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Pumiglia L, Wilson L, Rashidi L. Clostridioides difficile Colitis. Surg Clin North Am 2024; 104:545-556. [PMID: 38677819 DOI: 10.1016/j.suc.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2024]
Abstract
Clostridioides difficile colitis is an important source of hospital-acquired diarrhea associated with antibiotic use. Symptoms are profuse watery diarrhea, typically following a course of antibiotics; however, some cases of fulminant disease may manifest with shock, ileus, or megacolon. Nonfulminant colitis is treated with oral fidaxomicin. C difficile colitis has a high potential for recurrence, and recurrent episodes are also treated with fidaxomicin. Bezlotoxumab is another medication that may be used in populations at high risk for further recurrence. Fulminant disease is treated with maximal medical therapy and early surgical consultation. Antibiotic stewardship is critical to preventing C difficile colitis.
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Affiliation(s)
- Luke Pumiglia
- Department of General Surgery, Madigan Army Medical Center, 9040 Jackson Avenue, Joint Base Lewis-McChord, WA 98431, USA
| | - Lexi Wilson
- Department of Colorectal Surgery, Swedish Medical Center, 747 Broadway, Seattle, WA 98122, USA
| | - Laila Rashidi
- Department of Surgery, MultiCare Health Care System, Washington State University, 3124 19th Street Suite 220, Tacoma, WA 98405, USA.
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Successful Fecal Microbiota Transplant Delivered by Foley Catheter Through a Loop Ileostomy in a Patient With Severe Complicated Clostridioides difficile Infection. ACG Case Rep J 2022; 9:e00801. [PMID: 35919409 PMCID: PMC9278911 DOI: 10.14309/crj.0000000000000801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 03/20/2022] [Indexed: 11/17/2022] Open
Abstract
Clostridioides difficile infection (CDI) is a potentially life-threatening cause of diarrhea that can result in multiple complications. Fulminant CDI that is nonresponsive to antibiotics may require surgical ileostomy or fecal microbiota transplant (FMT). We present a case of a patient with fulminant CDI requiring surgical loop ileostomy who underwent a successful FMT delivered by Foley catheter through the ileostomy with symptom resolution. Delivery of FMT using a foley catheter in a patient with an ileostomy may be safe and effective for patients who are at a higher risk of complications associated with the instillation of FMT through colonoscopy with anesthesia.
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Carlson TJ, Gonzales-Luna AJ, Garey KW. Fulminant Clostridioides difficile Infection: A Review of Treatment Options for a Life-Threatening Infection. Semin Respir Crit Care Med 2022; 43:28-38. [PMID: 35172356 DOI: 10.1055/s-0041-1740973] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Fulminant Clostridioides difficile infection (FCDI) encompasses 3 to 5% of all CDI cases with associated mortality rates between 30 and 40%. Major treatment modalities include surgery and medical management with antibiotic and nonantibiotic therapies. However, identification of patients with CDI that will progress to FCDI is difficult and makes it challenging to direct medical management and identify those who may benefit from surgery. Furthermore, since it is difficult to study such a critically ill population, data investigating treatment options are limited. Surgical management with diverting loop ileostomy (LI) instead of a total abdominal colectomy (TAC) with end ileostomy has several appealing advantages, and studies have not consistently demonstrated a clinical benefit with this less-invasive strategy, so both LI and TAC remain acceptable surgical options. Successful medical management of FCDI is complicated by pharmacokinetic changes that occur in critically ill patients, and there is an absence of high-quality studies that included patients with FCDI. Recommendations accordingly include a combination of antibiotics administered via multiple routes to ensure adequate drug concentrations in the colon: intravenous metronidazole, high-dose oral vancomycin, and rectal vancomycin. Although fidaxomicin is now recommended as first-line therapy for non-FCDI, there are limited clinical data to support its use in FCDI. Several nonantibiotic therapies, including fecal microbiota transplantation and intravenous immunoglobulin, have shown success as adjunctive therapies, but they are unlikely to be effective alone. In this review, we aim to summarize diagnosis and treatment options for FCDI.
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Affiliation(s)
- Travis J Carlson
- Department of Clinical Sciences, High Point University Fred Wilson School of Pharmacy, High Point, North Carolina
| | - Anne J Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas
| | - Kevin W Garey
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas
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Risk factors of surgical mortality in patients with Clostridium difficile colitis. A novel scoring system. Eur J Trauma Emerg Surg 2021; 48:2013-2022. [PMID: 34480588 DOI: 10.1007/s00068-021-01769-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 08/09/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND The purpose of the study is to identify the risk factors of mortality and develop a risk scoring system in patients who underwent colectomy due to Clostridium difficile colitis (CD-C). METHODS Patient information was extracted using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) data from 2012 to 2016. All adult patients who underwent colectomy for CD-C were included in the study. The data were split into training and testing data sets. A multiple logistic regression model was developed by backward deletion methods for risk assessment. To test the performance of the prediction model for 30-day mortality, a receiver operating characteristic (ROC) curve was generated and an area under the curve (AUC) was created. RESULTS The training data set consisted of 434 (80%) patients, and the testing data set consisted of 91 (20%) patients. The overall mortality was 35%. No significant differences were found between the training and testing data sets for patient characteristics, comorbidities and mortality. The final model of the logistic regression model revealed a highly significant 30-day mortality for an age of ≥ 75 years old, ventilator dependency, Septic shock prior to surgery and a history of steroid use. The AUC value was 0.745 (95% CI 0.660-0.826). The risk of mortality scores range from 0 to 37. The highest score of 37 was related to an 83.9% predicted mortality. CONCLUSION Older age, septic shock, ventilator dependency requiring supportive care and a history of chronic steroid use were highly associated with mortality. A nomogram showing the scores and their relationship to mortality may provide guidance to point of care physicians for deciding the goal of care. LEVEL OF EVIDENCE Level of evidence: IV.
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Clostridioides difficile Infection. Dis Colon Rectum 2021; 64:650-668. [PMID: 33769319 DOI: 10.1097/dcr.0000000000002047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Asano S, Katsura M. Determining the optimal surgical timing of fulminant Clostridium difficile colitis by using four objective factors and computed tomography findings: A case report. Int J Surg Case Rep 2021; 80:105633. [PMID: 33609944 PMCID: PMC7903337 DOI: 10.1016/j.ijscr.2021.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 02/05/2021] [Accepted: 02/07/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION AND IMPORTANCE Clostridium difficile colitis is increasingly seen in everyday clinical situations, and most cases are treated with antibiotics. Fulminant C. difficile colitis (FCDC) is rare; however, it is extremely virulent, and understanding its appropriate surgical treatment is critical. The surgical timing is controversial because of the lack of concrete decision-making factors. We report a case of FCDC with a favourable outcome, which was achieved by using four objective factors and computed tomography (CT) findings. CASE PRESENTATION A patient with head trauma developed pneumonia at 2 days post-admission. He was prescribed with antibiotics. Fever and leucocytosis persisted on hospital day 10. Clostridium was detected in the stool on day 12, and metronidazole was administered. His condition did not improve; thus, he was started on vancomycin on day 14. The marked deterioration in the four laboratory parameters (white blood cell, albumin [Alb], creatinine, and body temperature) on day 15 and CT findings contributed to the decision to perform emergency subtotal colectomy and ileostomy. His condition improved dramatically postoperatively. CLINICAL DISCUSSION Many factors of FCDC are already suggested for surgical intervention in the guidelines; however, they are often seen at the late stage of FCDC. Early detection of FCDC is the key to favourable surgical outcome. Following the trend of these objective factors guides in making appropriate surgical decisions. CONCLUSION Focusing on the four objective factors and CT findings of FCDC could help surgeons detect FCDC at an early stage and decide the optimal surgical timing.
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Affiliation(s)
- Shima Asano
- Department of General Surgery, Okinawa Miyako Hospital, 427-1 Shimosato, Hirara, Miyakojima, Okinawa, 9060013, Japan.
| | - Morihiro Katsura
- Department of General Surgery, Okinawa Chubu Hospital, 281 Miyazato, Uruma-city, Okinawa, 9042293, Japan.
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Ahmed N, Kuo YH. Early Colectomy Saves Lives in Toxic Megacolon Due to Clostridium difficile Infection. South Med J 2021; 113:345-349. [PMID: 32617595 DOI: 10.14423/smj.0000000000001118] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The purpose of the study was to evaluate whether early colectomy in patients who have toxic megacolon due to Clostridium difficile colitis reduces mortality. METHODS The study was performed using the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2016. All patients 18 to 89 years of age who underwent colectomy for toxic megacolon resulting from C. difficile colitis were included in the study. Other variables included in the study were patient demography, comorbidities, and outcomes. Patients who underwent colectomy before the presentation of septic shock (early group) were compared with patients who underwent colectomy after the onset of septic shock (late group). The main outcome of the study is 30-day all-cause mortality. Because there were some significant differences found in patient baseline characteristics in the univariate analysis, the propensity score of each patient was calculated and pair-matched analysis was performed. All P values are reported as 2-sided, and P < 0.05 was considered statistically significant. RESULTS One hundred sixty-three patients met the inclusion criteria of the study. Approximately 85% of the patients underwent total abdominal colectomy. The average age of the patients was 65 years old, 51% of the patients were female, and 66% of the patients were white. The overall 30-day mortality was approximately 39%. The mortality rate of patients who underwent colectomy early compared to late was 13 (21%) vs 28 (45%), P = 0.009. The absolute risk difference was 0.24 with 95% CI: 0.07-0.42. CONCLUSIONS There was a reduction of 24% in 30-day mortality when colectomies were performed before the development of septic shock.
