morbidity, and mortality were analyzed, and results of surgical treatment were compared with the literature.

RESULTS

Mean age was 66.4 (17-95) years, with a male to female ratio of 1.8:1. First treatment was metronidazole by mouth in 15 patients (25.4 percent), vancomycin by mouth in 30 patients (50.8 percent), sequential by mouth vancomycin/metronidazole in 3 patients (5.1 percent), and intravenous metronidazole in 5 patients (8.5 percent). Six patients had no medical therapy before surgery or discharge. Ten patients (17 percent) had recurrence and 12 (20.3 percent) required surgery for progressive toxicity or peritonitis. Of three patients who were initially treated by diverting stomas, one died and two required total colectomy (TAC). Two underwent partial resection (1 that was nearly a total colectomy), and seven others had a TAC. Surgical patients had worse mean APACHE II scores at diagnosis (24.4 vs. 19.9; P < 0.001). Thirty-day mortality in surgical patients was 41.7 vs. 14.7 percent in medical patients (P < 0.5).

CONCLUSION

Twenty percent of critically ill patients with CDC required operation. TAC and diversion appeared to be more effective surgical treatments than diversion alone.

Toxic megacolon complicating pseudomembranous enterocolitis

PURPOSE

Toxic megacolon is a rare complication of pseudomembranous enterocolitis. We reviewed our recent experience with this complication.

METHODS

The first five patients of the series were studied retrospectively, and six others were followed prospectively.

RESULTS

Between June 1992 and May 1994, 11 patients (8 male, 3 female) developed toxic megacolon secondary to pseudomembranous enterocolitis. Mean age was 60.7 +/- 11.8 (range, 40-79) years. Presenting symptoms and signs included diarrhea, 100 percent; malaise, 91 percent; abdominal pain, 82 percent; abdominal distention, 82 percent; abdominal tenderness, 72 percent; anemia less than 12 gm, 72 percent; albumin less than 3 gm, 64 percent; tachycardia greater than 100, 55 percent; fever greater than 38.5 degrees celsius, 45 percent; shock or hypotension, 45 percent. Predisposing factors included antibiotics, 64 percent; immunosuppressants or chemotherapy, 36 percent; antidiarrheals, 27 percent; and barium enema in one patient. Five patients (45 percent) had more than one predisposing factor. X-rays showed transverse colon dilation and loss of haustrations in eight patients (72 percent), with a mean diameter of 9.9 +/- 3.4 cm. Flexible proctosigmoidoscopy showed pseudomembranes in all scoped patients, and toxin assay for Clostridium difficile was positive in all patients. One patient had emergency surgery. Ten patients were initially treated medically with nasogastric suction and intravenous resuscitation (90 percent) and antibiotics (100 percent), usually in the intensive care unit (80 percent). Four patients did not respond and underwent surgery; two others improved, then deteriorated, and also underwent surgery. Altogether, 7 of 11 patients (64 percent) underwent surgery. Three patients (27 percent) responded well to medical treatment. One patient was deemed too ill to undergo surgery and died. Mean delay to surgery was 3.0 +/- 1.3 days. No sealed or overt perforation was found at laparotomy. All patients who underwent surgery had a subtotal colectomy, with either a Hartmann's stump (71 percent) or a mucous fistula (29 percent). Eventually, five of seven patients who were operated on and two of four medically treated patients died (overall mortality, 64 percent). Only one patient underwent closure of ileostomy and anastomosis.

CONCLUSION

Toxic megacolon complicating pseudomembranous enterocolitis is a serious problem that carries a high morbidity and mortality rate, regardless of treatment.

Necrotising colitis with perforation in diarrhoic patients treated with loperamide

Two cases of necrotising enterocolitis with perforation occurred in patients with paralytic ileus after loperamide therapy. The possible role of loperamide in the pathogenesis of the complications is suggested.

Role of surgery in antibiotic-induced pseudomembranous enterocolitis

With the increased use of prophylactic and broad-spectrum antibiotics, pseudomembranous colitis has emerged as a significant clinical problem. Management with specific anti-Clostridium difficile therapy (vancomycin or metronidazole) has reduced mortality to less than 2%. Nevertheless, the disease may progress to a fulminant toxic colitis or colonic perforation. Additionally, another subset of patients will present with a dramatic clinical picture, suggesting acute peritonitis, eventuating in unnecessary laparotomy. This report reviews both the medical and surgical literature during the past 15 years of patients treated for pseudomembranous colitis. Analysis of this clinical data has provided us with the opportunity to both define the role of surgery in this disorder and illustrate the necessity for a combined medical and surgical cooperative approach in the early management of this iatrogenic disease.