Fulminant Clostridium Difficile Colitis Research Articles

Current role of surgery for the treatment of fulminant Clostridium difficile colitis

Objective This review discusses the current status and progress in studies on fulminant Clostridium difficile colitis (FCDC), including the definition, risk factor, diagnostic role of CT, surgical treatment, postoperative mortality, and new therapeutic strategy. Data sources A literature search was conducted mainly in Medline and PubMed published in English between January 2000 and May 2011. The search terms were “fulminant Clostridium difficile colitis”, “treatment””, “surgery” and “mortality”. Results Recent studies show that the overall mortality rate for FCDC remains high despite early surgical intervention. It has been difficult to identify the real value for surgical intervention in patients with FCDC due to the absence of prospective, randomized studies. Early recognition of patients with FCDC will help a clinician decide the need for treatment in an intensive care setting, multi-disciplinary consultation, and appropriate therapeutic selection. Some studies emphasize the importance of early recognition and emergent surgery at a less severe stage. Monoclonal antibody therapy and intravenous immunoglobulin treatment may be useful for the treatment of FCDC. Conclusions Present studies do not provide strong evidence for guiding the surgical treatment of FCDC; hence, creation of collaborative research networks is crucial in order to undertake large prospective multi-center studies for improvement in overall survival.

Current status of surgical treatment for fulminantclostridium difficilecolitis

Mortality rates attributable to fulminant Clostridium difficile (C. difficile) colitis remain high and are reported to be 38%-80%. Historically, the threshold for surgical intervention has been judged empirically because level I evidence to guide decision making is lacking. Studies of the surgical management of C. difficile infection have been limited by small sample size and the lack of a standard definition of fulminancy. Multiple small and medium-sized series have examined the surgical management of C. difficile. However, because of a lack of prospective, randomized studies, it has been difficult to identify the optimal point for surgical intervention in patients with severe fulminant C. difficile colitis. Our goal was to analyze the existing body of literature in an attempt to define host constellations, which would predict the development of the more aggressive form of this disease and hence justify an early or earlier surgical intervention. A Pubmed search was conducted using the keywords "fulminant", "clostridium difficile", "surgery", and "colitis". Reviews and meta-analyses proposing indications for surgical consultation or operative management in patients with C. difficile colitis were included. After analyzing current literature, we identified a number of parameters that are associated with unfavorable outcomes. The parameters include age greater than 65 years old, peritoneal signs on physical examination, abdominal distension, signs of end-organ failure, hypotension less than 90 mmHg systolic blood pressure, tachycardia greater than 100 bpm, vasopressor requirement, elevated WBC count of greater than at least 16 × 10(9)/μL, serum lactate of greater than 2.2 mmol/L, and lastly, radiologic findings suggestive of pancolitis, ascites, megacolon, or colonic perforation. Even though fairly strong evidence exists in contemporary literature, we recommend use of these identified parameters with caution in clinical practice when it comes to the actual decision to treat certain patients more aggressively. The identified risk factors should be used to lower surgeons' threshold for operative treatment early in the course of the disease.

双口式回腸瘻造設+大腸洗浄にて大腸亜全摘を回避しえた劇症型<i>Clostridium difficile</i>腸炎の1例

症例は71歳の男性で，敗血症性ショックの状態で当施設へ搬送された．同日，試験開腹を施行したが，炎症性腹水のみの手術所見であった．術後も敗血症性ショックが遷延したため，感染源の検索として造影CTを行い，大腸全域にわたる壁肥厚を認めた．Clostridium difficle（以下，CDと略記）腸炎の既往と高度な白血球増多を認め，さらに下部消化管内視鏡検査では偽膜形成を認めたため，CD腸炎による敗血症性ショックの診断に至った．入院4日目に双口式回腸瘻造設+大腸洗浄を施行し，術後は回腸瘻から大腸側へのバンコマイシン投与を14日間継続した．術後経過は良好で，術後27日目にICUを退室し，術後56日目にリハビリ継続目的で転院した．CD腸炎に対する外科的治療は大腸亜全摘+回腸瘻造設が標準であるが，今回，我々は双口式回腸瘻造設+大腸洗浄を施行し，大腸亜全摘を回避しえたので，報告する．