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Affiliation(s)
- Nasim Ahmed
- From the Division of Trauma & Surgical Critical Care and the Department of Research Administration, Jersey Shore University Medical Center, Neptune, New Jersey
| | - Yen-Hong Kuo
- From the Division of Trauma & Surgical Critical Care and the Department of Research Administration, Jersey Shore University Medical Center, Neptune, New Jersey
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Kampouri E, Croxatto A, Prod’hom G, Guery B. Clostridioides difficile Infection, Still a Long Way to Go. J Clin Med 2021; 10:jcm10030389. [PMID: 33498428 PMCID: PMC7864166 DOI: 10.3390/jcm10030389] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/12/2021] [Accepted: 01/14/2021] [Indexed: 12/11/2022] Open
Abstract
Clostridioides difficile is an increasingly common pathogen both within and outside the hospital and is responsible for a large clinical spectrum from asymptomatic carriage to complicated infection associated with a high mortality. While diagnostic methods have considerably progressed over the years, the optimal diagnostic algorithm is still debated and there is no single diagnostic test that can be used as a standalone test. More importantly, the heterogeneity in diagnostic practices between centers along with the lack of robust surveillance systems in all countries and an important degree of underdiagnosis due to lack of clinical suspicion in the community, hinder a more accurate evaluation of the burden of disease. Our improved understanding of the physiopathology of CDI has allowed some significant progress in the treatment of CDI, including a broader use of fidaxomicine, the use of fecal microbiota transplantation for multiples recurrences and newer approaches including antibodies, vaccines and new molecules, already developed or in the pipeline. However, the management of CDI recurrences and severe infections remain challenging and the main question remains: how to best target these often expensive treatments to the right population. In this review we discuss current diagnostic approaches, treatment and potential prevention strategies, with a special focus on recent advances in the field as well as areas of uncertainty and unmet needs and how to address them.
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Affiliation(s)
- Eleftheria Kampouri
- Infectious Diseases Service, Department of Medicine, University Hospital and University of Lausanne, 1011 Lausanne, Switzerland;
| | - Antony Croxatto
- Institute of Microbiology, Department of Medical Laboratory and Pathology, University Hospital and University of Lausanne, 1011 Lausanne, Switzerland; (A.C.); (G.P.)
| | - Guy Prod’hom
- Institute of Microbiology, Department of Medical Laboratory and Pathology, University Hospital and University of Lausanne, 1011 Lausanne, Switzerland; (A.C.); (G.P.)
| | - Benoit Guery
- Infectious Diseases Service, Department of Medicine, University Hospital and University of Lausanne, 1011 Lausanne, Switzerland;
- Correspondence: ; Tel.: +41-21-314-1643
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Mahatanan R, Tantisattamo E, Charoenpong P, Ferrey A. Outcomes of C difficile infection in solid-organ transplant recipients: The National Inpatient Sample (NIS) 2015-2016. Transpl Infect Dis 2020; 23:e13459. [PMID: 32894617 DOI: 10.1111/tid.13459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 08/04/2020] [Accepted: 08/20/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Clostridioides (formerly Clostridium) difficile infection (CDI) is one of the leading causes of morbidity and mortality worldwide. Solid organ transplant (SOT) recipients are at an increased risk for CDI. A recent study showed an overall improvement in mortality amongst hospitalized individuals with CDI, but it is unclear if this benefit extends to SOT recipients. METHODS We scrutinized the 2015 and 2016 National Inpatient Sample (NIS), the largest all-payer inpatient database in the United States for CDI data in patients with SOT. SOT was defined as any recipient who had received a heart, lung, liver, intestinal, kidney, pancreas, or combined thoracic and/or abdominal organ transplantation. Baseline characteristics, comorbidities, and concomitant diagnosis of pneumonia or urinary tract infection were adjusted for in our analysis. Primary outcomes included inpatient mortality, hospital length of stay and total hospital charges. RESULTS A total of 105 780 hospital discharges of SOT recipients were included. The incidence of CDI was 3554 (3.36%) among SOTs. CDI was associated with a higher inpatient mortality (OR 1.85, 95% CI 1.56-2.20, P < .01), longer length of hospital stay (mean difference 5.07 days, 95% CI 4.43-5.71, P < .01) and higher total hospital charges (mean difference 43 958 US dollars, P < .01). CONCLUSION Our study found that CDI is associated with poorer overall outcomes among hospitalized SOT recipients. However, there was a possible improving trend of the outcomes when compare to previous studies.
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Affiliation(s)
- Rattanaporn Mahatanan
- Department of Internal Medicine, Redington-Fairview General Hospital, Skowhegan, ME, USA.,Division of Infectious Disease, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Ekamol Tantisattamo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, University of California Irvine School of Medicine, Orange, CA, USA.,Nephrology Section, Department of Medicine, Tibor Rubin Veterans Affairs Medical Center, VA Long Beach Healthcare System, Long Beach, CA, USA.,Multi-Organ Transplant Center, Section of Nephrology, Department of Internal Medicine, William Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
| | - Prangthip Charoenpong
- Division of Pulmonary and Critical Care Medicine, Louisiana State University Health Sciences Center - Shreveport, Shreveport, LA, USA
| | - Antoney Ferrey
- Nephrology Section, Department of Medicine, Tibor Rubin Veterans Affairs Medical Center, VA Long Beach Healthcare System, Long Beach, CA, USA
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Cheng YW, Phelps E, Nemes S, Rogers N, Sagi S, Bohm M, El-Halabi M, Allegretti JR, Kassam Z, Xu H, Fischer M. Fecal Microbiota Transplant Decreases Mortality in Patients with Refractory Severe or Fulminant Clostridioides difficile Infection. Clin Gastroenterol Hepatol 2020; 18:2234-2243.e1. [PMID: 31923639 DOI: 10.1016/j.cgh.2019.12.029] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 12/23/2019] [Accepted: 12/26/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Fecal microbiota transplantation (FMT) is recommended for recurrent Clostridioides difficile infection (CDI). FMT cures nearly 80% of patients with severe or fulminant CDI (SFCDI) when utilized in a sequential manner. We compared outcomes of hospitalized patients before and after implementation of an FMT program for SFCDI and investigated whether the changes could be directly attributed to the FMT program. METHODS We performed a retrospective analysis of characteristics and outcomes of patients hospitalized for SFCDI (430 hospitalizations) at a single center, from January 2009 through December 2016. We performed subgroup analyses of 199 patients with fulminant CDI and 110 patients with refractory SFCDI (no improvement after 5 or more days of maximal anti-CDI antibiotic therapy). We compared CDI-related mortality within 30 days of hospitalization, CDI-related colectomy, length of hospital stay, and readmission to the hospital within 30 days before (2009-2012) vs after (2013-2016) implementation of the inpatient FMT program. RESULTS CDI-related mortality and colectomy were lower after implementation of the FMT program. Overall, CDI-related mortality was 10.2% before the FMT program was implemented vs 4.4% after (P = .02). For patients with fulminant CDI, CDI-related mortality was 21.3% before the FMT program was implemented vs 9.1% after (P = .015). For patients with refractory SFCDI, CDI-related mortality was 43.2% before the FMT program vs 12.1% after (P < .001). The FMT program significantly reduced CDI-related colectomy in patients with SFCDI (6.8% before vs 2.7% after; P = .041), in patients with fulminant CDI (15.7% before vs 5.5% after; P = .017), and patients with refractory SFCDI (31.8% vs 7.6%; P = .001). The effect of FMT program implementation on CDI-related mortality remained significant for patients with refractory SFCDI after we accounted for the underlying secular trend (odds ratio, 0.09 for level change; P = .023). CONCLUSIONS An FMT program significantly decreased CDI-related mortality among patients hospitalized with refractory SFCDI.
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Affiliation(s)
- Yao-Wen Cheng
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Emmalee Phelps
- Division of Gastroenterology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Sara Nemes
- Division of Gastroenterology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Nicholas Rogers
- Division of Gastroenterology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Sashidhar Sagi
- Division of Gastroenterology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Matthew Bohm
- Division of Gastroenterology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Mustapha El-Halabi
- Division of Gastroenterology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jessica R Allegretti
- Division of Gastroenterology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Zain Kassam
- Finch Therapeutics Group, Somerville, Massachusetts
| | - Huiping Xu
- Department of Biostatistics, Richard M. Fairbanks School of Public Health and School of Medicine, Indiana University, Indianapolis, Indiana
| | - Monika Fischer
- Division of Gastroenterology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.
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McDonald LC, Gerding DN, Johnson S, Bakken JS, Carroll KC, Coffin SE, Dubberke ER, Garey KW, Gould CV, Kelly C, Loo V, Shaklee Sammons J, Sandora TJ, Wilcox MH. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis 2019; 66:e1-e48. [PMID: 29462280 DOI: 10.1093/cid/cix1085] [Citation(s) in RCA: 1237] [Impact Index Per Article: 247.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
A panel of experts was convened by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to update the 2010 clinical practice guideline on Clostridium difficile infection (CDI) in adults. The update, which has incorporated recommendations for children (following the adult recommendations for epidemiology, diagnosis, and treatment), includes significant changes in the management of this infection and reflects the evolving controversy over best methods for diagnosis. Clostridium difficile remains the most important cause of healthcare-associated diarrhea and has become the most commonly identified cause of healthcare-associated infection in adults in the United States. Moreover, C. difficile has established itself as an important community pathogen. Although the prevalence of the epidemic and virulent ribotype 027 strain has declined markedly along with overall CDI rates in parts of Europe, it remains one of the most commonly identified strains in the United States where it causes a sizable minority of CDIs, especially healthcare-associated CDIs. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, infection prevention, and environmental management.
