Fulminant Clostridium Difficile Colitis Research Articles

A Case Report on Fulminant Clostridium difficile Colitis Managed with Vancomycin Administered through Ileostomy

A Case Report on Fulminant Clostridium difficile Colitis Managed with Vancomycin Administered through Ileostomy

Fulminant colitis due to Clostridium Difficile in a patient with a history of liver transplantation: a severe life-threatening complication.

Clostridium difficile´s fulminant colitis is characterized by the development of severe acute inflammation of the colon, associated with systemic toxicity. Fulminant colitis is the most serious form of acute colitis with a mortality of up to 80%. We present the case of a 45-year-old man who presented to the emergency department with acute abdominal pain, diarrhea and fever. Computed tomography showed circumferential diffuse parietal thickening of the colon, including the rectum, associated with striation of the surrounding tissues and ganglionic formations. In the following hours the patient evolved with worsening of the general condition, increased inotropic requirements and lactic acidosis. Emergency laparotomy was decided and total colectomy was performed. Fulminant Clostridium difficile colitis is a potentially deadly disease. The lability of the pathology in many occasions forces quick decision making, therefore fulminant colitis represents a medical surgical emergency being time crucial.

Outcomes of total versus partial colectomy in fulminant Clostridium difficile colitis: a propensity matched analysis

BackgroundThe Total Abdominal Colectomy (TAC) is the recommended procedure for Fulminant Clostridium Difficile Colitis (FCDC), however, occasionally, FCDC is also treated with partial colectomies. The purpose of the study was to identify the outcomes of partial colectomy in FCDC cases.MethodThe National Surgical Quality Improvement Program database was accessed and eligible patients from 2012 through 2016 were reviewed. Patients 18 years and older who were diagnosed with FCDC and who underwent colectomies were included in the study. Patients’ demography, clinical characteristics, comorbidities, mortality, morbidities, length of hospital stay and discharge disposition were compared between the group who underwent partial colectomy and the group who underwent TAC. Univariate analysis followed by propensity matching was performed. A P value of < 0.05 is considered as statistically significant.ResultsOut of 491 patients who qualified for the study, 93 (18.9%) patients underwent partial colectomy. The pair matched analysis showed no significant difference in patients’ characteristics and comorbidities in the two groups. There was no significant difference found in mortality between the two groups (30.1% vs. 30.1%, P > 0.99). There were no differences found in the median [95% CI] hospital length of stay (LOS) (23 days [19–31] vs. 21 [17–25], P = 0.30), post-operative complications (all P > 0.05), and discharged disposition to home ( 33.8% vs. 43.1%) or transfer to rehab (21.55 vs. 12.3%, P = 0.357) between the TAC and partial colectomy groups.ConclusionThe overall 30 days mortality remains very high in FCDC. Partial colectomy did not increase risk of mortality or morbidities and LOS.Level of evidenceLevel IV.Study typeObservational cohort.

Colon Involvement in Necrotizing Pancreatitis: Incidence, Risk Factors, and Outcomes.

To investigate the incidence, risk factors, and outcomes of colon involvement in patients with necrotizing pancreatitis. Necrotizing pancreatitis is characterized by a profound inflammatory response with local and systemic implications. Mesocolic involvement can compromise colonic blood supply leading to ischemic complications; however, few data exist regarding this problem. We hypothesized that the development of colon involvement in necrotizing pancreatitis (NP) negatively affects morbidity and mortality. Six hundred forty-seven NP patients treated between 2005 and 2017 were retrospectively reviewed to identify patients with colon complications, including ischemia, perforation, fistula, stricture/obstruction, and fulminant Clostridium difficile colitis. Clinical characteristics were analyzed to identify risk factors and effect of colon involvement on morbidity and mortality. Colon involvement was seen in 11% (69/647) of NP patients. Ischemia was the most common pathology (n = 29) followed by perforation (n = 18), fistula (n = 12), inflammatory stricture (n = 7), and fulminant C difficile colitis (n = 3). Statistically significant risk factors for developing colon pathology include tobacco use (odds ratio (OR), 2.0; 95% confidence interval (CI), 1.2-3.4, P = 0.009), coronary artery disease (OR, 1.9; 95% CI, 1.1-3.7; P = 0.04), and respiratory failure (OR, 4.7; 95% CI, 1.1-26.3; P = 0.049). When compared with patients without colon involvement, NP patients with colon involvement had significantly increased overall morbidity (86% vs 96%, P = 0.03) and mortality (8% vs 19%, P = 0.002). Colon involvement in necrotizing pancreatitis is common; clinical deterioration should prompt its evaluation. Risk factors include tobacco use, coronary artery disease, and respiratory failure. Colon involvement in necrotizing pancreatitis is associated with substantial morbidity and mortality.

