Loop ileostomy versus total colectomy as surgical treatment for Clostridium difficile-associated disease: An Eastern Association for the Surgery of Trauma multicenter trial

Clostridioides difficile infection: history, epidemiology, risk factors, prevention, clinical manifestations, treatment, and future options

SUMMARYClostridioides difficile infection (CDI) is one of the major issues in nosocomial infections. This bacterium is constantly evolving and poses complex challenges for clinicians, often encountered in real-life scenarios. In the face of CDI, we are increasingly equipped with new therapeutic strategies, such as monoclonal antibodies and live biotherapeutic products, which need to be thoroughly understood to fully harness their benefits. Moreover, interesting options are currently under study for the future, including bacteriophages, vaccines, and antibiotic inhibitors. Surveillance and prevention strategies continue to play a pivotal role in limiting the spread of the infection. In this review, we aim to provide the reader with a comprehensive overview of epidemiological aspects, predisposing factors, clinical manifestations, diagnostic tools, and current and future prophylactic and therapeutic options for C. difficile infection.

Review article: The epidemiology and management of Clostridioides difficile infection-A clinical update

BACKGROUND

Clostridioides difficile is the most common cause of healthcare-associated infection, and severe cases can result in significant complications. While anti-microbial therapy is central to infection management, adjunctive therapies may be utilised as preventative strategies.

AIM

This article aims to review updates in the epidemiology, diagnosis, and management, including treatment and prevention, of C. difficile infections.

METHODS

A narrative review was performed to evaluate the current literature between 1986 and 2023.

RESULTS

The incidence of C. difficile infection remains significantly high in both hospital and community settings, though with an overall decline in recent years and similar surveillance estimates globally. Vancomycin and fidaxomicin remain the first line antibiotics for treatment of non-severe C. difficile infection, though due to lower recurrence rates, infectious disease society guidelines now favour use of fidaxomicin. Faecal microbiota transplantation should still be considered to prevent recurrent C. difficile infection. However, in the past year the field has had a significant advancement with the approval of the first two live biotherapeutic products-faecal microbiota spores-live brpk, an oral capsule preparation, and faecal microbiota live-jslm-both indicated for the prevention of recurrent C. difficile infection, with additional therapies on the horizon.

CONCLUSION

Although the prevalence of C. difficile infection remains high, there have been significant advances in the development of novel therapeutics and preventative measures following changes in recent practice guidelines, and will continue to evolve in the future.

Clostridioides difficile Colitis

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.

Clostridioides difficile Infection: A Clinical Review of Pathogenesis, Clinical Considerations, and Treatment Strategies

BACKGROUND

Clostridioides difficile infection (CDI) is a common nosocomial infection. Risk factors for developing CDI include prior hospitalization, being older than 65 years old, antibiotic use, and chronic disease. It is linked with diarrhea and colitis and can vary in severity. It is a major cause of increased morbidity and mortality among hospitalized patients. However, community-acquired CDI is also increasing. Proper diagnosis and determination of severity are crucial for the treatment of CDI. Depending on how severe the CDI is, the patient may endorse different symptoms and physical exam findings. The severity of CDI will determine how aggressively it is treated. Management and treatment: Laboratory studies can be helpful in the diagnosis of CDI. In this regard, common labs include complete blood count, stool assays, and, in certain cases, radiography and endoscopy. Mild-to-moderate colitis is treated with antibiotics, but severe colitis requires a different approach, which may include surgery. Several alternative therapies for CDI exist and have shown promising results. This review will touch upon these therapies, which include fecal transplants, intravenous immunoglobulin, and the use of cholestyramine and tigecycline.

CONCLUSION

Prevention of CDI can be achieved by proper hygiene, vaccinations, and detecting the infection early. Proper hygiene is indeed noted to be one of the best ways to prevent CDI in the hospital setting. Overprescribing antibiotics is also another huge reason why CDI occurs. Proper prescription of antibiotics can also help reduce the chances of acquiring CDI.

Total Abdominal Colectomy Versus Diverting Loop Ileostomy and Antegrade Colonic Lavage for Fulminant Clostridioides Colitis: Analysis of the National Inpatient Sample 2016-2019

BACKGROUND

When surgery is indicated for fulminant Clostridioides difficile infection (CDI), total abdominal colectomy (TAC) is the most common approach. Diverting loop ileostomy (DLI) with antegrade colonic lavage has been introduced as a colon-sparing surgical approach. Prior analyses of National Inpatient Sample (NIS) data suggested equivalent postoperative outcomes between groups but did not evaluate healthcare resource utilization. As such, we aimed to analyze a more recent NIS cohort to compare these two approaches in terms of both postoperative outcomes and healthcare resource utilization.

METHODS

A retrospective analysis of the NIS from 2016 to 2019 was conducted. The primary outcome was postoperative in-hospital morbidity. Secondary outcomes included postoperative in-hospital mortality, system-specific postoperative complications, total admission cost, and length of stay (LOS). Univariable and multivariable regressions were utilized to compare the two operative approaches.