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Affiliation(s)
| | | | - Stuart Johnson
- Edward Hines Jr Veterans Administration Hospital, Hines.,Loyola University Medical Center, Maywood, Illinois
| | | | - Karen C Carroll
- Johns Hopkins University School of Medicine, Baltimore, Maryl
| | | | - Erik R Dubberke
- Washington University School of Medicine, St Louis, Missouri
| | | | - Carolyn V Gould
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ciaran Kelly
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Vivian Loo
- McGill University Health Centre, McGill University, Montréal, Québec, Canada
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Schluger A, Rosenblatt R, Knotts R, Verna EC, Pereira MR. Clostridioides difficile infection and recurrence among 2622 solid organ transplant recipients. Transpl Infect Dis 2019; 21:e13184. [PMID: 31571380 DOI: 10.1111/tid.13184] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 09/22/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Clostridioides difficile infection (CDI) is common after solid organ transplant (SOT) and is associated with high morbidity and mortality. METHODS We assessed incidence, risk factors, and outcomes of CDI among SOT patients at a large multi-organ transplant center. Multivariable logistic regression was used to identify risk factors for initial and recurrent CDI. RESULTS A total of 2622 SOT patients were included. 224 (8.5%) had CDI 1 year post-SOT. The highest incidence of CDI was among pancreas recipients (12.5%) followed by lung (11.7%), liver (11.0%), heart (10.8%), and kidney (5.8%). Median time to CDI was 56 days (range 2-354) post-SOT. About 64% of patients had severe CDI. About 56.3% were treated with metronidazole, 13.8% with oral vancomycin, and 28.6% with both. About 28.6% of patients had recurrent CDI. In multivariable modeling, lung transplant recipient status was the only significant predictor of recurrent CDI (OR 4.97, 95% CI 2.11-11.78, P < .001) controlling for age, severe CDI, and pre-SOT CDI. Post-SOT CDI nearly doubled the risk of mortality at one year, in particular among those with severe CDI. CONCLUSIONS In summary, CDI is highly prevalent, occurs early in the post-transplant period, usually severe, with a high rate of recurrence, and associated with increased mortality within 1 year after transplant. The early post-transplant period may be a crucial window to reduce CDI rates.
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Affiliation(s)
- Aaron Schluger
- Department of Medicine, Westchester Medical Center, Valhalla, NY, USA
| | - Russell Rosenblatt
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, NY, USA
| | - Rita Knotts
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, NY, USA
| | - Elizabeth C Verna
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, NY, USA
| | - Marcus R Pereira
- Division of Infectious Diseases, Columbia University Irving Medical Center, New York, NY, USA
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Abstract
This review describes a systematic approach to the interpretation of colonic biopsy specimens of patients with acute colitis. Five main histologic patterns are discussed: acute colitis, focal active colitis, pseudomembranous colitis, hemorrhagic colitis, and ischemic colitis. For each pattern, the most common etiologic associations and their differential diagnoses are presented. Strategies based on histologic analysis and clinical considerations to differentiate acute from chronic colitides are discussed.
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Affiliation(s)
- Jose Jessurun
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine New York, Starr 1031 B, 1300 York Avenue, New York, NY 10065, USA.
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14
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The Impact of Clostridium difficile Infection on Future Outcomes of Solid Organ Transplant Recipients. Infect Control Hosp Epidemiol 2018; 39:563-570. [PMID: 29553007 DOI: 10.1017/ice.2018.48] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVEClostridium difficile infection (CDI) is common in solid organ transplant (SOT) recipients, but few studies have examined long-term outcomes. We studied the impact of CDI after SOT on mortality and transplant organ complication-related hospitalizations (TOH).METHODSSOT recipients ≥18 years of age with at least 1 year of posttransplant data were analyzed using the MarketScan database for 2007-2014. Patients who died within one year of transplant were followed until death. Patients were grouped as early CDI (ie, first occurrence ≤90 days posttransplant), late CDI (ie, first occurrence >90 days posttransplant) and controls (ie, no CDI occurrence during follow-up). The risk of mortality or TOH after CDI was evaluated using Cox and logistic regressions, respectively.RESULTSOverall, 96 patients had early CDI, 97 patients had late CDI, and 5,913 patients were used as controls. The risk for death was significantly higher in the early CDI group than the control group (hazard ratio [HR],1.92; 95% confidence interval [CI], 1.12-3.29; P=.018); there was no significant difference between the late CDI group and the control group (HR, 0.86; 95% CI, 0.38-1.94; P=.717). Both the early CDI group (odds ratio [OR], 2.19; 95% CI, 1.45-3.31; P90 days posttransplant, both the early CDI group (n=89) and the late CDI group (n=97) had increased risk for death or TOH during follow-up than the control group (n=5,734).CONCLUSIONThough our study could not prove causality, both early and late CDI occurrence in SOT recipients were associated with worse future outcomes than for SOT recipients without CDI.Infect Control Hosp Epidemiol 2018;39:563-570.
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Evolving Treatment Strategies for Severe Clostridium difficile Colitis: Defining the Therapeutic Window. HOT TOPICS IN ACUTE CARE SURGERY AND TRAUMA 2018. [DOI: 10.1007/978-3-319-59704-1_15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Figh ML, Zoog ESL, Moore RA, Dart BW, Heath G, Butler RM, Gao C, Kong JC, Stanley JD. External Validation of Velazquez-Gomez Severity Score Index and ATLAS Scores and the Identification of Risk Factors Associated with Mortality in Clostridium difficile Infections. Am Surg 2017. [DOI: 10.1177/000313481708301216] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Treatment guidelines for Clostridium difficile infection (CDI) are limited by a lack of widely accepted clinical prediction tools (CPTs). Two published CPTs, the Velazquez-Gomez Severity Score Index (VGSSI) and ATLAS scores, were evaluated, and variables showing the greatest correlation with mortality in patients with CDI were identified to further develop an objective, mortality-based CPT. A retrospective review of the charts of 271 hospitalized patients with CDI was performed. VGSSI and ATLAS scores were assigned. Means and correlations of these scores with mortality were evaluated. Multivariate logistic regression analysis was performed on 32 known potential mortality predictor variables. Mortality was overall strongly associated with VGSSI and ATLAS scores with poor correlation within the intermediate ranges. Mean scores for nonsurvivors indicated poor calibration. The variables most associated with mortality were Age, vasopressors, steroids, creatinine level, and albumin. Although both CPTs revealed the ability to discriminate patients at greater risk for mortality, precision and overall calibration were lacking. Five variables were identified which had the greatest correlation with mortality. Utilization of these variables to enhance or modify the existing CPTs is suggested as the next step in the development of a useful and accurate mortality-based CPT for the treatment of CDI.
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Affiliation(s)
- Matthew L. Figh
- Departments of Surgery University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee
| | - Evon S. L. Zoog
- Departments of Surgery University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee
| | - Richard A. Moore
- Departments of Surgery University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee
| | - Benjamin W. Dart
- Departments of Surgery University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee
| | - Gregory Heath
- Departments of Internal Medicine, University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee
| | - Reed M. Butler
- Departments of Surgery University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee
| | - Cuilan Gao
- Department of Health and Human Performance, University of Tennessee at Chattanooga, Chattanooga, Tennessee
| | - Joseph C. Kong
- Department of Surgical Oncology, University of Melbourne, East Melbourne, Australia
| | - J. Daniel Stanley
- Departments of Surgery University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee
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Fecal Microbiota Transplant in Severe/Complicated Clostridium difficile Infection. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2017. [DOI: 10.1097/ipc.0000000000000508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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18
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Abstract
OPINION STATEMENT PURPOSE OF REVIEW: This article will review current literature describing fecal microbiota transplantation (FMT) in the treatment of various diseases, and its potential role in elderly patients (age ≥ 65 years). RECENT FINDINGS Research on FMT has blossomed in the last decade and its pivotal role in the treatment of recurrent Clostridium difficile infection (CDI) has been recognized by the American College of Gastroenterology in the latest guidelines. There is also emerging evidence that FMT may be beneficial in the treatment of severe and/or complicated CDI refractory to medical therapy, resulting in decreased rates of colectomy and mortality. In the elderly, CDI is associated with markedly higher rates of mortality and colectomy; outcomes are even worse when patients have underlying inflammatory bowel disease (IBD). While the majority of patients who receive FMT for CDI are older, only a handful of studies focused specifically on FMT treatment outcomes and safety in this age group. Current data corroborate the efficacy and safety profile of FMT, while also supporting its use for recurrent, severe, and/or complicated CDI in the elderly population. FMT is recommended for the treatment of recurrent, severe, and/or complicated CDI in patients older than 65 years of age. It may be prudent to offer FMT earlier in the disease course, possibly after just the second recurrence and for the first episode of severe CDI to avert complications including colectomy and end-organ failure that elderly patients are more prone to developing.
