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Rajack F, Medford S, Naab T. Clostridioides difficile infection leading to fulminant colitis with toxic megacolon. Autops Case Rep 2023; 13:e2023457. [PMID: 38034515 PMCID: PMC10687841 DOI: 10.4322/acr.2023.457] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/14/2023] [Indexed: 12/02/2023]
Abstract
Clostridioidesdifficile infection (CDI) is the culprit of millions of nosocomial infections in the United States. Programs that successfully decrease its incidence, therefore, render cost savings for the healthcare system. Toxic megacolon and perforation are two of the most significant complications with increased mortality rates. We report a 23-year-old nursing home resident hospitalized for fever, cough, and green sputum. After 3 days of antibiotic therapy, he developed abdominal distension, diarrhea, and vomiting and underwent a total colectomy. The colon was dilated to a maximum of 11 cm with markedly edematous mucosa and yellow pseudomembranes. Qualitative PCR of the stool detected Clostridioides difficile toxin B gene. While there is no consensus for the required interval between antibiotic treatment and CDI, this presentation 3 days after starting the antibiotic therapy is earlier than most proposed ranges.
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Affiliation(s)
- Fareed Rajack
- Howard University Hospital, Department of Pathology and Laboratory Medicine, Washington, D.C., United States of America
| | - Shawn Medford
- Howard University College of Medicine, Washington, D.C., United States of America
| | - Tammey Naab
- Howard University Hospital, Department of Pathology and Laboratory Medicine, Washington, D.C., United States of America
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Rubak T, Baunwall SMD, Gregersen M, Hansen TK, Rosenbæk JB, Erikstrup LT, Hvas CL, Damsgaard EMS. Frailty level at discharge predicts mortality in older patients with Clostridioides difficile more accurately than age or disease severity. Eur Geriatr Med 2023:10.1007/s41999-023-00772-3. [PMID: 37046032 PMCID: PMC10097521 DOI: 10.1007/s41999-023-00772-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 03/22/2023] [Indexed: 04/14/2023]
Abstract
PURPOSE Clostridioides difficile infection (CDI) has a high mortality among older patients. Identification of older patients with CDI in increased mortality risk is important to target treatment and thereby reduce mortality. The aim of this study was to investigate mortality rates and compare frailty levels at discharge, measured by the record-based Multidimensional Prognostic Index (MPI), with age and severity of CDI as mortality predictors in patients with CDI diagnosed during hospitalisation. METHODS This was a population-based cohort study from Central Denmark Region, Denmark, including all patients ≥ 60 years with a positive CD toxin test without prior infection and diagnosed from 1 January to 31 December 2018. Frailty level, estimated from the electronic medical record, was defined as low, moderate, or severe frailty. CDI severity was graded according to international guidelines. Primary outcome was 90-day mortality. RESULTS We included 457 patients with median age 77 years (interquartile range 69-84) and females (49%). Overall, 90-day mortality was 28%, and this was associated with age (hazard ratio (HR): 2.71 (95% confidence interval 1.64-4.47)), CDI severity (HR 4.58 (3.04-6.88)) and frailty (HR 10.15 (4.06-25.36)). Frailty was a better predictor of 90-day mortality than both age (p < 0.001) and CDI severity (p = 0.04) with a receiver operating characteristic curve area of 77%. CONCLUSION The 90-day mortality among older patients with CDI in a Danish region is 28%. Frailty measured by record-based MPI at discharge outperforms age and disease severity markers in predicting mortality in older patients with CDI.