RESULTS

In total, 886 patients underwent TAC and 409 patients underwent DLI with antegrade colonic lavage. Adjusted analyses demonstrated no difference between groups in postoperative in-hospital morbidity (aOR 0.96, 95%CI 0.64-1.44, p = 0.851) or in-hospital mortality (aOR 1.15, 95%CI 0.81-1.64, p = 0.436). Patients undergoing TAC experienced significantly decreased total admission cost (MD $79,715.34, 95%CI 133,841-25,588, p = 0.004) and shorter postoperative LOS (MD 4.06 days, 95%CI 6.96-1.15, p = 0.006).

CONCLUSIONS

There are minimal differences between TAC and DLI with antegrade colonic lavage for fulminant CDI in terms of postoperative morbidity and mortality. Healthcare resource utilization, however, is significantly improved when patients undergo TAC as evidenced by clinically important decreases in total admission cost and postoperative LOS.

Management of Clostridioides difficile infection in adults and challenges in clinical practice: review and comparison of current IDSA/SHEA, ESCMID and ASID guidelines

Clostridioides difficile infection (CDI) remains a significant clinical challenge both in the management of severe and severe-complicated disease and the prevention of recurrence. Guidelines released by the Infectious Diseases Society of America and Society for Healthcare Epidemiology of America (IDSA/SHEA) and ESCMID had some consensus as well as some discrepancies in disease severity classification and treatment recommendations. We review and compare the key clinical strategies from updated IDSA/SHEA, ESCMID and current Australasian guidelines for CDI management in adults and discuss relevant issues for clinicians, particularly in the management of severe-complicated infection. Updated IDSA/SHEA and ESCMID guidelines now reflect the increased efficacy of fidaxomicin in preventing recurrence and have both promoted fidaxomicin to first-line therapy with an initial CDI episode in both non-severe and severe disease and endorsed the role of bezlotoxumab in the prevention of recurrent infection. Vancomycin remains acceptable therapy and metronidazole is not preferred. For severe-complicated infection the IDSA/SHEA recommends high-dose oral ± rectal vancomycin and IV metronidazole, whilst in an important development, ESCMID has endorsed fidaxomicin and tigecycline as part of combination anti-CDI therapy, for the first time. The role of faecal microbiota transplantation (FMT) in second CDI recurrence is now clearer, but timing and mode of FMT in severe-complicated refractory disease still requires further study.

Acute Responses to Infectious and Inflammatory Disorders of the Gastrointestinal System

Infectious and inflammatory disorders of the gastrointestinal system are life-threatening and occur frequently in hospitalized adults. Inflammatory and inflammation-related diseases of the gastrointestinal tract seen in the acutely and critically ill have numerous causes. In acute pancreatitis and toxic infections caused by the bacterium Clostridium difficile, where severe infections can develop, inflammation plays a causative and crucial role. Severe acute pancreatitis puts a patient at risk for infected necrosis, which can result in septicemia and shock. Similarly, patients treated with antibiotics are at risk for C difficile colitis, which can progress to toxic megacolon. These conditions require volume resuscitation and interventions supported by current evidence. Percutaneous or surgical interventions are often undertaken at a critical point in these illnesses. Patients who require surgery for these diagnoses present challenges for the interprofessional team. Inflammatory and infectious disorders often can lead to complications of systemic inflammatory response syndrome, sepsis, and multiorgan failure. New strategies are on the horizon to prevent the onset of and improve care for patients with severe acute pancreatitis, fulminant C difficile infection, and megacolon.

Surgical Infection Society Guidelines for Total Abdominal Colectomy versus Diverting Loop Ileostomy with Antegrade Intra-Colonic Lavage for the Surgical Management of Severe or Fulminant, Non-Perforated Clostridioides difficile Colitis

Background: Clostridioides difficile infection (CDI) can result in life-threatening illness requiring surgery. Surgical options for managing severe or fulminant, non-perforated C. difficile colitis include total abdominal colectomy with end ileostomy or creation of a diverting loop ileostomy with antegrade vancomycin lavage. Methods: The Surgical Infection Society's Therapeutics and Guidelines Committee convened to develop guidelines for summarizing the current SIS recommendations for total abdominal colectomy versus diverting loop ileostomy with antegrade lavage for severe or fulminant, non-perforated C. difficile colitis. PubMed, Embase, and the Cochrane database were searched for pertinent studies. Severe infection was defined as laboratory diagnosis of C. difficile infection with leukocytosis (white blood cell count of ≥15,000 cells/mL) or elevated creatinine (serum creatinine level >1.5 mg/dL). Fulminant infection was defined as laboratory diagnosis of C. difficile infection with hypotension or shock, ileus, or megacolon. Perforation was defined as complete disruption of the colon wall. Total abdominal colectomy was defined as resection of the ascending, transverse, descending, and sigmoid colon with end ileostomy. For the purpose of the guideline, the terms subtotal colectomy, total abdominal colectomy, and rectal-sparing total colectomy were used interchangeably. Diverting loop ileostomy with antegrade enema was defined as creation of both a diverting loop ileostomy with intra-operative colonic lavage and post-operative antegrade vancomycin unless otherwise specified. Evaluation of the published evidence was performed using the Grades of Recommendation Assessment, Development and Evaluation (GRADE) system. Using a process of iterative consensus, all committee members voted to accept or reject each recommendation. Results: We recommend that total abdominal colectomy be the procedure of choice for definitive therapy of severe or fulminant, non-perforated C. difficile colitis. In select patients, colon preservation using diverting loop ileostomy with intra-colonic vancomycin may be associated with higher rates of ostomy reversal and restoration of gastrointestinal continuity but may lead to development of recurrent C. difficile colitis. Conclusions: This guideline summarizes the current Surgical Infection Society recommendations regarding use of total abdominal colectomy versus diverting loop ileostomy with antegrade lavage for adults with severe or fulminant, non-perforated C. difficile infection.