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van der Wilden GM, Velmahos GC, Chang Y, Bajwa E, O'Donnell WJ, Finn K, Harris NS, Yeh DD, King DR, de Moya MA, Fagenholz PJ. Effects of a New Hospital-Wide Surgical Consultation Protocol in Patients with Clostridium difficile Colitis. Surg Infect (Larchmt) 2017; 18:563-569. [PMID: 28557651 DOI: 10.1089/sur.2016.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Fulminant Clostridium difficile colitis (fCDC) occurs in 2%-8% of patients with CDC and carries a high death rate. Prompt operation may reduce death. Our aim was to determine whether a standardized hospital-wide protocol for surgical referral in CDC would result in earlier surgical consultation, earlier identification of patients who could benefit from surgical therapy, and reduced deaths from fCDC. METHODS A multidisciplinary team developed consensus criteria for surgical consultation. Compliance was evaluated by prospective review of all inpatient CDC cases. Outcomes of the prospective cohort (POST) were compared to an historic control group (PRE). RESULTS From November 1, 2010 to October 31, 2012, we identified 1,106 inpatients with CDC; 339 patients matched the consultation criteria, of whom 213 received a surgical consultation, resulting in an overall compliance rate of 62.8%. All those with fCDC received a surgical consultation, with a median time to surgical referral of three hours. Of 46 patients with fCDC, 11 (23.9%) died, compared with 34.8% in the historical control group (p = 0.15). The death rate was 14.7% in the POST group, when excluding patients with limitations of care and those transferred to our institution in a fulminant state. There was a shorter interval between admission and surgical intervention for those who required operation in the POST group-three (1-11) days versus 1.5 (0-3) days, respectively, in the PRE and POST groups (p = 0.018), and a shorter adjusted median hospital length of stay (adjusted difference 9.0, 95% CI 2.2-12.3, p = 0.007) Conclusions: A hospital-wide protocol with established criteria for surgical consultation resulted in faster intervention and a shorter adjusted median hospital length of stay. The overall death rate for fCDC patients without limitations of life-sustaining treatment who presented to our emergency department or in whom fCDC developed while they were admitted to our hospital was 14.7%.
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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.,4 Department of Trauma Surgery, Leiden University Medical Center and Leiden University , The Netherlands
| | - George C Velmahos
- 1 Department of Surgery, Division of Trauma, Emergency Surgery & Critical Care, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
| | - Yuchiao Chang
- 2 Department of Medicine, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
| | - Ed Bajwa
- 2 Department of Medicine, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
| | - Walter J O'Donnell
- 2 Department of Medicine, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
| | - Kathleen Finn
- 2 Department of Medicine, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
| | - N Stuart Harris
- 3 Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
| | - D Dante Yeh
- 1 Department of Surgery, Division of Trauma, Emergency Surgery & Critical Care, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
| | - David R King
- 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
| | - Peter J Fagenholz
- 1 Department of Surgery, Division of Trauma, Emergency Surgery & Critical Care, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
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20
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Abstract
Laparoscopic surgery has revolutionized the delivery of care to the surgical patient undergoing colorectal resection. Since the first laparoscopic-assisted colectomy in 1991, significant advances have been made in minimally invasive colorectal surgery. For many benign conditions, laparoscopic colectomy has been proven to be safe and effective, and in some instances superior when compared with open surgery. Complex laparoscopic resections such as those for diverticulitis and inflammatory bowel disease have also been shown to have equivalent outcomes when compared with open surgery. Short-term benefits of a minimally invasive approach include less pain, decreased rates of wound infection and postoperative morbidity, faster return of bowel function, and shorter length of stay. Improvements in long-term complications have also been noted with lower incidence of incisional hernias and small bowel obstructions secondary to adhesions. As surgeons become more facile with laparoscopic resection, more complex cases such as those for complicated diverticulitis and reoperative surgery for inflammatory bowel disease can be completed with shorter operative times and decreased cost.
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Affiliation(s)
- Radhika Smith
- University of Chicago, Section of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida
| | - David J. Maron
- Department of Colon and Rectal Surgery, Cleveland Clinic Florida, Weston, Florida
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21
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Silva-Velazco J, Hull TL, Messick C, Church JM. Medical versus Surgical Patients with Clostridium difficile Infection: Is There Any Difference? Am Surg 2016. [DOI: 10.1177/000313481608201219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Severity of Clostridium difficile infection (CDI) varies from one patient to another. We aimed to test the hypothesis that surgical patients would suffer more severe CDIs than medical patients. Patients receiving in-hospital medical or surgical treatment for any underlying disease from 2007 to 2012, who developed CDI, were divided into two groups: “Medical group” and “Surgical group.” Demographics, disease characteristics, and outcomes including mortality and recurrence were compared. Of 3231 patients with CDI evaluated, 1984 (61.4%) and 1247 (38.6%) were medical and surgical patients, respectively. Surgical patients had more severe CDIs than medical. However, the long-term effects of CDI were worse in medical patients, with more and quicker deaths. Recurrence was comparable between groups. Surgical patients were more frequently male, older, and obese; had higher white blood cells but lower levels of hemoglobin, hematocrit, and prealbumin; and had a higher rate of severe CDI. Conversely, medical patients had fewer in-hospital days, CDI appeared earlier, and had greater 30-day mortality and total number of deaths, with death after CDI occurring earlier. Although surgical patients tend to have a stormier clinical course related to CDI, overall they do better than medical patients. Future studies focusing on modifiable risk factors for each group are needed.
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Affiliation(s)
- Jorge Silva-Velazco
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Tracy L. Hull
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Craig Messick
- Department of Colon and Rectal Surgery, Division of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - James M. Church
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
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22
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Minami K, Sakaguchi Y, Yoshida D, Yamamoto M, Ikebe M, Morita M, Toh Y. Successful treatments with polymyxin B hemoperfusion and recombinant human thrombomodulin for fulminant Clostridium difficile-associated colitis with septic shock and disseminated intravascular coagulation: a case report. Surg Case Rep 2016; 2:76. [PMID: 27468959 PMCID: PMC4965360 DOI: 10.1186/s40792-016-0199-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 07/01/2016] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Clostridium difficile (CD)-associated colitis (CDAC) is endemic and a common nosocomial enteric disease encountered by surgeons in modern hospitals due to prophylactic or therapeutic antibiotic therapies. Currently, the incidence of fulminant CDAC, which readily causes septic shock followed by multiple organ dysfunction syndromes, is increasing. Fulminant CDAC requires surgeons to perform a prompt surgery, such as subtotal colectomy, to remove the septic source. It is known that fulminant CDAC is caused by the shift from an inflammatory response at a local mucosal level to a general systemic inflammatory reaction in which CD toxin-induced mediators' cascades disseminate. Recently, it has been proven that polymyxin B hemoperfusion (PMX-HP) improves septic shock and recombinant human thrombomodulin (rhTM) controls disseminated intravascular coagulation (DIC). In addition, clinically and basically, it has been shown that these treatments can control serous chemical mediators. Therefore, it is considered that these treatments are promising ones for patients with fulminant CDAC. In the current report, we present that these treatments without surgery contributed to the improvement of sepsis due to fulminant CDAC. CASE PRESENTATION We encountered a case who developed fulminant CDAC with septic shock and DIC after laparoscopic gastrectomy for gastric cancer. At admission to the intensive care unit, his APACHE II score was 22, which indicated an estimated risk of hospital death of 42.4 %. Our therapies were not the subtotal colectomy to remove septic sources but the combination treatments with both PMX-HP and rhTM. These combination therapies resulted in excellent outcomes, namely the dramatic improvement of septic shock and DIC and the patient's survival. We speculate that these combination therapies completely inhibit the CD toxin-induced mediators' cascades and correspond to the removal of septic sources. CONCLUSIONS We recommend both PMX-HP and rhTM for patients who develop fulminant CDAC with septic shock and DIC to increase the survival benefit and replace the need for surgical treatment.
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Affiliation(s)
- Kazuhito Minami
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, Notame 3-1-1, Minami-ku, Fukuoka, 811-1395, Japan.
| | - Yoshihisa Sakaguchi
- Department of Gastroenterological Surgery, National Hospital Organization Kyushu Medical Center, Jigyohama 1-8-1, Chuo-ku, Fukuoka, 810-8563, Japan
| | - Daisuke Yoshida
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, Notame 3-1-1, Minami-ku, Fukuoka, 811-1395, Japan
| | - Manabu Yamamoto
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, Notame 3-1-1, Minami-ku, Fukuoka, 811-1395, Japan
| | - Masahiko Ikebe
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, Notame 3-1-1, Minami-ku, Fukuoka, 811-1395, Japan
| | - Masaru Morita
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, Notame 3-1-1, Minami-ku, Fukuoka, 811-1395, Japan
| | - Yasushi Toh
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, Notame 3-1-1, Minami-ku, Fukuoka, 811-1395, Japan
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Han S, Shannahan S, Pellish R. Fecal Microbiota Transplant. J Intensive Care Med 2016; 31:577-86. [DOI: 10.1177/0885066615594344] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 05/14/2015] [Indexed: 12/16/2022]
Abstract
Clostridium difficile infection (CDI) has steadily increased in incidence since the 1990s, with an associated increase in recurrence and severity, which has in turn lead to more intensive care unit (ICU) admissions. The development of recurrent CDI, in particular, has been associated with increasing patient morbidity and mortality as well as an immense financial burden on the health care system. Recently, fecal microbiota transplantation (FMT) has received much publicity as an effective means of treatment for recurrent CDI. The goal of this review is to provide evidence-based recommendations for the diagnosis and management of CDI, with a particular focus on FMT and its utilization in the ICU.
