Polyethylene glycol intestinal lavage in addition to usual antibiotic treatment for severe Clostridium difficile colitis: a randomised controlled pilot study

Loop Ileostomy With Colonic Lavage: Case Report of an Alternative to Total Colectomy in the Setting of Fulminant Clostridium difficile Colitis

Fulminant Clostridium difficile colitis is a severe and potentially life-threatening form of Clostridium difficile-associated bacterial disease leading to inflammation and damage to the colon. Complications such as toxic megacolon, sepsis, and multi-organ failure commonly occur in individuals with compromised immune systems and recent antibiotic use. Management of Clostridium difficile colitis involves optimization of fluid and electrolyte balance, and elimination of bacteria commonly by administering vancomycin or fidaxomicin. In cases where pharmacological management has been ineffective, fecal microbiota transplantation and surgical intervention demonstrated success. Historically, surgical intervention has involved a total abdominal colectomy with end ileostomy; however, other surgical options have shown increasing benefits with preservation of the colon.  This case report aims to provide an example of an alternative management strategy for fulminant Clostridium difficile infections, via the use of a loop ileostomy and colonic lavage. The combination of loop ileostomy and colonic lavage promotes bowel rest, removes toxins, and promotes healing while decreasing inflammation. As with all management modalities, it is essential to recognize the associated complications. The potential benefits should be carefully weighed against the risks on a case-by-case basis with the help of a multidisciplinary team as illustrated through this case report. Overall, early recognition and treatment of fulminant Clostridium difficile colitis using loop ileostomy and colonic lavage prevents further disease progression and improves patient outcomes.

Uncommon Presentation of Clostridioides difficile in the Small Bowel: A Case Report and Review of Literature

Clostridioides difficile infection (CDI) is a prevalent source of hospital-acquired diarrhea. The most common presentation of CDI is colitis. In cases of fulminant colitis/toxic megacolon, a colectomy and end ileostomy are part of the treatment plan. There is evidence to suggest that it may be beneficial to surgically treat severe complex CDI by constructing a loop ileostomy for fecal stream diversion followed by colonic lavage, also referred to as the Pittsburgh protocol, which has demonstrated decreased death rates in this patient population. In our case study, we present a rare case of a 60-year-old female patient diagnosed with fulminant small bowel CDI requiring resection of the necrotic small bowel. This was followed by creating an ileostomy and the Pittsburgh protocol, leading to a complete recovery. With an increasing incidence of CDI, it is important to be aware of the small bowel C. difficile infection and its treatment.

Colonic lavage in treatment of refractory Clostridium difficile infection: an adaptation of the Pittsburgh protocol

Clostridium difficile infection (CDI) is a common nosocomial sequela in patients treated with antibiotics. Surgical intervention is indicated in fulminant cases. However, the mortality associated with total colectomy and end ileostomy is high. Previous reports have indicated that surgical intervention for severe complicated CDI with formation of a loop ileostomy leading to the diversion of fecal stream followed by colonic lavage can be beneficial in treating severe CDI. This procedure is known as the Pittsburgh protocol and has been reported to decrease the mortality and the need for a total colectomy in patients with severe complicated CDI. In this case, we present a 75-year-old female with refractory CDI. In her treatment, we adapted the Pittsburgh protocol and utilized a 20-French MIC gastrostomy tube to recreate the ileocecal valve and control the colonic lavage without retrograde flow.

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.

Early Rescue from Acute Severe Clostridium Difficile: A Novel Treatment Strategy

BACKGROUND

Severe Clostridium difficile infections (CDI) can lead to significant impediments to effective treatment. We developed a novel treatment protocol utilizing bedside gastrointestinal lavage (GIL) for the management of patients with severe, complicated CDI. We describe the development and early outcomes of non-operative bedside GIL in hospitalized patients with severe, complicated CDI following the Idea, Development, Exploration, Assessment, Long Term Study (IDEAL) framework at the Idea stage. We compared our results with those of a cohort of patients managed with colectomy.

METHODS

We conducted a retrospective cohort study of hospitalized patients with severe, complicated CDI who failed conventional medical therapy and were referred for surgical consultation at two academic tertiary-care hospitals between January 2009 and January 2015. After surgical assessment, the attending surgeon decided to proceed either with bedside GIL or directly to colectomy. Bedside GIL involved nasojejunal tube insertion followed by flushing with 8 L of polyethylene glycol 3350/electrolyte solution over 48 h. Both patient groups received standard medical treatment with vancomycin 500 mg q 6 h enterally and metronidazole 500 mg intravenously three times daily for 14 d. The main outcomes of interest were the incidence of colectomy, complications, and mortality rate.

RESULTS

Nineteen and seventeen patients underwent GIL and direct colectomy, respectively. There were no significant differences between the groups in terms of demographics, American Society of Anesthesiologists class, disease severity, need for intensive care unit admission, mechanical ventilation, vasopressor use, serum lactate concentration, or proportion presenting with hypotension, acute kidney injury, or a white blood cell count >16,000/mcL or <4,000/mcL (p > 0.1). The in-hospital mortality rate was 26% (5/19) and 41% (7/17) for the GIL and colectomy groups, respectively (p = 0.35). Only one patient in the GIL group failed the protocol, requiring colectomy. There were no significant differences in complications in the two groups.

CONCLUSIONS

Bedside GIL appeared to be safe for the treatment of patients with severe, complicated CDI who had failed conventional medical therapy. It did not appear to increase the risk of morbidity or death compared with the traditional strategy of proceeding directly to colectomy.