Fulminant Clostridioides difficile Infection: A Review of Treatment Options for a Life-Threatening Infection

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.

European Society of Clinical Microbiology and Infectious Diseases: 2021 update on the treatment guidance document for Clostridioides difficile infection in adults

SCOPE

In 2009, the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) published the first treatment guidance document for Clostridioides difficile infection (CDI). This document was updated in 2014. The growing literature on CDI antimicrobial treatment and novel treatment approaches, such as faecal microbiota transplantation (FMT) and toxin-binding monoclonal antibodies, prompted the ESCMID study group on C. difficile (ESGCD) to update the 2014 treatment guidance document for CDI in adults.

METHODS AND QUESTIONS

Key questions on CDI treatment were formulated by the guideline committee and included: What is the best treatment for initial, severe, severe-complicated, refractory, recurrent and multiple recurrent CDI? What is the best treatment when no oral therapy is possible? Can prognostic factors identify patients at risk for severe and recurrent CDI and is there a place for CDI prophylaxis? Outcome measures for treatment strategy were: clinical cure, recurrence and sustained cure. For studies on surgical interventions and severe-complicated CDI the outcome was mortality. Appraisal of available literature and drafting of recommendations was performed by the guideline drafting group. The total body of evidence for the recommendations on CDI treatment consists of the literature described in the previous guidelines, supplemented with a systematic literature search on randomized clinical trials and observational studies from 2012 and onwards. 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 guideline committee was invited to comment on the recommendations. The guideline draft was sent to external experts and a patients' representative for review. Full ESCMID endorsement was obtained after a public consultation procedure.

RECOMMENDATIONS

Important changes compared with previous guideline include but are not limited to: metronidazole is no longer recommended for treatment of CDI when fidaxomicin or vancomycin are available, fidaxomicin is the preferred agent for treatment of initial CDI and the first recurrence of CDI when available and feasible, FMT or bezlotoxumab in addition to standard of care antibiotics (SoC) are preferred for treatment of a second or further recurrence of CDI, bezlotoxumab in addition to SoC is recommended for the first recurrence of CDI when fidaxomicin was used to manage the initial CDI episode, and bezlotoxumab is considered as an ancillary treatment to vancomycin for a CDI episode with high risk of recurrence when fidaxomicin is not available. Contrary to the previous guideline, in the current guideline emphasis is placed on risk for recurrence as a factor that determines treatment strategy for the individual patient, rather than the disease severity.

Danish national guideline for the treatment of Clostridioides difficile infection and use of faecal microbiota transplantation (FMT)

Aim: This Danish national guideline describes the treatment of adult patients with Clostridioides (formerly Clostridium) difficile (CD) infection and the use of faecal microbiota transplantation (FMT). It suggests minimum standard for implementing an FMT service.Method: Four scientific societies appointed members for a working group which conducted a systematic literature review and agreed on the text and recommendations. All clinical recommendations were evalluated for evidence level and grade of recommendation.Results: In CD infection, the use of marketed and experimental antibiotics as well as microbiota-based therapies including FMT are described. An algorithm for evaluating treatment effect is suggested. The organisation of FMT, donor recruitment and screening, laboratory preparation, clinical application and follow-up are described.Conclusion: Updated evidence for the treatment of CD infection and the use of FMT is provided.

Perioperative Pain Management Issues Unique to Older Adults Undergoing Surgery: A Narrative Review

INTRODUCTION

The older population is growing and with this growth there is a parallel rise in the operations performed on this vulnerable group. The perioperative pain management strategy for older adults is unique and requires a team-based approach for provision of high-quality surgical care.

METHODS

Literature search was performed using PubMed in addition to review of relevant protocols and guidelines from geriatric, surgical, and anesthesia societies. Systematic reviews and meta-analyses, randomized trials, observational studies, and society guidelines were summarized in this review.

MANAGEMENT

The optimal approach to a pain management strategy for older adults undergoing surgery involves addressing all phases of perioperative care. For example, preoperative assessment of a patient's cognitive function and presence of chronic pain may impact the pain management plan. Consideration should be also given to intraoperative strategies to improve pain control and minimize both the dose and side effects from opioids (e.g. regional anesthetic techniques). Postoperative pain control (e.g. under or over treatment of pain) may impact the development of elderly-specific complications such as postoperative delirium and functional decline. Finally, pain management does not stop after the older adult patient leaves the hospital. Both discharge planning and post-operative clinic follow-up provide important opportunities for collaboration and intervention.

CONCLUSIONS

An opioid-sparing pain management strategy for older adults can be accomplished with a comprehensive and collaborative interdisciplinary strategy addressing all phases of perioperative care.