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Affiliation(s)
- Samuel Han
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Sarah Shannahan
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Randall Pellish
- University of Massachusetts Medical School, Worcester, MA, USA
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Abstract
Successful surgical salvage after transanal excision (TAE) of rectal cancers has historically been considered feasible, but results vary. We examine our experience in surgical salvage of locally recurrent rectal cancers after TAE. A retrospective review of patients undergoing salvage surgery for locally recurrent early-stage rectal cancer after TAE from March 1990 to March 2008 at our institution is presented here. Seventy-eight patients underwent TAE for tumor invades submucosa (T1) rectal cancer. Average age of patients was 68.3 years. Recurrence occurred in 17 patients (21.8%). Median number of months between the first operation and the recurrence was 41 months. Sixteen out of 17 patients recurred locally whereas one had only distant recurrence. Fourteen were eligible for surgical salvage. Ten patients underwent abdominoperineal resection, whereas four underwent repeat local excision. Eleven deaths were noted and the median survival after the first operation was 70.3 months. Disease-free survival after salvage surgery was 53 per cent (9/17), with a median follow-up of 68 months from the original surgery. Disease-specific mortality was 47 per cent (8/17), with a median survival of 72 months from the original surgery. Five-year survival in the recurrence group was 11/16 (69%). In conclusion, TAE for T1 rectal cancer carries a higher risk of recurrence. Of the local recurrences, 87.5 per cent underwent microscopic negative margins (R0) resection at the time of salvage and had a five-year survival of 69 per cent. Long-term surveillance is encouraged, as recurrence can be seen even after 10 years from initial treatment. TAE can be considered for T1 rectal tumor with reasonable outcomes.
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Affiliation(s)
- Sachin Vaid
- Christiana Hospital, Newark, Delaware
- St. Francis Hospital, Wilmington, Delaware
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25
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Carmo J, Marques S, Chapim I, Túlio MA, Rodrigues JP, Bispo M, Chagas C. Leaping Forward in the Treatment of Clostridium Difficile Infection: Update in 2015. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2015; 22:259-267. [PMID: 28868417 PMCID: PMC5579984 DOI: 10.1016/j.jpge.2015.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 07/01/2015] [Indexed: 12/15/2022]
Abstract
In recent years, significant advances in the treatment of Clostridium difficile infection (CDI) have risen. We review the most relevant updated recommendations in the current standard of care of CDI and discuss emerging therapies, including antibiotic, alternative therapies (probiotics, toxin-binding resins, immunotherapy) and new data on fecal transplantation. Upcoming surgical options and other rescue therapies for severe refractory disease are also addressed. Although oral metronidazole is a first-line therapy for non-severe CDI, emerging data have demonstrated its inferiority relatively to vancomycin, particularly in the setting of recurrent and/or severe infection. After a CDI recurrence for the first time, fidaxomicin has been shown to be associated with lower likelihood of CDI recurrence compared to vancomycin. Fecal transplantation is now strongly recommended for multiple recurrent CDI and may have a role in refractory disease. Oral, frozen stool capsules may simplify fecal transplantation in the future, with preliminary promising results. Diverting loop ileostomy combined with colonic lavage is a potential alternative to colectomy in severe complicated CDI. Potential alternative therapies requiring further investigation include toxin-binding resins and immunotherapy.
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Affiliation(s)
- Joana Carmo
- Gastroenterology Department, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Susana Marques
- Gastroenterology Department, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Iolanda Chapim
- Gastroenterology Department, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Maria Ana Túlio
- Gastroenterology Department, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - José Pedro Rodrigues
- Gastroenterology Department, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Miguel Bispo
- Gastroenterology Department, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal.,Gastroenterology and Digestive Endoscopy Center, Hospital da Luz, Lisbon, Portugal
| | - Cristina Chagas
- Gastroenterology Department, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
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26
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Abstract
Background Clostridium difficile infections (CDI) are increasingly important in patients with antibiotic treatments, ranging from mild, self-limiting to severe, life-threatening disease. Currently, diagnostic algorithms and treatment guidelines are being adapted to novel tests and therapeutic options for recurrent CDI. Methods A systematic literature search using the terms ‘Clostridium difficile’ and ‘treatment’ was carried out. Current guidelines are being discussed from a clinical point of view. Results State-of-the-art diagnostics for C. difficile diagnosis rely on the patient's history, clinical symptoms, and laboratory examination of stool. Recommendations are in favour of glutamate dehydrogenase (GDH) screening tests and confirmatory detection of C. difficile toxin genes (polymerase chain reaction (PCR)). Therapeutic strategies depend on disease severity (mild vs. severe) and endorse metronidazole and vancomycin as well as fidaxomycin for recurrent disease. In very severe cases, surgical therapy is recommended. For relapsing diseases, faecal transfer is considered as a therapeutic option if available. Conclusion Current guidelines have been adapted to new pathways in diagnosing CDI and have included statements on novel therapeutic options such as fidaxomycin and faecal transplant for recurrent disease. Depending on the severity of the disease, standard therapy with either metronidazole or vancomycin is recommended.
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Affiliation(s)
- Peter M Keller
- Clinic of Internal Medicine IV, Gastroenterology, Hepatology, and Infectious Diseases, University Hospital Jena, Jena, Germany
| | - Marko H Weber
- Clinic of Internal Medicine IV, Gastroenterology, Hepatology, and Infectious Diseases, University Hospital Jena, Jena, Germany
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27
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Lübbert C, John E, von Müller L. Clostridium difficile infection: guideline-based diagnosis and treatment. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 111:723-31. [PMID: 25404529 DOI: 10.3238/arztebl.2014.0723] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 08/14/2014] [Accepted: 08/14/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Clostridium difficile (C. difficile) is the pathogen that most commonly causes nosocomial and antibiotic-associated diarrheal disease. Optimized algorithms for diagnosis, treatment, and hygiene can help lower the incidence, morbidity, and mortality of C. difficile infection (CDI). METHODS This review is based on pertinent articles that were retrieved by a selective search in PubMed for recommendations on diagnosis and treatment(up to March 2014), with particular attention to the current epidemiological situation in Germany. RESULTS The incidence of CDI in Germany is 5 to 20 cases per 100,000 persons per year. In recent years, a steady increase in severe, reportable cases of CDI has been observed, and the highly virulent epidemic strain Ribotype 027 has spread across nearly the entire country. For therapeutic and hygiene management, it is important that the diagnosis be made as early as possible with a sensitive screening test, followed by a confirmatory test for the toxigenic infection. Special disinfection measures are needed because of the formation of spores. The treatment of CDI is evidence-based; depending on the severity of the infection, it is treated orally with metronidazole, or else with vancomycin or fidaxomicin. Fulminant infections and recurrences call for specifically adapted treatment modalities. Treatment with fecal bacteria (stool transplantation) is performed in gastroenterological centers that have experience with this form of treatment after multiple failures of drug treatment for recurrent infection. For critically ill patients, treatment is administered by an interdisciplinary team and consists of early surgical intervention in combination with drug treatment. A therapeutic algorithm developed on the basis of current guidelines and recommendations enables risk-adapted, individualized treatment. CONCLUSION The growing clinical and epidemiological significance of CDI compels a robust implementation of multimodal diagnostic, therapeutic, and hygienic standards. In the years to come, anti-toxin antibodies, toxoid vaccines, and focused bacterial therapy will be developed as new treatment strategies for CDI.
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Affiliation(s)
- Christoph Lübbert
- Division of Infectious Diseases and Tropical Medicine, Department of Gastroenterology and Rheumatology, Department of Internal Medicine, Neurology and Dermatology, Leipzig University Hospital, Department of General, Visceral and Vascular Surgery, University Hospital of Halle (Saale), Institute of Medical Microbiology and Hygiene, Saarland University Medical Center, National Advisory Laboratory for Clostridium difficile
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To KB, Napolitano LM. Clostridium difficile infection: update on diagnosis, epidemiology, and treatment strategies. Surg Infect (Larchmt) 2015; 15:490-502. [PMID: 25314344 DOI: 10.1089/sur.2013.186] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Clostridium difficile infection (CDI) has increased in incidence and severity over the past quarter century, and is now considered a major cause of healthcare-associated infections. METHODS Review of the pertinent English-language medical literature. RESULTS There has been a substantial change in the management of CDI. The emergence of the NAP1/BI/O27 strain in the early to mid-2000s has been associated with more severe forms of CDI. The pathophysiology, epidemiology, clinical manifestations and diagnosis, as well as new strategies for medical and surgical management are discussed in this review. CONCLUSIONS Clostridium difficile infection can range from benign diarrhea to severe disease associated with substantial morbidity and mortality. Treatment modalities vary based on disease severity and timing of onset. The mainstay of medical treatment remains metronidazole and oral/rectal vancomycin. New management strategies are evolving, including adjunctive treatments such as monoclonal antibodies, vaccination, and fecal transplant. In patients with severe disease or clinical deterioration, early surgical consultation for total colectomy or loop ileostomy may be life-saving. Infection control measures are vital to mitigating the spread of CDI.