A systematic review and meta-analysis of diverting loop ileostomy versus total abdominal colectomy for the treatment of Clostridium difficile colitis.

Clostridium difficile is an increasingly common source of in-patient morbidity and mortality. We aim to assess the effects of diverting loop ileostomy (DLI) versus total abdominal colectomy (TAC) for Clostridium difficile colitis (CDC), in terms of mortality and morbidity. Systematic literature search was performed using PubMed, Embase, Cochrane, and Web of Science databases for randomized and non-randomized studies comparing DLI and TAC for fulminant CDC. Meta-analysis was carried out for mortality and postoperative complications. Five non-randomized studies qualified for inclusion in the quantitative synthesis. In total, 3683 patients were allocated to DLI (n = 733) or TAC (n = 2950). The overall mortality was equivalent (OR 0.73; 95% CI 0.45-1.20; P = 0.22). Regarding secondary outcomes, the pooled analysis revealed the following equivalent rates of postoperative events: thromboembolism (OR 0.45; 95% CI 0.14-1.43; P = 0.18), acute renal failure (OR 1.71; 95% CI 0.91-3.23; P = 0.10), surgical site infection (OR 0.95; 95% CI 0.11-8.59; P = 0.97), pneumonia (OR 0.98; 95% CI 0.36-2.66; P = 0.97), urinary tract infection (OR 0.81; 95% CI 0.26-2.52; P = 0.72), and reoperation (OR 0.95; 95% CI 0.50-1.82; P = 0.78). The ostomy reversal rate was significantly higher in DLI (OR 12.55; 95% CI 3.31-47.55; P = 0.0002). The overall morbidity and mortality rates between DLI and TAC for the treatment of CDC seemed to be equivalent. Evidence from a randomized controlled trial is needed to clarify the timing and understand the impact of DLI for CDC.

A case report of successful management of fulminant Clostridium difficile colitis post-ileostomy reversal with administration of vancomycin through a transverse colostomy

A case report of successful management of fulminant Clostridium difficile colitis post-ileostomy reversal with administration of vancomycin through a transverse colostomy

Development and validation of a clinical risk calculator for mortality after colectomy for fulminant Clostridium difficile colitis.

Clostridium difficile colitis is an increasingly important cause of morbidity and mortality. Fulminant C. difficile colitis (FCDC) is a severe form of the colitis driven by a significant systemic inflammatory response, and managed with a total abdominal colectomy. Despite surgery, postoperative mortality rates remain high. The aim of this study was to develop a bedside calculator to predict the risk of 30-day postoperative mortality for patients with FCDC. After institutional review board approval, the American College of Surgeons National Surgical Quality Improvement Program database (2005-2015) was used to include adult patients who underwent emergency surgery for FCDC. A priori preoperative predictors of mortality were selected from the literature: age, immunosuppression, preoperative shock, intubation, and laboratory values. The predictive accuracy of different logistic regression models was measured by calculating the area under the receiver-operating characteristic curve. A cohort of 124 patients from Québec was used to validate the developed mortality calculator. A total of 557 patients met the inclusion criteria, and the overall mortality was 44%. After developing the calculator, no statistically significant differences were found in comparison with the American College of Surgeons National Surgical Quality Improvement Program probability of mortality available in the database (area under the receiver operating curve, 75.61 vs. 75.14; p = 0.79). External validation with the cohort of patients from Quebec showed an area under the curve of 74.0% (95% confidence interval, 65.0-82.9). A clinically applicable calculator using preoperative variables to predict postoperative mortality for patients with FCDC was developed and externally validated. This calculator may help guide preoperative decision making. Prognostic and epidemiological study, level III.