ACG Clinical Guidelines: Prevention, Diagnosis, and Treatment of Clostridioides difficile Infections

Clostridioides difficile infection occurs when the bacterium produces toxin that causes diarrhea and inflammation of the colon. These guidelines indicate the preferred approach to the management of adults with C. difficile infection and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation process. In instances where the evidence was not appropriate for Grading of Recommendations Assessment, Development, and Evaluation but there was consensus of significant clinical merit, key concept statements were developed using expert consensus. These guidelines are meant to be broadly applicable and should be viewed as the preferred, but not the only, approach to clinical scenarios.

MALDI-TOF MS: An alternative approach for ribotyping Clostridioides difficile isolates in Brazil

Clostridioides difficile is an important organism causing healthcare-associated infections. It has been documented that specific strains caused multiple outbreaks globally, and patients infected with those strains are more likely to develop severe C. difficile infection (CDI). With the appearance of a variant strain, BI/NAP1 ribotype 027, responsible for several outbreaks and high mortality rates worldwide, the epidemiology of the CDI changed drastically in the United States, Europe, and some Latin American countries. Although the epidemic strain 027 was not yet detected in Brazil, there are ribotypes exclusively found in the country, such as, 131, 132, 133, 135, 142 and 143, which are responsible for outbreaks in Brazilian hospitals and nursing homes. Although PCR-ribotyping is the most used method in epidemiology studies of C. difficile, it is not available in Brazil. This study aimed to develop and validate an in-house database for detecting C. difficile ribotypes, usually involved in CDI in Brazilian hospitals, by using MALDI-TOF MS. A database with 19 different ribotypes, 13 with worldwide circulation and 6 Brazilian-restricted, was created based on 27 spectra readings of each ribotype. After BioNumerics analysis, neighbor-joining trees revealed that spectra were distributed in clusters according to ribotypes, showing that MALDI-TOF MS could discriminate all 19 ribotypes. Moreover, each ribotype showed a different profile with 42 biomarkers detected in total. Based on their intensity and occurrence, 13 biomarkers were chosen to compose ribotype-specific profiles, and in silico analysis showed that most of these biomarkers were uncharacterized proteins or well-conserved peptides, such as ribosomal proteins. A double-blind assessment using the 13 biomarkers correctly assigned the ribotype in 73% of the spectra analyzed, with 94%-100% of correct hits for 027 and for Brazilian ribotypes. Although further analyses are required, our results show that MALDI-TOF MS might be a reliable, fast and feasible alternative for epidemiological surveillance of C. difficile in Brazil.

Diverting Loop Ileostomy for Clostridium Difficile Colitis: A Systematic Review and Meta-analysis

Diverting loop ileostomy (DLI) with colonic lavage has been proposed as an alternative to total abdominal colectomy (TAC) for fulminant Clostridium difficile infection (CDI). Controversy exists regarding the mortality benefit and outcomes of this surgical approach. We conducted a MEDLINE database search for articles between 1999 and 2019 pertaining to DLI for the surgical treatment of CDI. Five articles met the inclusion criteria. Four studies were retrospective and one was a prospective matched cohort study. 3683 patients were included in the 5 studies; 733 patients (20%) underwent DLI, while 2950 patients (80%) underwent TAC. The only shared outcome measure across all 5 studies was mortality. The overall mortality rate for the entire cohort undergoing both procedures was 30.3%. There was no statistically significant difference in pooled mortality between DLI and TAC (OR: .73; 95% CI, .45-1.2; P = .22). Reporting of other postoperative outcomes was variable. Fulminant CDI remains a life-threatening condition with high mortality. Loop ileostomy may be a viable surgical alternative to total colectomy with similar mortality; however, further work is needed to determine specific patient characteristics that warrant routine use of DLI.

Critical Care Management of the Patient with Clostridioides difficile

OBJECTIVES

To review published clinical evidence on management of Clostridioides difficile infection in critically ill patients.

DATA SOURCES

We obtained relevant studies from a PubMed literature review and bibliographies of reviewed articles.

STUDY SELECTION

We selected English-language studies addressing aspects of C. difficile infection relevant to critical care clinicians including epidemiology, risk factors, diagnosis, treatment, and prevention, with a focus on high-quality clinical evidence.

DATA EXTRACTION

We reviewed potentially relevant studies and abstracted information on study design, methods, patient selection, and results of relevant studies. This is a synthetic (i.e., not systematic) review.

DATA SYNTHESIS

C. difficile infection is the most common healthcare-associated infection in the United States. Antibiotics are the most significant C. difficile infection risk factor, and among antibiotics, cephalosporins, clindamycin, carbapenems, fluoroquinolones, and piperacillin-tazobactam confer the highest risk. Age, diabetes mellitus, inflammatory bowel disease, and end-stage renal disease are risk factors for C. difficile infection development and mortality. C. difficile infection diagnosis is based on testing appropriately selected patients with diarrhea or on clinical suspicion for patients with ileus. Patients with fulminant disease (C. difficile infection with hypotension, shock, ileus, or megacolon) should be treated with oral vancomycin and IV metronidazole, as well as rectal vancomycin in case of ileus. Patients who do not respond to initial therapy should be considered for fecal microbiota transplant or surgery. Proper infection prevention practices decrease C. difficile infection risk.