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Affiliation(s)
- Tone Rubak
- Department of Geriatrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Simon Mark Dahl Baunwall
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Merete Gregersen
- Department of Geriatrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Troels Kjærskov Hansen
- Department of Geriatrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | | | | | - Christian Lodberg Hvas
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Else Marie Skjøde Damsgaard
- Department of Geriatrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Timerbulatov MV, Aitova LR, Grishina EE, Sakaev EM, Shchekin VS, Shchekin SV, Nizamutdinov TR. [Severe pseudomembranous colitis in patients with previous coronavirus infection]. Khirurgiia (Mosk) 2022:53-60. [PMID: 35920223 DOI: 10.17116/hirurgia202208153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To analyze treatment outcomes in patients with severe pseudomembranous colitis and previous coronavirus infection. MATERIAL AND METHODS We retrospectively analyzed treatment outcomes, clinical, laboratory and histological data in convalescents of COVID-19 who admitted to the department of coloproctology for moderate-to-severe pseudomembranous colitis confirmed by endoscopic examination between 2020 and 2021. RESULTS There were 13 patients with moderate pseudomembranous colitis and 6 ones with severe pseudomembranous colitis. Mean period after recovery from coronavirus infection was 19 days. Endoscopy revealed whitish-yellow or gray raised plaques on colonic mucosa in all cases. Four patients with signs of peritonitis underwent emergency surgery. Three patients had perforation of caecum; one patient had perforation of sigmoid colon and widespread peritonitis. Two patients underwent urgent surgery for progressive toxic megacolon and ineffective therapy. Subtotal colectomy and ileostomy were performed in all cases. Histological examination revealed necrosis of not only superficial layer of colon mucosa typical for clostridial colitis, but also the entire thickness of mucosa, as well as submucosal and partially muscular layers in some cases. Mucosal crypt atrophy, fibrinoid effusion in muscular layer, diffuse polymorphonuclear cell infiltration and necrosis of muscular and submucosal nerve plexuses, as well as necrosis of vascular walls with deposition of hyaline-like structures characterize microcirculatory ischemic processes in the colon wall. CONCLUSION Severe pseudomembranous colitis associated with COVID-19 may not be associated with clostridial infection. Further analysis of possible ischemic etiology and pathogenesis of gastrointestinal lesions in COVID-19 is needed for preventive and therapeutic measures.
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Affiliation(s)
- M V Timerbulatov
- Bashkir State Medical University, Ufa, Republic of Bashkortostan
| | - L R Aitova
- Bashkir State Medical University, Ufa, Republic of Bashkortostan
| | - E E Grishina
- Bashkir State Medical University, Ufa, Republic of Bashkortostan
| | - E M Sakaev
- Bashkir State Medical University, Ufa, Republic of Bashkortostan
| | - V S Shchekin
- Ufa City Clinical Hospital No. 21, Ufa, Republic of Bashkortostan
| | - S V Shchekin
- Ufa City Clinical Hospital No. 21, Ufa, Republic of Bashkortostan
| | - T R Nizamutdinov
- Bashkir State Medical University, Ufa, Republic of Bashkortostan
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Trejo-Avila M, Vergara-Fernandez O, Solórzano-Vicuña D, Santes O, Sainz-Hernández JC, Moctezuma-Velázquez P, Salgado-Nesme N. A systematic review and meta-analysis of diverting loop ileostomy versus total abdominal colectomy for the treatment of Clostridium difficile colitis. Langenbecks Arch Surg 2020; 405:715-723. [DOI: 10.1007/s00423-020-01910-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/12/2020] [Indexed: 01/28/2023]
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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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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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Gahagan JV, Halabi WJ, Nguyen VQ, Carmichael JC, Pigazzi A, Stamos MJ, Mills SD. Colorectal Surgery in Patients with HIV and AIDS: Trends and Outcomes over a 10-Year Period in the USA. J Gastrointest Surg 2016; 20:1239-46. [PMID: 26940943 DOI: 10.1007/s11605-016-3119-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 02/22/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND HIV has become a chronic disease, which may render this population more prone to developing the colorectal pathologies that typically affect older Americans. METHODS A retrospective review of the Nationwide Inpatient Sample was performed to identify patients who underwent colon and rectal surgery from 2001 to 2010. Multivariate analysis was used to evaluate outcomes among the general population, patients with HIV, and patients with AIDS. RESULTS Hospital admissions for colon and rectal procedures of patients with HIV/AIDS grew at a faster rate than all-cause admissions of patients with HIV/AIDS, with mean yearly increases of 17.8 and 2.1 %, respectively (p < 0.05). Patients with HIV/AIDS undergoing colon and rectal operations for cancer, polyps, diverticular disease, and Clostridium difficile were younger than the general population (51 vs. 65 years; p < 0.01). AIDS was independently associated with increased odds of mortality (OR 2.11; 95 % CI 1.24, 3.61), wound complications (OR 1.53; 95 % CI 1.09, 2.17), and pneumonia (OR 2.02; 95 % CI 1.33, 3.08). Risk-adjusted outcomes of colorectal surgery in patients with HIV did not differ significantly from the general population. CONCLUSION Postoperative outcomes in patients with HIV are similar to the general population, while patients with AIDS have a higher risk of mortality and certain complications.
