The changing face of Clostridium difficile: what treatment options remain?

Clostridium Difficile Infection from a Surgical Perspective

BACKGROUND

The incidence and the severity of Clostridium difficile infection (CDI) have increased significantly over the last decade, especially in high-risk populations such as patients with inflammatory bowel disease (IBD). Surgeons must be able to both identify and minimize the risk of CDI in their own surgical patients and determine which CDI patients will benefit from surgery.

PURPOSE

We sought to define the risk factors, compare the treatment options, define the surgical indications, and identify factors that affect surgical outcomes for CDI based on the currently available literature.

RESULTS

Antibiotic use, exposure to the C. difficile bacteria, IBD, and higher levels of co-morbidity are all risk factors for CDI. The majority of CDI can be treated with antibiotics. Severe or fulminant colitis, however, has a high potential for poor outcome, but experience and some data suggest a lower mortality rate with colectomy rather than with continued medical treatment. Open total abdominal colectomy with end ileostomy is typically the preferred surgical strategy. It is often difficult to determine which patients will fail medical management as some may not manifest clinical signs of severe infection. Surrogate parameters of failure of medical therapy include respiratory and/or renal insufficiency, age greater than 60 years, peripheral vascular disease, congestive heart failure, and coagulopathy, all of which have been associated with worse surgical outcomes. Evidence suggests that in appropriately selected patients, colectomy performed before the development of shock requiring vasopressors, respiratory failure, renal failure, multi-organ dysfunction, and mental status changes may reduce mortality of the most severe forms of colitis. For less severe or recurrent presentations, creation of a loop ileostomy with intra-operative colonic lavage, fecal microbiota transfer, and C. difficile vaccinations are being discussed but have only been studied in small case-controlled series.

CONCLUSIONS

Prevention, containment, and non-surgical treatment are the cornerstone of management for CDI. However, the most severe forms with toxic colitis benefit from involvement of a surgical team. Swift open total abdominal colectomy with end ileostomy in patients with severe or fulminant C. difficile colitis has the best chance to reduce mortality if it is not delayed until shock, end organ damage, vasopressor requirement, mental status changes develop. Less aggressive approaches may be appropriate for milder and refractory forms but require further study before their applicability can be determined.

Clostridium difficile infection in older adults: a review and update on its management

BACKGROUND

Clostridium difficile is a main cause of health care-associated infections. The incidence and severity have been increasing. Elderly persons are at an increased risk of morbidity and mortality from C. difficile infection (CDI). Relatively few advances have been made in the treatment of CDI since it was first identified as a cause of antibiotic-associated diarrhea more than 30 years ago.

OBJECTIVE

This article reviews CDI and provides an update on its treatment, including recently published clinical practice guidelines and the recently approved drug, fidaxomicin.

METHODS

English-language literature was identified through a search of PubMed (1966-October 2011), Iowa Drug Information Service (1966-October 2011), and International Pharmaceutical Abstracts (1970-October 2011). Key search terms included Clostridium difficile, Clostridium infections, pseudomembranous colitis, antibiotic-associated diarrhea, Clostridium difficile-associated diarrhea, elderly, geriatric, epidemiology, microbiology, diagnosis, risk factors, treatment, drug therapy, vancomycin, metronidazole, and fidaxomicin.

RESULTS

Metronidazole and vancomycin remain the mainstays of CDI treatment. Current guidelines recommend oral metronidazole for initial mild to moderate episodes or first recurrence. Oral vancomycin is recommended for initial severe episodes, or first or second recurrence. Fidaxomicin was approved in 2011 for treatment of CDI, but its place in therapy has yet to be determined. Other antibiotics have been used with variable success. Saccharomyces boulardii is the only probiotic that has shown efficacy in CDI. Fecal transplants have been used successfully in some patients, but randomized studies are needed. Immune therapy with a vaccine and monoclonal antibodies is being studied in clinical trials.

CONCLUSIONS

Treatment of CDI is challenging due to the limited number of drugs that have proven to be effective, concerns about antibiotic resistance, and recurring disease. The recent approval of fidaxomicin provides a new alternative. Immune therapy will likely play a greater role in the future.