CONCLUSIONS

Strong clinical evidence supports limiting antibiotics when possible to decrease C. difficile infection risk. For patients with fulminant C. difficile infection, oral vancomycin reduces mortality, and adjunctive therapies (including IV metronidazole) and interventions (including fecal microbiota transplant) may benefit select patients. Several important questions remain regarding fulminant C. difficile infection management, including which patients benefit from fecal microbiota transplant or surgery.

Meta-analysis of Postoperative Mortality and Morbidity After Total Abdominal Colectomy Versus Loop Ileostomy With Colonic Lavage for Fulminant Clostridium Difficile Colitis

BACKGROUND

Emergency surgery is often required for fulminant Clostridium difficile colitis. Total abdominal colectomy has been the treatment of choice despite high morbidity and mortality.

OBJECTIVE

The aim of this meta-analysis was to evaluate postoperative mortality and morbidity after total abdominal colectomy and loop ileostomy with colonic lavage in patients with fulminant C difficile colitis.

DATA SOURCES

Studies comparing total abdominal colectomy to loop ileostomy for fulminant C difficile colitis were identified by a systematic search of PubMed, Cochrane Library, MEDLINE, and CINAHL.

STUDY SELECTION

Relevant records were detected and screened using a cascade system (title, abstract, and/or full text article).

INTERVENTION(S)

Total abdominal colectomy (rectal-sparing resection of the entire colon with end ileostomy) was compared to loop ileostomy (exteriorization of an ileal loop not far from the ileocecal junction for colonic lavage).

MAIN OUTCOMES MEASURES

This meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Guidelines. Primary outcome was postoperative mortality, defined as death occurring within 30 days after the intervention. Secondary end points were the rates of ostomy reversal, deep venous thrombosis/embolism, surgical site infection, urinary tract infection, respiratory complications, reoperations, and adverse events. Mantel-Haenszel method with random-effects model was used for meta-analysis.

RESULTS

Five observational studies (3 cohort and 2 database analysis studies) totaling 3683 patients were included. Postoperative mortality rate was 31.3% after total abdominal colectomy and 26.2% after loop ileostomy (OR = 1.36 (95% CI, 0.83-2.24); p = 0.22; number needed to treat/harm = 20; I = 55%). Ostomy reversal rate was both statistically and clinically significantly higher after loop ileostomy as compared with total abdominal colectomy (80% vs 25%; OR = 0.08 (95% CI, 0.02-0.30); p = 0.002; number needed to treat/harm = 2) with low heterogeneity (I = 0%).

LIMITATIONS

A limitation is the observational nature of the included studies introducing an overall high risk of selection bias.

CONCLUSIONS

This meta-analysis suggests that loop ileostomy with colonic lavage for fulminant C difficile colitis may be associated with similar survival and decreased surgical site infection rates as compared with total abdominal colectomy. Although loop ileostomy with colonic lavage was associated with higher ostomy reversal rates, this finding was based on the data from only 2 studies.

Stop the Bleed: Effective Training in Need of Improvement

BACKGROUND

The "Stop the Bleed" (StB) campaign aims to educate laypersons on performing bleeding control techniques in any setting that requires hemorrhage control, such as motor vehicle crashes or mass casualty incidents. Participants undergo a didactic and practical session, the latter incorporating a mannequin. We hypothesized that participants would increase content knowledge after StB participation and that the training could be improved by a more life-like bleeding modification of the mannequin.

MATERIALS AND METHODS

From July 2017 to January 2018, hospital and community members from a major metropolitan area participated in StB training. Participants provided demographic data regarding prior emergency training and were asked pre- and post-test questions (five-point Likert scale) regarding their response to hemorrhage. Individuals also evaluated the mannequin on bleeding simulation. Scores were reported as means with standard deviation or medians with interquartile ranges (IQRs) with subset analysis stratified by experience.

RESULTS

Of 402 participants, 310 provided complete data. On the composite, pre-test self-assessment, participants had a median score of 24 of 30 points (IQR 16-30). Post-testing demonstrated a statistically significant increase with a median score of 29 (IQR 25-30, P < 0.05). Subset analysis by prior emergency training (n = 102) demonstrated that both those with prior emergency training and those with no prior emergency training had significant improvement. On evaluation of the mannequin, participants reported that a more realistic model would increase their confidence in technique. Both subgroups reported that training would be enhanced if the mannequins were more realistic.

CONCLUSIONS

StB is an effective education program. Those without prior experience or training in hemorrhage cessation demonstrated the most improvement. Regardless of background, participants reported overwhelmingly that the training would be more effective if it were more realistic. Future work to design and develop cost-effective mannequins demonstrating pulsatile blood flow and cessation of hemorrhage could enable learners to actually "Stop the Bleed".

Trends in Diverting Loop Ileostomy vs Total Abdominal Colectomy as Surgical Management for Clostridium difficile Colitis

Importance

Diverting loop ileostomy and colonic lavage has generated much interest since it was first reported as a potential alternative to total abdominal colectomy for treating Clostridium difficile colitis in 2011. To our knowledge, few studies have validated the benefit reported in the initial description, and the association of this new approach with practice patterns has not been described.

Objective

To examine the national adoption pattern and outcomes of diverting loop ileostomy vs total abdominal colectomy as treatment for fulminant C difficile colitis.