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Affiliation(s)
- John V Gahagan
- Department of Surgery, Irvine School of Medicine, University of California, Irvine, CA, USA
| | - Wissam J Halabi
- Department of Surgery, Irvine School of Medicine, University of California, Irvine, CA, USA
| | - Vinh Q Nguyen
- Department of Statistics, University of California Irvine, Irvine, CA, USA
| | - Joseph C Carmichael
- Department of Surgery, Irvine School of Medicine, University of California, Irvine, CA, USA
| | - Alessio Pigazzi
- Department of Surgery, Irvine School of Medicine, University of California, Irvine, CA, USA
| | - Michael J Stamos
- Department of Surgery, Irvine School of Medicine, University of California, Irvine, CA, USA
| | - Steven D Mills
- Department of Surgery, Irvine School of Medicine, University of California, Irvine, CA, USA.
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Tallón-Aguilar L, de la Herranz-Guerrero P, López-Ruiz JA, Sánchez-Moreno L, López-Pérez J, Padillo-Ruiz FJ. [Role of care surgery in the treatment of pseudomembranous colitis]. CIR CIR 2016; 85:330-333. [PMID: 27209466 DOI: 10.1016/j.circir.2016.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 03/14/2016] [Accepted: 03/15/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Pseudomembranous colitis, caused by Clostridium difficile, has seen an increased incidence in recent years, driven mainly by the indiscriminate use of antibiotics. Although initial treatment is medical, the role of emergency surgery has gained ground due to high mortality and the emergence of increasingly virulent strains. In our country the prevalence is still low so that sometimes our experience in handling is limited. AIM To analyze our surgical experience in treatment of this disease and to remember the role of surgery as well as some technical aspects of it. CLINICAL CASES We present 2 cases of patients who have suffered a fulminant pseudomembranous colitis unresponsive to initial medical treatment and requiring urgent surgical intervention with a good response to it. CONCLUSIONS It is important to keep in mind the surgical option in treatment of pseudomembranous colitis, especially when it presents as fulminant colitis, there are associated complications or failure to respond to medical treatment.
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Affiliation(s)
- Luis Tallón-Aguilar
- Unidad de Cirugía de Urgencias, Complejo Hospitalario Universitario de Sevilla Virgen Macarena-Virgen del Rocío, Sevilla, España.
| | - Pablo de la Herranz-Guerrero
- Unidad de Cirugía de Urgencias, Complejo Hospitalario Universitario de Sevilla Virgen Macarena-Virgen del Rocío, Sevilla, España
| | - José Antonio López-Ruiz
- Unidad de Cirugía de Urgencias, Complejo Hospitalario Universitario de Sevilla Virgen Macarena-Virgen del Rocío, Sevilla, España
| | - Laura Sánchez-Moreno
- Unidad de Cirugía de Urgencias, Complejo Hospitalario Universitario de Sevilla Virgen Macarena-Virgen del Rocío, Sevilla, España
| | - José López-Pérez
- Unidad de Cirugía de Urgencias, Complejo Hospitalario Universitario de Sevilla Virgen Macarena-Virgen del Rocío, Sevilla, España
| | - Francisco Javier Padillo-Ruiz
- Unidad de Cirugía de Urgencias, Complejo Hospitalario Universitario de Sevilla Virgen Macarena-Virgen del Rocío, Sevilla, España
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Kwon JH, Olsen MA, Dubberke ER. The morbidity, mortality, and costs associated with Clostridium difficile infection. Infect Dis Clin North Am 2015; 29:123-34. [PMID: 25677706 DOI: 10.1016/j.idc.2014.11.003] [Citation(s) in RCA: 137] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Clostridium difficile infection (CDI) is the most common cause of infectious health care-associated diarrhea and is a major burden to patients and the health care system. The incidence and severity of CDI remain at historically high levels. This article reviews the morbidity, mortality, and costs associated with CDI.