Intracolonic Administration of Vancomycin via Cecal Tube in Intensive Care Unit Patients With Fulminant Clostridium difficile Colitis

Introduction: Clostridium difficile infection (CDI) is a major cause of antibiotic-associated diarrhea worldwide. The incidence of sepsis has been shown to be increasing due to fulminant colitis. Oral vancomycin is the treatment of choice for CDI, but it is often ineffective in patients in the intensive care unit due to poor intestinal motility. We present a review of eight cases with fulminant CDI treated with adjunctive intracolonic vancomycin administration. Methods: A retrospective chart review identified patients in sepsis with fulminant colitis and positive Clostridium difficile toxin A or B. Patients who had failed standard therapy for CDI were given adjunctive intracolonic vancomycin through an enteric tube at the level of cecum or ascending colon, which was inserted via colonoscopy. The patients selected had required over 20 mcg/min of norepinephrine and on vasopressin for vasopressor support. Results: Eight patients (37% females) received this adjunctive treatment; mean age was 73.25. The average APACHE2 score at the time of the procedure was 39. The median length of stay was 5.5 days, with an in-hospital mortality of 37.5 % and an average time to death of 1.33 days from the day of colonoscopy. Conclusion: Colonoscopic decompression and administration of vancomycin for fulminant CDI using an enteric tube can have favorable outcomes. We propose that adjunctive use of ICV could in certain cases obviate the need for surgery and salvage the colon, especially for patients who are not surgical candidates given their age and co-morbidities. Further larger randomized controlled trials are needed to evaluate its efficacy.

A Nomogram for Prediction of Mortality in Patients who Undergo Surgery for Fulminant Clostridium Difficile Colitis: Results from the American College of Surgeons-NSQIP Database

A Nomogram for Prediction of Mortality in Patients who Undergo Surgery for Fulminant Clostridium Difficile Colitis: Results from the American College of Surgeons-NSQIP Database

Fulminant Clostridium difficile colitis: new challenges in critical care medicine

Fulminant Clostridium difficile colitis (FCDC) means severe Clostridium difficile colitis (CDC), which often manifested with severe diarrhea, fever, abdominal distention, electrolyte disorder, hypoalbuminemia, and it can lead to pseudo membrane colonitis, toxic megacolon, bowel perforation, septic shock, and multiple organ dysfunction. Now Clostridium difficile (CD) becomes one of the most important medical institutions related infectious pathogens. In particular, the recently discovered mutant CD strain NAP1/BI/ribotype 027 has high pathogenicity in the global epidemic and its outbreak. The morbidity and mortality of FCDC has a significant upward trend in the global in recent years. All broad spectrum antimicrobials usage is considered to be the primary risk factor for the onset of FCDC. Therefore, FCDC has become a new challenge for clinical work. The epidemiology, related risk factors, pathogenesis, diagnosis, severity classification, recent progress in clinical treatment of FCDC were reviewed in order to provide help for clinical treatment of FCDC and related research.

Effects of a New Hospital-Wide Surgical Consultation Protocol in Patients with Clostridium difficile Colitis.