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Affiliation(s)
- Kathleen B To
- Department of Surgery, University of Michigan , Ann Arbor, Michigan
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29
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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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Kachrimanidou M, Sarmourli T, Skoura L, Metallidis S, Malisiovas N. Clostridium difficile infection: New insights into therapeutic options. Crit Rev Microbiol 2015; 42:773-9. [PMID: 25955884 DOI: 10.3109/1040841x.2015.1027171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Clostridium difficile infection (CDI) is an important cause of mortality and morbidity in healthcare settings and represents a major social and economic burden. The major virulence determinants are large clostridial toxins, toxin A (TcdA) and toxin B (TcdB), encoded within the pathogenicity locus. Traditional therapies, such as metronidazole and vancomycin, frequently lead to a vicious circle of recurrences due to their action against normal human microbiome. New disease management strategies together with the development of novel therapeutic and containment approaches are needed in order to better control outbreaks and treat patients. This article provides an overview of currently available CDI treatment options and discusses the most promising therapies under development.
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Affiliation(s)
- Melina Kachrimanidou
- a Department of Microbiology , Medical School, Aristotle University of Thessaloniki , Greece , Thessaloniki , Greece and
| | - Theopisti Sarmourli
- a Department of Microbiology , Medical School, Aristotle University of Thessaloniki , Greece , Thessaloniki , Greece and
| | - Lemonia Skoura
- a Department of Microbiology , Medical School, Aristotle University of Thessaloniki , Greece , Thessaloniki , Greece and
| | - Symeon Metallidis
- b Infectious Diseases Division, Department of Internal Medicine , Medical School, Aristotle University of Thessaloniki , Thessaloniki , Greece
| | - Nikolaos Malisiovas
- a Department of Microbiology , Medical School, Aristotle University of Thessaloniki , Greece , Thessaloniki , Greece and
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Paudel S, Zacharioudakis IM, Zervou FN, Ziakas PD, Mylonakis E. Prevalence of Clostridium difficile infection among solid organ transplant recipients: a meta-analysis of published studies. PLoS One 2015; 10:e0124483. [PMID: 25886133 PMCID: PMC4401454 DOI: 10.1371/journal.pone.0124483] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 03/02/2015] [Indexed: 01/10/2023] Open
Abstract
Several factors including antibiotic use, immunosuppression and frequent hospitalizations make solid organ transplant (SOT) recipients vulnerable to Clostridium difficile infection (CDI). We conducted a meta-analysis of published studies from 1991-2014 to estimate the prevalence of CDI in this patient population. We searched PubMed, EMBASE and Google Scholar databases. Among the 75,940 retrieved citations, we found 30 studies coded from 35 articles that were relevant to our study. Based on these studies, we estimated the prevalence of CDI among 21,683 patients who underwent transplantation of kidney, liver, lungs, heart, pancreas, intestine or more than one organ and stratified each study based on the type of transplanted organ, place of the study conduction, and size of patient population. The overall estimated prevalence in SOT recipients was 7.4% [95%CI, (5.6-9.5%)] and it varied based on the type of organ transplant. The prevalence was 12.7% [95%CI, (6.4%-20.9%)] among patients who underwent transplantation for more than one organ. The prevalence among other SOT recipients was: lung 10.8% [95% CI, (5.5%-17.7%)], liver 9.1 % [95%CI, (5.8%-13.2%)], intestine 8% [95% CI, (2.6%-15.9%)], heart 5.2% [95%CI, (1.8%-10.2%)], kidney 4.7% [95% CI, (2.6%-7.3%)], and pancreas 3.2% [95% CI, (0.5%-7.9%)]. Among the studies that reported relevant data, the estimated prevalence of severe CDI was 5.3% [95% CI (2.3%-9.3%)] and the overall recurrence rate was 19.7% [95% CI, (13.7%-26.6%)]. In summary, CDI is a significant complication after SOT and preventive strategies are important in order to reduce the CDI related morbidity and mortality.
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Affiliation(s)
- Suresh Paudel
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, United States of America
| | - Ioannis M. Zacharioudakis
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, United States of America
| | - Fainareti N. Zervou
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, United States of America
| | - Panayiotis D. Ziakas
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, United States of America
| | - Eleftherios Mylonakis
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, United States of America
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Malamood M, Nellis E, Ehrlich AC, Friedenberg FK. Vancomycin Enemas as Adjunctive Therapy for Clostridium difficile Infection. J Clin Med Res 2015; 7:422-7. [PMID: 25883704 PMCID: PMC4394914 DOI: 10.14740/jocmr2117w] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2015] [Indexed: 12/20/2022] Open
Abstract
Background For severe, complicated Clostridium difficile infection (CDI), concomitant treatment with IV metronidazole and oral vancomycin is usually prescribed. Sometimes vancomycin per rectum (VPR) is added to increase colonic drug delivery. Our purpose was to examine clinical outcomes of patients with CDI treated with VPR and compare results to a matched control group. Methods This was a retrospective case-control study in a setting of tertiary-care ICU on diarrhea patients with a positive toxin test for C. difficile. We identified all ICU patients prescribed VPR from January 2003 to December 2013. The dose of VPR mixed in 100 cc of tap water ranged from 125 to 250 mg Q 6 - 8 hours. All patients had diarrhea and a positive test for C. difficile toxin. Included patients received ≥ 4 doses of VPR. The primary outcome was the combined endpoint of colon surgery or death. We matched VPR cases 1:2 with CDI controls that had identical APACHE II scores. Results We identified 24 CDI patients who received VPR and met inclusion criteria: 11 male, mean age 61.8 ± 15.9 years. All patients received concomitant CDI therapy. Four patients (16.7%) required colectomy, and overall mortality was 45.8%. For the 48 controls, need for surgery was identical (16.7%; P = 1.00). The mortality rate also did not differ (41.7%; P = 0.74). For the combined outcome of surgery or death, the rate was 45.8% for the controls and 50.0% for the VPR group (P = 0.73). Conclusion In a case-control study, the use of VPR was not demonstrated to reduce the need for colectomy or decrease mortality. Based on our modest sample size and failure to show efficacy, we cannot strongly advocate for the use of VPR.
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Affiliation(s)
- Mark Malamood
- Gastroenterology Section, Temple University School of Medicine, Philadelphia, PA, USA
| | - Eric Nellis
- Gastroenterology Section, Temple University School of Medicine, Philadelphia, PA, USA
| | - Adam C Ehrlich
- Gastroenterology Section, Temple University School of Medicine, Philadelphia, PA, USA
| | - Frank K Friedenberg
- Gastroenterology Section, Temple University School of Medicine, Philadelphia, PA, USA
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Affiliation(s)
- Priya D Farooq
- University of Maryland Medical Center (Department of Medicine, Division of Gastroenterology and Hepatology), Baltimore, Maryland; National Institutes of Health (National Institute of Diabetes and Digestive and Kidney Diseases), Bethesda, Maryland; Veterans Affairs Maryland Health Center System (Veterans Affairs), Baltimore, Maryland
| | - Nathalie H Urrunaga
- University of Maryland Medical Center (Department of Medicine, Division of Gastroenterology and Hepatology), Baltimore, Maryland; National Institutes of Health (National Institute of Diabetes and Digestive and Kidney Diseases), Bethesda, Maryland; Veterans Affairs Maryland Health Center System (Veterans Affairs), Baltimore, Maryland
| | - Derek M Tang
- University of Maryland Medical Center (Department of Medicine, Division of Gastroenterology and Hepatology), Baltimore, Maryland; National Institutes of Health (National Institute of Diabetes and Digestive and Kidney Diseases), Bethesda, Maryland; Veterans Affairs Maryland Health Center System (Veterans Affairs), Baltimore, Maryland
| | - Erik C von Rosenvinge
- University of Maryland Medical Center (Department of Medicine, Division of Gastroenterology and Hepatology), Baltimore, Maryland; National Institutes of Health (National Institute of Diabetes and Digestive and Kidney Diseases), Bethesda, Maryland; Veterans Affairs Maryland Health Center System (Veterans Affairs), Baltimore, Maryland
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Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC, Pepin J, Wilcox MH. Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol 2015; 31:431-55. [PMID: 20307191 DOI: 10.1086/651706] [Citation(s) in RCA: 2180] [Impact Index Per Article: 242.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Since publication of the Society for Healthcare Epidemiology of America position paper onClostridium difficileinfection in 1995, significant changes have occurred in the epidemiology and treatment of this infection.C. difficileremains the most important cause of healthcare-associated diarrhea and is increasingly important as a community pathogen. A more virulent strain ofC. difficilehas been identified and has been responsible for more-severe cases of disease worldwide. Data reporting the decreased effectiveness of metronidazole in the treatment of severe disease have been published. Despite the increasing quantity of data available, areas of controversy still exist. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, and infection control and environmental management.