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Affiliation(s)
- Jennie H Kwon
- Division of Infectious Diseases, Washington University School of Medicine, 660 South Euclid Avenue, Box 8051, St Louis, MO 63110, USA.
| | - Margaret A Olsen
- Divisions of Infectious Diseases and Public Health Sciences, Washington University School of Medicine, 660 South Euclid Avenue, Box 8051, St Louis, MO 63110, USA
| | - Erik R Dubberke
- Division of Infectious Diseases, Section of Transplant Infectious Diseases, Washington University School of Medicine, 660 South Euclid Avenue, Box 8051, St Louis, MO 63110, USA
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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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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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Clostridium difficile: epidemiology, diagnostic and therapeutic possibilities-a systematic review. Tech Coloproctol 2013; 18:223-32. [PMID: 24178946 PMCID: PMC3950610 DOI: 10.1007/s10151-013-1081-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2013] [Accepted: 10/09/2013] [Indexed: 02/08/2023]
Abstract
This literature review looks at the epidemiology, clinical manifestations, diagnostics and current medical and surgical management of Clostridium difficile (C. difficile) infection. A literature search of PubMed and Cochrane database regarding C. difficile infection was performed. Information was extracted from 43 published articles from 2000 to the present day which met inclusion criteria. C. difficile is a gram-positive, anaerobic bacillus, which is widely found in the environment, especially in the soil. The occurrence of more resistant strains, which is mainly connected with the wide use of antibiotics, resulted in the rapid spread of the bacteria to different hospital departments. Particularly, elderly patients in surgical wards and intensive care units are at significant risk of developing C. difficile infection, which greatly increases morbidity and mortality. Symptoms of infection with C. difficile vary greatly. At one end of the spectrum, there are asymptomatic carriers, at the other patients with life-threatening toxic megacolon. Metronidazole is considered to be the drug of choice, but recent guidelines recommend Vancomycin. Fulminant colitis and toxic megacolon warrant surgical intervention. The optimal time for surgery is within 48 h of initiating conservative treatment without seeing a response, the development of multiple organ failure or a bowel perforation. A factor that has become increasingly important and relevant is the escalating expense of treatment for patients with C. difficile infection. It is, therefore, highly recommended to consider reviewing all hospital antibiotic policies and clinical guidelines that may contribute to the prevention of the infection.