Fulminant Clostridium difficile colitis (fCDC) occurs in 2%-8% of patients with CDC and carries a high death rate. Prompt operation may reduce death. Our aim was to determine whether a standardized hospital-wide protocol for surgical referral in CDC would result in earlier surgical consultation, earlier identification of patients who could benefit from surgical therapy, and reduced deaths from fCDC. A multidisciplinary team developed consensus criteria for surgical consultation. Compliance was evaluated by prospective review of all inpatient CDC cases. Outcomes of the prospective cohort (POST) were compared to an historic control group (PRE). From November 1, 2010 to October 31, 2012, we identified 1,106 inpatients with CDC; 339 patients matched the consultation criteria, of whom 213 received a surgical consultation, resulting in an overall compliance rate of 62.8%. All those with fCDC received a surgical consultation, with a median time to surgical referral of three hours. Of 46 patients with fCDC, 11 (23.9%) died, compared with 34.8% in the historical control group (p = 0.15). The death rate was 14.7% in the POST group, when excluding patients with limitations of care and those transferred to our institution in a fulminant state. There was a shorter interval between admission and surgical intervention for those who required operation in the POST group-three (1-11) days versus 1.5 (0-3) days, respectively, in the PRE and POST groups (p = 0.018), and a shorter adjusted median hospital length of stay (adjusted difference 9.0, 95% CI 2.2-12.3, p = 0.007) Conclusions: A hospital-wide protocol with established criteria for surgical consultation resulted in faster intervention and a shorter adjusted median hospital length of stay. The overall death rate for fCDC patients without limitations of life-sustaining treatment who presented to our emergency department or in whom fCDC developed while they were admitted to our hospital was 14.7%.

Cecostomy tube lavage for treatment of fulminant clostridium difficile colitis in a recent transplanted patient

Cecostomy tube lavage for treatment of fulminant clostridium difficile colitis in a recent transplanted patient

Fulminant Pseudomembranous Colitis and Abdominal Compartment Syndrome

Patients with cystic fibrosis have higher rates of Clostridium difficile colonization than the general population. However, complicated forms of presentation are rare. We present a case of pseudomembranous fulminant pancolitis with abdominal compartment syndrome in a 9-year-old boy with cystic fibrosis. Conclusion: The incidence of Clostridium difficile infection is higher in patients with cystic fibrosis. Although it is rare, fulminant colitis can be associated with abdominal compartment syndrome. This is the only reported case of fulminant Clostridium difficile colitis associated with abdominal compartment syndrome in children who survived without total colectomy.

Antibiotic Regimen after a Total Abdominal Colectomy with Ileostomy for Fulminant Clostridium difficile Colitis: A Multi-Institutional Study.

Fulminant Clostridium difficile colitis (fCDC) is a highly lethal disease with mortality rates ranging between 12% and 80%. Although often these patients require a total abdominal colectomy (TAC) with ileostomy, there is no established management protocol for post-operative antibiotics. In this study we aim to make some recommendations for post-operative antibiotic usage, while describing the practice across different institutions. Multi-institutional retrospective case series including fCDC patients who underwent a TAC between January 1, 2007, and June 30, 2012. We first analyzed the complete cohort and consecutively performed a survivor analysis, comparing different antibiotic regimens. Additionally we stratified by time interval (antibiotics for ≤7 d, or ≥8 d). Primary outcome was in-hospital mortality. Additional secondary outcomes included hospital length of stay (HLOS), ICU LOS, number of ventilator-free days, and occurrence of intra-abdominal complications (proctitis, abscess, sepsis, etc.). A total of 100 fCDC patients that underwent a TAC were included across five institutions. Four different antibiotic regimens were compared; A (metronidazole IV+vancomycin PO), B (metronidazole IV), C (metronidazole IV+vanco PO and PR), and D (metronidazole IV+vancomycin PR). The combination of IV metronidazole with or without PO vancomycin showed superior outcomes in terms of a shorter ICU length of stay and more ventilator-free days. However, when comparing metronidazole alone vs. metronidazole and any combination of vancomycin, no significant differences were found. Neither the addition of vancomycin enema, nor the time interval changed outcomes. Patients, after a TAC for fCDC, may be placed on either IV metronidazole or PO vancomycin depending upon local antibiograms, and proctitis may be treated with the addition of a vancomycin enema (PR). There was no data to support routine treatment of more than 7 d.