Design, Setting, and Participants

This retrospective cohort study used data from hospitals participating in the National Inpatient Sample database across the United States from January 2011 to September 2015 and included 3021 adult patients who underwent surgery for C difficile colitis during the study period, comprising 2408 subtotal colectomies and 613 loop ileostomies. The data were analyzed between November 2018 and April 2019.

Exposures

Loop ileostomy as surgery of choice.

Main Outcomes and Measures

In-hospital mortality.

Results

Of 2408 participants, 1416 (58.8%) were women, 1781 (78.4%) were white, and 627 (21.6%) were individuals of color and the mean (SD) age was 68.2 (14.8) years. During the overall study period, 613 patients (20.28%) underwent diverting loop ileostomy without total abdominal colectomy. The annual proportion of patients undergoing only diversion increased from 11.16% in 2011 to 25.30% in 2015. Significantly more loop ileostomies were performed within the first day of hospitalization, in contrast to subtotal colectomies (23.31% vs 12.21%; P < .01). There was no significant difference in in-hospital mortality rates between the 2 groups (25.98% vs 31.18%; P = .28).

Conclusions and Relevance

This study demonstrates the adoption of diverting loop ileostomy to treat C difficile colitis across the United States. While fulminant C difficile colitis remains a condition with high mortality rates, no significant difference in this outcome was observed between loop ileostomy and total abdominal colectomy. Loop ileostomy may represent a viable surgical alternative to total abdominal colectomy, although the grounds for selection of treatment need to be clarified.

[Updated review of Clostridium difficile infection in elderly]

Clostridium difficile infection is the most common cause of health care-associated diarrhoea, and its incidence increases with age. Clinical challenges, risk of resistance to treatment, risk of recurrence, and treatment responses are different in elderly. The aim of this review is to discuss the updated epidemiology, pathophysiology, diagnosis, and therapeutic management of C. difficile infection in elderly with the available data.

Diverting loop ileostomy versus total abdominal colectomy for clostridioides difficile colitis: outcomes beyond the index admission

INTRODUCTION

Diverting loop ileostomy (DLI) and colonic lavage has emerged as a valid alternative to total abdominal colectomy (TAC) for the surgical management of Clostridioides difficile colitis (CDC). However, little data are available on outcomes beyond the index admission. The objective of this study was to compare post-discharge outcomes between patients who underwent DLI and TAC for CDC.

METHODS

Adult patients who underwent DLI or TAC for CDC between 2011 and 2016 were identified from the Nationwide Readmissions Database, and only discharges between January and September in each calendar year were included to allow for a 90-day follow-up period for all cases. Ninety-day overall in-hospital mortality (index admission mortality plus 90-day post-discharge mortality) and 90-day unplanned readmissions were compared. To assess 6-month ileostomy reversal rates, the cohort was then truncated to exclude discharges after June in each calendar year. Multivariate regression was used to adjust for patient demographics and disease severity.

RESULTS

In total, 2070 patients were discharged between January and September of each included year: 1486 (71.8%) TAC compared to 584 (28.2%) DLI. Overall in-hospital mortality was higher among patients who underwent TAC (34.5% vs. 27.7%, p = 0.004); however, this association did not remain on multivariate regression (OR 1.14, 95% CI 0.91-1.43). Among the 1434 patients who were discharged alive, the 90-day unplanned readmission rate was similar in both groups (TAC: 26.1% vs. DLI: 23.1%, p = 0.26). After truncating the cohort to those patients discharged alive between January and June of each included year (n = 1016), patients who underwent DLI had a significantly greater 6-month ileostomy reversal rate (26.4% vs. 8.3%, p < 0.001). DLI was independently associated with higher odds of 6-month ileostomy reversal (OR 2.68, 95% CI 1.80-4.00).

CONCLUSIONS

In the surgical management of CDC, DLI is associated with equivalent mortality and unplanned readmission, but greater likelihood of 6-month ileostomy reversal, compared to TAC.

Recommendations for the diagnosis and treatment of Clostridioides difficile infection: An official clinical practice guideline of the Spanish Society of Chemotherapy (SEQ), Spanish Society of Internal Medicine (SEMI) and the working group of Postoperative Infection of the Spanish Society of Anesthesia and Reanimation (SEDAR)

This document gathers the opinion of a multidisciplinary forum of experts on different aspects of the diagnosis and treatment of Clostridioides difficile infection (CDI) in Spain. It has been structured around a series of questions that the attendees considered relevant and in which a consensus opinion was reached. The main messages were as follows: CDI should be suspected in patients older than 2 years of age in the presence of diarrhea, paralytic ileus and unexplained leukocytosis, even in the absence of classical risk factors. With a few exceptions, a single stool sample is sufficient for diagnosis, which can be sent to the laboratory with or without transportation media for enteropathogenic bacteria. In the absence of diarrhoea, rectal swabs may be valid. The microbiology laboratory should include C. difficile among the pathogens routinely searched in patients with diarrhoea. Laboratory tests in different order and sequence schemes include GDH detection, presence of toxins, molecular tests and toxigenic culture. Immediate determination of sensitivity to drugs such as vancomycin, metronidazole or fidaxomycin is not required. The evolution of toxin persistence is not a suitable test for follow up. Laboratory diagnosis of CDI should be rapid and results reported and interpreted to clinicians immediately. In addition to the basic support of all diarrheic episodes, CDI treatment requires the suppression of antiperistaltic agents, proton pump inhibitors and antibiotics, where possible. Oral vancomycin and fidaxomycin are the antibacterials of choice in treatment, intravenous metronidazole being restricted for patients in whom the presence of the above drugs in the intestinal lumen cannot be assured. Fecal material transplantation is the treatment of choice for patients with multiple recurrences but uncertainties persist regarding its standardization and safety. Bezlotoxumab is a monoclonal antibody to C. difficile toxin B that should be administered to patients at high risk of recurrence. Surgery is becoming less and less necessary and prevention with vaccines is under research. Probiotics have so far not been shown to be therapeutically or preventively effective. The therapeutic strategy should be based, rather than on the number of episodes, on the severity of the episodes and on their potential to recur. Some data point to the efficacy of oral vancomycin prophylaxis in patients who reccur CDI when systemic antibiotics are required again.