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Affiliation(s)
- Stuart H Cohen
- Department of Internal Medicine, Division of Infectious and Immunologic Diseases, University of California Davis Medical Center, Sacramento, California, USA
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Jaber MR, Reeves M, Couperus J. Is Diarrhea Enough to Assess the Severity of Clostridium difficile–Associated Disease? Infect Control Hosp Epidemiol 2015; 29:187-9; author reply 189-90. [DOI: 10.1086/524337] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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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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Debast SB, Bauer MP, Kuijper EJ. European Society of Clinical Microbiology and Infectious Diseases: update of the treatment guidance document for Clostridium difficile infection. Clin Microbiol Infect 2014; 20 Suppl 2:1-26. [PMID: 24118601 DOI: 10.1111/1469-0691.12418] [Citation(s) in RCA: 767] [Impact Index Per Article: 76.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 09/22/2013] [Accepted: 09/27/2013] [Indexed: 12/11/2022]
Abstract
In 2009 the first European Society of Clinical Microbiology and Infection (ESCMID) treatment guidance document for Clostridium difficile infection (CDI) was published. The guideline has been applied widely in clinical practice. In this document an update and review on the comparative effectiveness of the currently available treatment modalities of CDI is given, thereby providing evidence-based recommendations on this issue. A computerized literature search was carried out to investigate randomized and non-randomized trials investigating the effect of an intervention on the clinical outcome of CDI. The Grades of Recommendation Assessment, Development and Evaluation (GRADE) system was used to grade the strength of our recommendations and the quality of the evidence. The ESCMID and an international team of experts from 11 European countries supported the process. To improve clinical guidance in the treatment of CDI, recommendations are specified for various patient groups, e.g. initial non-severe disease, severe CDI, first recurrence or risk for recurrent disease, multiple recurrences and treatment of CDI when oral administration is not possible. Treatment options that are reviewed include: antibiotics, toxin-binding resins and polymers, immunotherapy, probiotics, and faecal or bacterial intestinal transplantation. Except for very mild CDI that is clearly induced by antibiotic usage antibiotic treatment is advised. The main antibiotics that are recommended are metronidazole, vancomycin and fidaxomicin. Faecal transplantation is strongly recommended for multiple recurrent CDI. In case of perforation of the colon and/or systemic inflammation and deteriorating clinical condition despite antibiotic therapy, total abdominal colectomy or diverting loop ileostomy combined with colonic lavage is recommended.
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Shakhsheer B, Alverdy J. Surgery for fulminant Clostridium difficile infection. SEMINARS IN COLON AND RECTAL SURGERY 2014. [DOI: 10.1053/j.scrs.2014.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Clostridium difficile infection in hospitalized patients at a Czech tertiary center: analysis of epidemiology, clinical features, and risk factors of fulminant course. Eur J Gastroenterol Hepatol 2014; 26:880-7. [PMID: 24942955 DOI: 10.1097/meg.0000000000000139] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Clostridium difficile infection (CDI) has been increasing in incidence, with significant morbidity and mortality, and is subject to geographical and institutional variability. We aimed to characterize epidemiology and clinical manifestations of CDI in a Czech tertiary care center and to identify risk factors of fulminant course. METHODS All adult patients hospitalized with primary CDI in a 3-year period were retrospectively identified. Epidemiological and clinically descriptive data were extracted from medical records. Multivariate analysis was used to identify the risk factors of fulminant course. The relationship between incidence of CDI and antibiotic consumption was evaluated. RESULTS Overall, 183 CDI patients, median age 67 years, were enrolled. Hospital-acquired CDI was present in 85% of cases. The incidence of CDI was 1/10,000 patient-days. Hospital-acquired CDI hospital mortality was 22.4%. Severe CDI (SCDI) was identified in 15.8% of patients, with 62% mortality. SCDI patients had longer onset of symptoms to diagnosis interval compared with mild CDI (P=0.05). Multivariate analysis showed that SCDI patients were older (P=0.018), and more frequently had abnormal abdominal physical findings (P=0.001), higher inflammatory markers (P<0.001), higher creatinine (P=0.002), and lower albumin (P<0.001) than patients with mild CDI. Analysis of antibiotic consumption at departments with the highest incidence of CDI showed a trend toward higher incidence of CDI associated with penicillin use (P=0.08) and a negative correlation of CDI incidence with nitroimidazoles consumption (P=0.03). CONCLUSION CDI is less frequent in the conditions studied compared with literary data; however, the fulminant form has a very high mortality. Delayed recognition and treatment is a crucial determinant of the severity of CDI. The association between CDI and antibiotic consumption is less clear.
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Walters PR, Zuckerbraun BS. Clostridium difficile Infection: Clinical Challenges and Management Strategies. Crit Care Nurse 2014; 34:24-34; quiz 35. [DOI: 10.4037/ccn2014822] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Clostridium difficile has become the leading cause of nosocomial diarrhea in adults. A substantial increase has occurred in morbidity and mortality associated with disease caused by C difficile and in the identification of new hypervirulent strains, warranting a high clinical index of suspicion for infections due to this organism. Prevention of infection requires a multidisciplinary approach, including early recognition of disease, effective contact isolation precautions, adherence to disinfectant policies, and judicious use of antibiotics. Current treatment approaches are based on the severity of illness. As hypervirulent strains evolve, unsuccessful treatments are more common. Complicated colitis caused by C difficile may benefit from surgical intervention. Subtotal colectomy and end ileostomy have been the procedures of choice, but are associated with a high mortality rate because of late surgical consultation and use of surgery as a salvage therapy. A promising surgical alternative is creation of a diverting loop ileostomy with colonic lavage.
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Affiliation(s)
- Pamela R. Walters
- Pamela R. Walters is a nurse practitioner for the University of Pittsburgh Center for Sports Medicine, Pittsburgh, Pennsylvania
| | - Brian S. Zuckerbraun
- Brian S. Zuckerbraun is an associate professor at the University of Pittsburgh and the VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Timing and type of surgical treatment of Clostridium difficile-associated disease: a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2014; 76:1484-93. [PMID: 24854320 DOI: 10.1097/ta.0000000000000232] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Clostridium difficile infection is the leading cause of nosocomial diarrhea in the United States; however, few patients will develop fulminant C. difficile-associated disease (CDAD), necessitating an urgent operative intervention. Mortality for patients who require operative intervention is very high, up to 80% in some series. Since there is no consensus in the literature regarding the best operative treatment for this disease, we sought to answer the following:PICO [population, intervention, comparison, and outcome] Question 1: In adult patients with CDAD, does early surgery compared with late surgery, as defined by the need for vasopressors, decrease mortality?PICO Question 2: In adult patients with CDAD, does total abdominal colectomy (TAC) compared with other types of surgical intervention decrease mortality? METHODS A subcommittee of the Practice Management Guideline Committee of the Eastern Association for the Surgery of Trauma conducted a systematic review and meta-analysis for the selected questions. RevMan software was used to generate forest plots. Grading of Recommendations, Assessment, Development and Evaluations methodology was used to rate the quality of the evidence, using GRADEpro software to create evidence tables. RESULTS Reduction in mortality was significantly associated with early surgery, with a risk ratio (RR) of 0.5 (95% confidence interval [CI], 0.35-0.72). The quality of evidence was rated "moderate." Considering only the first procedure performed, mortality seemed to trend higher for TAC, with an RR of 1.11 (95% CI, 0.69-1.80). Considering only the actual procedure performed, the point estimate switched sides, showing a trend toward decreased mortality with TAC (RR, 0.86; 95% CI, 0.56-1.31). The quality of evidence was rated "very low." CONCLUSION We strongly recommend that adult patients with CDAD undergo early surgery, before the development of shock and need for vasopressors. We conditionally recommend total or subtotal colectomy (vs. partial colectomy or other surgery) when the diagnosis of The Centers for Disease Control and Prevention is known.
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Halaweish I, Alam HB. Surgical Management of Severe Colitis in the Intensive Care Unit. J Intensive Care Med 2014; 30:451-61. [DOI: 10.1177/0885066614534941] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 03/10/2014] [Indexed: 01/05/2023]
Abstract
Severe colitis, an umbrella encompassing several entities, is one of the most common acute gastrointestinal disorders resulting in critical illness. Clostridium difficile infection is responsible for the majority of nosocomial diarrhea with fulminant C difficile colitis (CDC) carrying a high mortality. Optimal outcomes can be achieved by early identification and treatment of fulminant CDC, with appropriate surgical intervention when indicated. Ischemic colitis, on the other hand, is uncommon with a range of etiological factors including abdominal aortic surgery, inotropic drugs, rheumatoid diseases, or often no obvious triggering factor. Most cases resolve with nonsurgical management; however, prompt recognition of full-thickness necrosis and gangrene is crucial for good patient outcomes. Fulminant colitis is a severe disease secondary to progressive ulcerative colitis with systemic deterioration. Surgical intervention is indicated for hemorrhage, perforation, or peritonitis and failure of medical therapy to control the disease. Although, failure of medical management is the most common indication, it can be difficult to define objectively and requires a collaborative multidisciplinary approach. This article proposes some simple management algorithms for these clinical entities, with a focus on critically ill patients.
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Affiliation(s)
- Ihab Halaweish
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Hasan B. Alam
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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Dallas KB, Condren A, Divino CM. Life after colectomy for fulminant Clostridium difficile colitis: a 7-year follow up study. Am J Surg 2014; 207:533-9. [PMID: 24674828 DOI: 10.1016/j.amjsurg.2013.04.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 04/19/2013] [Accepted: 04/29/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND The long-term prognosis of patients undergoing colectomy for fulminant Clostridium difficile colitis has not been well studied. The authors present 7-year survival trends in such patients. METHODS Patients were identified through a pathologic database. Medical records were reviewed and follow-up phone calls made to determine relevant patient history, longevity, and quality of life. RESULTS The 61 patients identified had mean and median survival of 18.1 and 3.2 months, respectively, and 1-year, 2-year, 5-year, and 7-year mortality of 68.5%, 79.6%, 88.9%, and 90.7%, respectively. Previous C difficile infection, hypotension, requirement of vasopressors, mental status changes, elevated arterial lactate, decreased platelet counts, intubation, and longer duration on nonoperative therapy were associated with in-hospital mortality. There were no factors correlated with long-term survival. CONCLUSIONS Patients who require colectomy for fulminant C difficile colitis have a poor prognosis with poor long-term survival and significant morbidity. Although there are several factors associated with in-hospital mortality, there were no factors correlated with long-term survival.