Fulminant Clostridium difficile Colitis: Comparing Computed Tomography with Histopathology: Are They Concordant?

A Total abdominal colectomy (TAC) is recommended for fulminant Clostridium difficile colitis (FCDC) because intraoperative assessment of diseased segments is inaccurate. To determine whether computerized tomography (CT) provides an accurate assessment of disease, we examined the concordance between CT and histopathologic colitis distribution in patients undergoing TAC for FCDC. The ileocolon was divided into seven distinct segments. Of 20 patients meeting criteria, the median interval between preoperative CT and TAC was 1.5 days (range, 0 to 23 days), and mortality was 65 per cent. The CT distribution of colitis was pancolitis in 12 patients and segmental in eight. Nine of the 12 patients with CT pancolitis had histologic pancolitis (75% concordance). Four of the eight patients with CT-diagnosed segmental disease had histologic segmental disease (50% concordance). For patients with FCDC, the distribution of colitis on CT agrees with the histopathologic extent of disease in the majority of patients. However, discordance between CT and histologic extent of disease was present in 25 to 50 per cent of patients. Therefore, the recommendation for TAC rather than segmental resection for FCDC remains justified.

Patience is a Virtue: An Argument for Delayed Surgical Intervention in Fulminant Clostridium difficile Colitis

Recently, the incidence and severity of Clostridium difficile infection (CDI) has increased. In cases of fulminant infection, surgery is a viable therapeutic option but associated with high mortality. We sought to examine factors associated with mortality in a large sample of patients with severe CDI that underwent surgery. A retrospective study was conducted in patients with severe CDI undergoing colectomy. Demographics, risk factors, comorbidities, clinical and laboratory data, and time between admission/diagnosis of CDI and colectomy were collected. Conventional markers of severity were evaluated as predictors of mortality. Sixty-four cases were included for analysis. The overall observed mortality rate was 45.3 per cent. Few conventional markers of severity were significantly associated with mortality. Risk factors that correlated with postsurgical mortality were vasopressor use (odds ratio, 3.08; 95% confidence interval, 1.00 to 9.92) and shorter time between diagnosis and surgery (median time, 2 vs 3 days, P = 0.009). This study suggests that a delay in surgery after diagnosis of severe CDI may improve overall outcomes. The finding regarding timing of surgery is contrary to traditional teaching and may be the result of improved medical treatment and stabilization before surgery. Consideration should be given to the importance of timing of colectomy in fulminant CDI, whereas prospective studies should be conducted to elucidate causal relationships.

Life after colectomy for fulminant Clostridium difficile colitis: a 7-year follow up study

BackgroundThe long-term prognosis of patients undergoing colectomy for fulminant Clostridium difficile colitis has not been well studied. The authors present 7-year survival trends in such patients. MethodsPatients were identified through a pathologic database. Medical records were reviewed and follow-up phone calls made to determine relevant patient history, longevity, and quality of life. ResultsThe 61 patients identified had mean and median survival of 18.1 and 3.2 months, respectively, and 1-year, 2-year, 5-year, and 7-year mortality of 68.5%, 79.6%, 88.9%, and 90.7%, respectively. Previous C difficile infection, hypotension, requirement of vasopressors, mental status changes, elevated arterial lactate, decreased platelet counts, intubation, and longer duration on nonoperative therapy were associated with in-hospital mortality. There were no factors correlated with long-term survival. ConclusionsPatients who require colectomy for fulminant C difficile colitis have a poor prognosis with poor long-term survival and significant morbidity. Although there are several factors associated with in-hospital mortality, there were no factors correlated with long-term survival.