Role of Surgery in Clostridium difficile Infection

Clostridium (reclassified as " Clostridioides ") difficile infection (CDI) occurs as a chronic or an acute illness with intensity varying from mild to severe. Although most cases of CDI can be managed with antibiotics and supportive care, when the patient presents with fulminant disease, the early decision to perform surgery is imperative for survival. The current standard of care is the subtotal colectomy. However, loop ileostomy with vancomycin enemas delivered into the colonic mucosa has been described as a viable option on selected patients.

Evolving Strategies to Manage Clostridium difficile Colitis

Clostridium difficile infection remains a common nosocomial illness with a significant impact on health care delivery. As molecular phenotyping of this organism has changed our understanding of its transmission and virulence, so too have diagnostic methods and treatment strategies evolved in recent years. The burden of this infection falls predominantly on elderly patients with comorbidities who have recently received antibiotics. Oral or enteral vancomycin is now preferred for first-line antimicrobial treatment across the disease spectrum, including mild-moderate initial cases. Fidaxomicin (a novel macrolide antibiotic), bezlotoxumab (a monoclonal antibody against toxin TcdB), and fecal microbiota transplantation expand the therapeutic armamentarium, particularly for recurrent infection. Operative treatment should be reserved for patients with fulminant infection, and early identification of patients who would benefit from an operation remains a challenge. Less invasive surgical options-such as laparoscopic diverting ileostomy with colonic irrigation-may improve survival and other outcomes relative to total abdominal colectomy and represent an attractive alternative particularly for frail patients.

Strategies to prevent adverse outcomes following Clostridioides difficile infection in the elderly

Introduction: Clostridioides difficile remains the most common cause of healthcare-associated infections in the US, and it disproportionately affects the elderly. Older patients are more susceptible and have a greater risk of adverse outcomes from C. difficile infection (CDI), despite advances in treatment and prevention.Areas covered: The epidemiology and pathogenesis of CDI, as well as risk factors in the aging host, will be reviewed. The importance of antimicrobial stewardship and infection prevention in order to avoid acquisition and transmission will be discussed, as well as strategies to prevent adverse outcomes and recurrent CDI, through optimization of CDI treatment s,election.Expert opinion: Appropriate CDI-prevention strategies to avoid adverse outcomes in this susceptible population involve antimicrobial stewardship and methods to prevent C. difficile transmission in healthcare settings. Management strategies to prevent adverse outcomes include initiation of supportive therapy and proper selection of CDI specific treatments. Many patients may also benefit from adjunctive therapies or additional procedures.

Diverting loop ileostomy with colonic lavage as an alternative to colectomy for fulminant Clostridioides difficile: a systematic review and meta-analysis

PURPOSE

Surgical consultation is recommended for all patients with fulminant Clostridioides difficile infection (CDI). If surgery is required, total abdominal colectomy (TAC) is most commonly performed. However, diverting loop ileostomy and colonic lavage have been recently developed as a potential colon-sparing approach to fulminant CDI. The aim of this review is to compare TAC and diverting loop ileostomy with colonic lavage for fulminant CDI.

METHODS

Search of MEDLINE, EMBASE, CENTRAL, and PubMed was performed. Articles were eligible for inclusion if they compared TAC and diverting loop ileostomy with colonic lavage. The primary outcome was postoperative mortality, and the secondary outcome was postoperative complications. Quality of included studies was assessed using Newcastle-Ottawa Scale.

RESULTS

From 64 relevant citations, 5 studies (4 retrospective cohorts, 1 case series) with 3683 patients were included. Compared to TAC, diverting loop ileostomy with colonic lavage did not significantly reduce overall mortality (RR 1.10, 95% CI 0.60 to 1.99, P = 0.77), rate of reoperation (RR 1.02, 95% CI, 0.63 to 1.63, P = 0.94), or overall postoperative complications (RR 0.51, 95% CI, 0.22 to 1.17, P = 0.11). Rates of colonic preservation with the use of diverting loop ileostomy with colonic lavage ranged from 76% to 100%.

CONCLUSION

There does not appear to be a survival advantage with the use of diverting loop ileostomy with colonic lavage compared to TAC for fulminant CDI. However, diverting loop ileostomy with colonic lavage results in increased rates of colonic preservation, restoration of intestinal continuity, and laparoscopic surgery. This review is limited by the small number of included studies.