C. difficile colitis--predictors of fatal outcome

PURPOSE

Clostridium difficile colitis (CDC) has a clinical spectrum ranging from mild diarrhea to fulminant, potentially fatal colitis. The pathophysiology for this variation remains poorly understood. A total abdominal colectomy may be lifesaving if performed before the point of no return. Identification of negative prognostic factors is desperately needed for optimization of the clinical and operative management.

METHODS

In-patients with CDC between 1999 and 2006 were identified through the discharge database (ICD-9: 008.45). Of these, patients with positive ELISA toxin or biopsy were included. Excluded were ELISA-negative patients. Data collected included general demographics, underlying medical conditions, APACHE II score, clinical and laboratory data, and duration of the medical treatment. Mortality and cure were the two endpoints. Regression analysis was used to identify parameters associated with mortality.

RESULTS

Three hundred ninety-eight patients (mean age 59, range 19-94) with CDC were analyzed. Fourteen patients (3.52%) underwent surgery. Mortality in the cohort was 10.3% (41/398 patients). Patients with fatal outcome had a longer pre-CDC hospital stay (11 vs. 6 days). Mortality was significantly (p<0.05) associated with a higher APACHE II score, a higher ASA class, a lower diastolic blood pressure, preexisting pulmonary and renal disease, use of steroids, evidence of toxic megacolon, higher WBCs, and clinical signs of sepsis and organ dysfunction (renal and pulmonary). Parameters without significant difference (p>0.05) included patient age, albumin, clinical presentation/examination parameters, and transplant status, other than the mentioned comorbidities. Of the 41 fatal outcomes, five patients (12.2%) underwent surgery, and 36 did not (87.8%). Mortality rate of the surgical group was 35.7% (four out of 14 patients). Comparison of the fatalities not undergoing surgery with the survivors revealed decreased clinical signs, suggesting a masking of the disease severity.

CONCLUSIONS

Our study identified several clinical factors, which were associated with mortality from CDC. Future clinical studies will have to focus on the disease progression and the fatalities occurring either without an attempt for or despite surgical intervention, as an earlier intervention might have proven lifesaving.

Clostridium difficile associated infection, diarrhea and colitis

A new, hypervirulent strain of Clostridium difficile, called NAP1/BI/027, has been implicated in C. difficile outbreaks associated with increased morbidity and mortality since the early 2000s. The epidemic strain is resistant to fluoroquinolones in vitro, which was infrequent prior to 2001. The name of this strain reflects its characteristics, demonstrated by different typing methods: pulsed-field gel electrophoresis (NAP1), restriction endonuclease analysis (BI) and polymerase chain reaction (027). In 2004 and 2005, the US Centers for Disease Control and Prevention (CDC) emphasized that the risk of C. difficile-associated diarrhea (CDAD) is increased, not only by the usual factors, including antibiotic exposure, but also gastrointestinal surgery/manipulation, prolonged length of stay in a healthcare setting, serious underlying illness, immune-compromising conditions, and aging. Patients on proton pump inhibitors (PPIs) have an elevated risk, as do peripartum women and heart transplant recipients. Before 2002, toxic megacolon in C. difficile-associated colitis (CDAC), was rare, but its incidence has increased dramatically. Up to two-thirds of hospitalized patients may be infected with C. difficile. Asymptomatic carriers admitted to healthcare facilities can transmit the organism to other susceptible patients, thereby becoming vectors. Fulminant colitis is reported more frequently during outbreaks of C. difficile infection in patients with inflammatory bowel disease (IBD). C. difficile infection with IBD carries a higher mortality than without underlying IBD. This article reviews the latest information on C. difficile infection, including presentation, vulnerable hosts and choice of antibiotics, alternative therapies, and probiotics and immunotherapy. We review contact precautions for patients with known or suspected C. difficile-associated disease. Healthcare institutions require accurate and rapid diagnosis for early detection of possible outbreaks, to initiate specific therapy and implement effective control measures. A comprehensive C. difficile infection control management rapid response team (RRT) is recommended for each health care facility. A communication network between RRTs is recommended, in coordination with each country’s department of health. Our aim is to convey a comprehensive source of information and to guide healthcare professionals in the difficult decisions that they face when caring for these oftentimes very ill patients.