A cluster of fulminant Clostridium difficile colitis in an intensive care unit in Italy

We describe, for the first time, a cluster of lethal fulminant health-care associated Clostridium difficile (CD) colitis in Italy, observed in the intensive care unit (ICU) of an Italian tertiary care hospital in Rome. For all cases the cause of ICU admission was CD-related septic shock. Three out of seven patients were residents in a long-term care facility in Rome, and the others had been transferred to the ICU from different medical wards of the same hospital. Five patients died within 96 h of ICU admission. Because of a clinical deterioration after 4 days of adequate antibiotic therapy, two patients underwent subtotal colectomy: both of them died within 30 days of surgical intervention. In four cases, ribotyping assay was performed and ribotype 027 was recognized. This high mortality rate could be attributable to three findings: the extent of disease severity induced by the strain 027, the delay in antimicrobial therapy administration, and the lack of efficacy of the standard antibiotic treatment for fulminant CD colitis compared to an earlier surgical approach. In order to contain a CD infection epidemic, control and surveillance measures should be implemented, and empirical therapy should be administered. Because of potential 027 ribotype CD spread in Italy, CDI should be regarded with a high index of suspicion in all patients presenting with shock and signs or symptoms suggesting abdominal disease, and an early surgical approach should be considered.

Is colectomy for fulminant Clostridium difficile colitis life saving? A systematic review

It is unclear whether colectomy for fulminant Clostridium difficile colitis (FCDC) leads to a improvement in survival compared with continued medical therapy for this moribund population. Selected studies from 1994-2010 were identified through a comprehensive search theme applied to MEDLINE (OvidSP and PubMed), EMBASE and by hand searching. Data regarding mortality rates between medically and surgically treated patients were extracted. Risk of bias was assessed using a Newcastle-Ottawa Scale score. A meta-analysis of the odds ratios for mortality between surgical and medical treatment for FCDC was conducted using the Mantel-Haenszel method and fixed-effects modelling. Five hundred and ten patients with FCDC were identified in six studies. The pooled adjusted odds ratio of mortality comparing surgery with medical therapy was 0.70 (0.49-0.99), suggesting that surgery provided a survival benefit. Emergent colectomy for patients with FCDC provides a survival advantage compared with continuing antibiotics. Though there is selection bias of patients having surgery, the results of this systematic review suggest that colectomy has a therapeutic role in treating severe forms of C.difficile colitis.

Impact of Preoperative Organ Failures on Survival in Intensive Care Unit Patients with Colectomy

The present study aimed to evaluate the prognostic value of preoperative changes in sequential organ failure assessment (SOFA) score, daily norepinephrine (NE) dose, lactate, C-reactive protein, and white blood cell count among patients with colectomy in the intensive care unit (ICU). We performed a retrospective analysis of 77 colectomized patients (30 female, 47 male) who were treated in a single tertiary-level mixed ICU during 2000-2009. The underlying conditions leading to colectomy included sepsis (31 patients), cardiovascular operations (21 patients), and fulminant Clostridium difficile colitis (25 patients). The 28-day mortality was 53.3 % (41/77). Nonsurvivors had significantly higher median values than survivors (p < 0.05) for the following parameters: admission SOFA [10.0 (25th-75th percentile 8.0-13.0) vs. 9.0 (6.5-10.0)], highest SOFA [14.0 (12.0-16.0) vs. 12.5 (9.5-14.5)], operative day lactate level (6.3 vs. 2.2 mmol/L), and NE dose (16.8 vs. 9.3 total mg/day). During the last three preoperative days, significant increases were observed in total SOFA score (p < 0.001) and in cardiovascular (p < 0.001), coagulation (p = 0.017), renal (p < 0.01), and respiratory (p < 0.001) SOFA subscores, without statistically significant differences between nonsurvivors and survivors. Increasing Glasgow Coma Scale score, preoperative lactate level, and NE dose were significantly associated with mortality. It should be prospectively studied whether preoperatively increasing lactate level and NE dose are surrogate markers for early laparotomy among ICU patents with colitis.