Toxic Megacolon – the Complication of an Infection with Clostridium difficile after an Odontogenic Abscess. Case Presentation

Background: Clostridium difficile (CD) is the major cause of nosocomial antibiotic-associated infections, having as main manifestation diarrhea and life-threatening inflammation of the colon. Surgery may be necessary in up to 80% of patients due to the frequent complications associated with this condition. The mortality rate of this devastating disease could reach 50% even after proper treatment.

Case report: We report a case of a 24-year-old female who was admitted with clinical signs of an odontal inflammatory process. After repeated surgical treatments and antibiotic therapy, she presented acute abdominal pain on the 14th postoperative day. The explorative laparotomy was negative. Clostridium difficile was isolated from her stool, and she was transferred to the Department of Infectious Diseases. After a few days without any favorable clinical outcome, she was transferred to the intensive care unit (ICU), where she developed acute respiratory distress syndrome. Despite the immediate surgical intervention and ICU care, she died within 15 days after admission.

Conclusions: CD infection is considered a complication of antibiotic treatment, having as main cause the combination of fluoroquinolones with antisecretory drugs. In the first phase, the changes of the colon can be minimal with the manifestation of a false acute surgical abdomen, but toxic colon can develop in evolution, leading to multi-system organ failure and death.

Faecal microbiota transplant decreases mortality in severe and fulminant Clostridioides difficile infection in critically ill patients

BACKGROUND

Severe and fulminant Clostridioides difficile infection is associated with high mortality rates. While faecal microbiota transplant has been shown to be effective for recurrent C difficile infection, there is little data on the utility of faecal microbiota transplant in severe or fulminant C difficile infection.

AIM

To compare the outcomes of antibiotics and faecal microbiota transplantation vs antibiotics alone (standard of care) in critically ill patients with severe or fulminant C difficile infection.

METHODS

This was a retrospective, matched cohort study in one urban tertiary academic care centre including 48 patients hospitalised with severe or fulminant C difficile infection who required care in intensive care unit.

RESULTS

Patients who received faecal microbiota transplantation (n = 16) had a 77% decrease in odds for mortality (OR 0.23, 95% CI 0.06-0.97) with a number needed to treat of 3 to prevent one death.

CONCLUSIONS

Faecal microbiota transplantation provides mortality benefit over standard of care for severe and fulminant C difficile infection and should be considered in critically ill patients.

Clostridioides difficile-associated diarrhea in surgical service patients in Mexico

INTRODUCTION

Clostridioides difficile is the first cause of healthcare-associated diarrhea in developed countries. In recent years the incidence of C. difficile infection (CDI) has increased worldwide. There is not much information on the topic in Mexico, and little is known about the risk factors for the infection in patients that are hospitalized in surgical services.

MATERIALS AND METHODS

A case-control study was conducted that compared the epidemiologic findings and risk factors between surgical patients with PCR-confirmed CDI, surgical patients with diarrhea and a negative PCR test, and surgical patients with no diarrhea. The statistical analysis was carried out using the SPSS version 22.0 program.

RESULTS

The majority of the surgical patients with CDI belonged to the areas of neurosurgery, cardiac surgery, orthopedics, and general surgery. A total of 53% of the CDI cases were associated with the hypervirulent CD NAP1/027 strain. The presence of mucus in stools (OR: 1.5, P=.001), fever (OR: 1.4, P=.011), leukocytes in stools (OR: 3.2, P<.001), hospitalization within the past 12weeks (OR: 2.0, P<.001), antibiotic use (OR: 1.3, P=.023), and ceftriaxone use (OR: 1.4, P=.01) were independent risk factors for the development of CDI.

CONCLUSIONS

C. difficile-induced diarrhea in the surgical services is frequent at the Hospital Civil de Guadalajara "Fray Antonio Alcalde".

2019 update of the WSES guidelines for management of Clostridioides (Clostridium) difficile infection in surgical patients

In the last three decades, Clostridium difficile infection (CDI) has increased in incidence and severity in many countries worldwide. The increase in CDI incidence has been particularly apparent among surgical patients. Therefore, prevention of CDI and optimization of management in the surgical patient are paramount. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for management of CDI in surgical patients according to the most recent available literature. The update includes recent changes introduced in the management of this infection.

2019 update of the WSES guidelines for management of Clostridioides (Clostridium) difficile infection in surgical patients

In the last three decades, Clostridium difficile infection (CDI) has increased in incidence and severity in many countries worldwide. The increase in CDI incidence has been particularly apparent among surgical patients. Therefore, prevention of CDI and optimization of management in the surgical patient are paramount. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for management of CDI in surgical patients according to the most recent available literature. The update includes recent changes introduced in the management of this infection.

Management of Clostridioides difficile colitis: insights for the gastroenterologist

Clostridioides difficile infection (CDI) is a common cause of diarrhea in both inpatient and outpatient settings. The last few years have seen major changes in the treatment spectrum of CDI, most notably, recommendations against using metronidazole for initial CDI, the addition of fidaxomicin and bezlotoxumab, and emergence of microbial replacement therapies. Several other therapies are undergoing clinical trials. This narrative review focuses on the treatment of CDI with a summary of literature on the newer modalities and the treatment guidelines issued by Infectious Diseases Society of America and European Society of Clinical Microbiology and Infectious Diseases.