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Affiliation(s)
- Kai B Dallas
- Department of Surgery, The Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1259, New York, NY 10029, USA
| | - Audree Condren
- Department of Surgery, The Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1259, New York, NY 10029, USA
| | - Celia M Divino
- Department of Surgery, The Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1259, New York, NY 10029, USA.
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Fulminant Clostridium difficile colitis: prospective development of a risk scoring system. J Trauma Acute Care Surg 2014; 76:424-30. [PMID: 24458048 DOI: 10.1097/ta.0000000000000105] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Of the patients with a Clostridium difficile infection, 2% to 8% will progress to fulminant C. difficile colitis (fCDC), which carries high morbidity and mortality. No system exists to rapidly identify patients at risk for developing fCDC and possibly in need of surgical intervention. Our aim was to design a simple and accurate risk scoring system (RSS) for daily clinical practice. METHODS We prospectively enrolled all patients diagnosed with a C. difficile infection and compared patients with and without fCDC. An expert panel, combined with data derived from previous studies, identified four risk factors, and a multivariable logistic regression model was performed to determine their effect in predicting fCDC. The RSS was created based on the predictive power of each factor, and calibration, discrimination, and test characteristics were subsequently determined. In addition, the RSS was compared with a previously proposed severity scoring system. RESULTS A total of 746 patients diagnosed with C. difficile infection were enrolled between November 2010 and October 2012. Based on the log (odds ratio) of each risk factor, age greater than 70 years was assigned 2 points, white blood cell count equal to or greater than 20,000/μL or equal to or less than 2,000/μL was assigned 1 point, cardiorespiratory failure was assigned 7 points, and diffuse abdominal tenderness on physical examination was assigned 6 points. With the use of this system, the discriminatory value of the RSS (c statistic) was 0.98 (95% confidence interval, 0.96-1).The Hosmer-Lemeshow goodness-of-fit test showed a p value of 0.78, and the Brier score was 0.019. A value of 6 points was determined to be the threshold for reliably dividing low-risk ( <6) from high-risk (≥ 6) patients. CONCLUSION The RSS is a valid and reliable tool to identify at the bedside patients who are at risk for developing fCDC. External validation is needed before widespread implementation. LEVEL OF EVIDENCE Prognostic study, level II.
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Guastalegname M, Grieco S, Giuliano S, Falcone M, Caccese R, Carfagna P, D'ambrosio M, Taliani G, Venditti M. A cluster of fulminant Clostridium difficile colitis in an intensive care unit in Italy. Infection 2014; 42:585-9. [PMID: 24523055 DOI: 10.1007/s15010-014-0597-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 01/23/2014] [Indexed: 11/26/2022]
Abstract
We describe, for the first time, a cluster of lethal fulminant health-care associated Clostridium difficile (CD) colitis in Italy, observed in the intensive care unit (ICU) of an Italian tertiary care hospital in Rome. For all cases the cause of ICU admission was CD-related septic shock. Three out of seven patients were residents in a long-term care facility in Rome, and the others had been transferred to the ICU from different medical wards of the same hospital. Five patients died within 96 h of ICU admission. Because of a clinical deterioration after 4 days of adequate antibiotic therapy, two patients underwent subtotal colectomy: both of them died within 30 days of surgical intervention. In four cases, ribotyping assay was performed and ribotype 027 was recognized. This high mortality rate could be attributable to three findings: the extent of disease severity induced by the strain 027, the delay in antimicrobial therapy administration, and the lack of efficacy of the standard antibiotic treatment for fulminant CD colitis compared to an earlier surgical approach. In order to contain a CD infection epidemic, control and surveillance measures should be implemented, and empirical therapy should be administered. Because of potential 027 ribotype CD spread in Italy, CDI should be regarded with a high index of suspicion in all patients presenting with shock and signs or symptoms suggesting abdominal disease, and an early surgical approach should be considered.
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Affiliation(s)
- M Guastalegname
- Department of Public Health and Infectious Diseases, Policlinico Umberto I, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
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IV ECO, III ECO, Johnson DA. Clinical update for the diagnosis and treatment of Clostridium difficile infection. World J Gastrointest Pharmacol Ther 2014; 5:1-26. [PMID: 24729930 PMCID: PMC3951810 DOI: 10.4292/wjgpt.v5.i1.1] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Revised: 10/06/2013] [Accepted: 12/09/2013] [Indexed: 02/06/2023] Open
Abstract
Clostridium difficile infection (CDI) presents a rapidly evolving challenge in the battle against hospital-acquired infections. Recent advances in CDI diagnosis and management include rapid changes in diagnostic approach with the introduction of newer tests, such as detection of glutamate dehydrogenase in stool and polymerase chain reaction to detect the gene for toxin production, which will soon revolutionize the diagnostic approach to CDI. New medications and multiple medical society guidelines have introduced changing concepts in the definitions of severity of CDI and the choice of therapeutic agents, while rapid expansion of data on the efficacy of fecal microbiota transplantation heralds a revolutionary change in the management of patients suffering multiple relapses of CDI. Through a comprehensive review of current medical literature, this article aims to offer an intensive review of the current state of CDI diagnosis, discuss the strengths and limitations of available laboratory tests, compare both current and future treatments options and offer recommendations for best practice strategies.
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Belmares J, Gerding DN, Tillotson G, Johnson S. Measuring the severity ofClostridium difficileinfection: implications for management and drug development. Expert Rev Anti Infect Ther 2014; 6:897-908. [DOI: 10.1586/14787210.6.6.897] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Abstract
Clostridium difficile infection (CDI) will progress to fulminant disease in 3 to 5% of cases. With the emergence of hypervirulent, multidrug-resistant strains, the incidence and severity of disease are continuing to rise. Prompt identification, early resuscitation, and treatment are critical in preventing morbidity and mortality in this increasingly common condition. Discontinuation of antibiotics and treatment with oral vancomycin and intravenous or oral metronidazole are first-line treatments, but complicated cases may require surgery. Subtotal colectomy with ileostomy remains the standard of care when toxic megacolon, perforation, or an acute surgical abdomen is present, but mortality rates are high. Recognition of risk factors for fulminant CDI and earlier surgical intervention may decrease mortality from this highly lethal disease.
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Affiliation(s)
- Ann K Seltman
- Colon and Rectal Surgery Associates Ltd., St. Paul, Minnesota ; Division of Colon and Rectal Surgery, University of Minnesota, St. Paul, Minnesota
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Halabi WJ, Nguyen VQ, Carmichael JC, Pigazzi A, Stamos MJ, Mills S. Clostridium difficile colitis in the United States: a decade of trends, outcomes, risk factors for colectomy, and mortality after colectomy. J Am Coll Surg 2013; 217:802-12. [PMID: 24011436 DOI: 10.1016/j.jamcollsurg.2013.05.028] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Revised: 05/30/2013] [Accepted: 05/30/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND Clostridium difficile colitis (CDC) is a major health concern in the United States (US), with earlier reports demonstrating a rising incidence. Studies analyzing predictors for total colectomy and mortality after colectomy are limited by small numbers. STUDY DESIGN The Nationwide Inpatient Sample (NIS) 2001 to 2010 was retrospectively reviewed for CDC trends, the associated colectomy and mortality rates. Patient and hospital variables were used in the LASSO algorithm for logistic regression with 10-fold cross validation to build a predictive model for colectomy requirement and mortality after colectomy. The association of colectomy day with mortality was also examined on multivariable logistic regression analysis. RESULTS An estimated 2,773,521 discharges with a diagnosis of CDC were identified in the US over a decade. Colectomy was required in 19,374 cases (0.7%), with an associated mortality of 30.7%. Compared with the 2001 to 2005 period, the 2006 to 2010 period witnessed a 47% increase in the rate of CDC and a 32% increase in the rate of colectomies. The LASSO algorithm identified the following predictors for colectomy: coagulopathy (odds ratio [OR] 2.71), weight loss (OR 2.25), teaching hospitals (OR 1.37), fluid or electrolyte disorders (OR 1.31), and large hospitals (OR 1.18). The predictors of mortality after colectomy were: coagulopathy (OR 2.38), age greater than 60 years (OR 1.97), acute renal failure (OR 1.67), respiratory failure (OR 1.61), sepsis (OR 1.40), peripheral vascular disease (OR 1.39), and congestive heart failure (OR 1.25). Surgery more than 3 days after admission was associated with higher mortality rates (OR 1.09; 95% CI 1.05 to 1.14; p < 0.05). CONCLUSIONS Clostridium difficile colitis is increasing in the US, with an associated increase in total colectomies. Mortality rates after colectomy remain elevated. Progression to colectomy and mortality thereafter are associated with several patient and hospital factors. Knowledge of these risk factors may help in risk-stratification and counseling.
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Affiliation(s)
- Wissam J Halabi
- Department of Surgery, University of California, Irvine School of Medicine, Irvine, CA
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