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Sears P, Ichikawa Y, Ruiz N, Gorbach S. Advances in the treatment ofClostridium difficilewith fidaxomicin: a narrow spectrum antibiotic. Ann N Y Acad Sci 2013; 1291:33-41. [DOI: 10.1111/nyas.12135] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Pamela Sears
- Optimer Pharmaceuticals, Inc; San Diego California
| | | | - Nancy Ruiz
- Optimer Pharmaceuticals, Inc; San Diego California
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Bhangu A, Nepogodiev D, Gupta A, Torrance A, Singh P. Systematic review and meta-analysis of outcomes following emergency surgery for Clostridium difficile colitis. Br J Surg 2012; 99:1501-13. [PMID: 22972525 DOI: 10.1002/bjs.8868] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2012] [Indexed: 12/17/2022]
Abstract
BACKGROUND Only a small proportion of patients with severe Clostridium difficile infection (CDI) undergo emergency surgery, the timing and nature of which is unclear. The aim of this study was to describe the operations performed and to identify factors predictive of death following emergency surgery for CDI. METHODS A systematic review of published literature was performed for studies comparing survivors and non-survivors of emergency surgery for CDI. Meta-analysis was carried out for 30-day and in-hospital mortality. RESULTS Overall 31 studies were included, which presented data on a total of 1433 patients undergoing emergency surgery for CDI. Some 1·1 per cent of all patients with CDI and 29·9 per cent with severe CDI underwent emergency surgery, although rates varied between studies (0·2-7·6 and 2·2-86 per cent respectively). The most commonly performed operation was total colectomy with end ileostomy (89·0 per cent, 1247 of 1401 detailed surgical procedures). When total colectomy with end ileostomy was not performed, reoperation to resect further bowel was needed in 15·9 per cent (20 of 126). Where described, the 30-day mortality rate was 41·3 per cent (160 of 387). Meta-analysis of high-quality studies revealed that the strongest predictors of postoperative death were those relating to preoperative physiological status: preoperative intubation, acute renal failure, multiple organ failure and shock requiring vasopressors. CONCLUSION This systematic review supports total colectomy with end ileostomy as the primary surgical treatment for patients with severe CDI; other surgical procedures are associated with high rates of reoperation and mortality. Less extensive surgery may have a role in selected patients with earlier-stage disease.
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Affiliation(s)
- A Bhangu
- West Midlands Research Collaborative, c/o Professor D. Morton, Academic Department of Surgery, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK.
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Walter Zea J, Lina Salazar C. Enfermedad asociada a Clostridium difficile: prevalencia y diagnóstico por laboratorio. INFECTIO 2012. [DOI: 10.1016/s0123-9392(12)70016-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
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Ohba T, Ebata S, Ando T, Ichikawa J, Clinton D, Kondo T, Haro H. Fulminant Clostridium Difficile Colitis After Surgical Treatment of Cervical Destructive Spondyloarthropathy: A Case Report. JBJS Case Connect 2011; 1:e2. [PMID: 29252252 DOI: 10.2106/jbjs.cc.k.00012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Tetsuro Ohba
- Department of Orthopaedic Surgery, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi 409-3898, Japan.
| | - Shigeto Ebata
- Department of Orthopaedic Surgery, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi 409-3898, Japan.
| | - Takashi Ando
- Department of Orthopaedic Surgery, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi 409-3898, Japan.
| | - Jiro Ichikawa
- Department of Orthopaedics, Vanderbilt University, Medical Center East, South Tower, 1215 21st Avenue South, Nashville, TN 37232
| | - Devin Clinton
- Department of Orthopaedics, Vanderbilt University, Medical Center East, South Tower, 1215 21st Avenue South, Nashville, TN 37232
| | - Tetsuo Kondo
- Department of Orthopaedic Surgery, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi 409-3898, Japan.
| | - Hirotaka Haro
- Department of Orthopaedic Surgery, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi 409-3898, Japan.
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Surawicz CM, Alexander J. Treatment of refractory and recurrent Clostridium difficile infection. Nat Rev Gastroenterol Hepatol 2011; 8:330-9. [PMID: 21502971 DOI: 10.1038/nrgastro.2011.59] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The incidence of Clostridium difficile infection (CDI) has increased since 2000, with greater numbers of severe cases reported, in part due to the emergence of a hypervirulent strain. Initial therapy with metronidazole is still recommended for mild to moderate CDI, but vancomycin is recommended for first-line therapy of severe CDI. Colectomy could be life-saving for some patients with severe disease that does not respond to maximal medical therapy. Recurrent CDI is a challenge to treat; no single effective therapy currently exists. Treatments include antibiotics, adjunct probiotics, fecal microbiota transplant and immune approaches. This Review discusses the various therapeutic approaches used for the treatment of refractory and recurrent CDI.
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Affiliation(s)
- Christina M Surawicz
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, 325 Ninth Avenue, Box 359773, Seattle, WA 98104, USA.
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