Clostridium difficile Infection in Ulcerative Colitis: Increased Risk of Colectomy and Postoperative Infectious Complications

Abstract

Purpose: Ulcerative colitis (UC) patients diagnosed with Clostridium difficile (C. difficile) in hospital have worse outcomes; however, the majority of studies have only evaluated the influence of in-hospital diagnosis of C. difficile. The aims of this study were to determine whether: 1) UC patients diagnosed with C. difficile infections in-hospital and up to 90 days prior to admission were more likely to have an emergent colectomy; and 2) whether C. difficile increased the risk of postoperative complications following colectomy. Methods: Population-based surveillance was conducted in the Calgary Health Zone between January 1, 2000 and December 31, 2009 to identify all adults (≥ 18 years) admitted to hospital for an UC flare (n=481). In addition, the Calgary Laboratory Services (CLS) laboratory provided all C. difficile toxin tests ordered within 90 days of hospital admission (n=123). UC patients admitted to hospital for flare who responded to medical management (n=295) and were discharged from hospital were compared to UC patients who failed medical management and required an in-hospital emergent colectomy (n=186). Secondly, the records of patients undergoing emergency colectomy were reviewed to assess for the occurrence of various postoperative complications stratified as any complication and infectious. Multivariate logistic regression analysis was performed to examine the association between C. difficile infection and: 1) emergent colectomy versus medically responsive UC flare; and 2) postoperative complications (any and infectious). Results: Patients diagnosed with C. difficile 90 days before or during hospitalization (n=18) were at higher risk for having a colectomy when compared to patients who were C. difficile negative (OR= 2.87; 95% CI: 1.03-8.03) after adjusting for age, sex, corticosteroid use in hospital and disease extent. UC patients who underwent emergent colectomy and were diagnosed with C. difficile prior to surgery were not at a statistically higher risk of developing postoperative complications in general (OR=3.48; 95% CI: 0.93-13). However, preoperative C. difficile infection increased the risk of specified infectious complications (OR=4.56; 95% CI: 1.07-18.34) in the postoperative period. Conclusion: UC patients were significantly less likely to be medically responsive and hence, required a colectomy when they were diagnosed with a C. difficile infections in-hospital or within 90 days of admission. Moreover, UC patients who had concomitant C. difficile, preoperatively were at a higher risk of infectious complications following colectomy.