Colectomy in Intensive Care Patients: Operative Findings and Outcomes

With a critical illness, intestinal complications are associated with high morbidity and mortality. Operative findings and outcomes of 77 intensive care unit (ICU) patients treated with colectomy are described. Three conditions led to colectomy: sepsis (S group; n = 31), fulminant Clostridium difficile colitis (Cl group; n = 25), and cardiovascular surgery (CV group; n = 21). The median Acute Physiology and Chronic Health score was >25 in all groups. Thickening and distension of the colon was more frequent in the Cl group (p = 0.001), and ischemia was more frequent in the S and CV groups (p < 0.001). Widespread necrosis was more frequent in the CV patients (p = 0.001). The kappa value for ischemic operative findings and histologic necrosis was 0.64 (95 % confidence interval 0.49-0.79). Hospital mortality was 35 % without multiple organ failure (MOF) (n = 31) and 74 % with MOF (n = 46) (p < 0.001). Overall, 38 % were alive at the 1-year follow-up. Although colectomy in ICU patients is associated with high hospital mortality, patients who survive beyond their hospital stay have a good 1-year outcome.

Reduced Mortality in Patients with Fulminant Clostridium Difficile Colitis Due to a New Management Protocol

Reduced Mortality in Patients with Fulminant Clostridium Difficile Colitis Due to a New Management Protocol

Emergency colectomy for fulminant Clostridium difficile colitis: Striking the right balance

The number of reported cases of Clostridium difficile (CD) infections has increased markedly worldwide. CD causes a spectrum of clinical syndromes, ranging from mild diarrhea to a very severe illness in the form of pseudomembranous colitis (PMC), toxic megacolon, leading to colonic perforation, peritonitis, and even death. In today's practice, toxic megacolon is more often caused by pseudomembranous colitis than ulcerative colitis. There is urgent need to establish clear guidelines about how and when to refer patients with fulminant CD colitis to surgeons. Furthermore, there is no strict protocol for the timing of surgical intervention. The aim of this review is to review the available evidence about the criteria for referral to surgeons and timing for surgery. Medline search was carried out for articles published on fulminant CD colitis with emergency colectomy from 1966 to 2010. There were no prospective randomized trails. All retrospective cohort and case control studies were included. We excluded case reports, letters, and studies with less than five patients. Our search showed that patients with confirmed or suspected CD who failed to respond to maximum medical therapy and develop three of the following should be referral for surgical assessment: abdominal pain, abdominal distension, localized tenderness, pyrexia >38°C, and tachycardia >100 beats per minute. In addition to the above, if the patient is above 65 years old and develops four of the following, they should be considered for an emergency colectomy: WBC >16 × 109/l, lactate >2.2 mmol/l, albumin <30 g/l, blood pressure <90 mm Hg, CT/endoscopy evidence of severe colitis in spite of maximum anti-clostridial therapy. Colectomy still carries a high mortality rate; however, timely surgical intervention in fulminant CD colitis (FCDC) prevents many deaths in selected cases. In the absence of published prospective multicenter trial, we suggest that our criteria may enhance early diagnosis and consideration of early referral for surgery. Ultimately, this may reduce the significant morbidity and mortality associated with FCDC.

Stoma pouch noise: meeting patient needs

British Journal of NursingVol. 20, No. 15 CommentStoma pouch noise: meeting patient needsRebecca DavenportRebecca DavenportSearch for more papers by this authorRebecca DavenportPublished Online:16 Aug 2013https://doi.org/10.12968/bjon.2011.20.15.908AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article FiguresReferencesRelatedDetailsCited byPsychosocial health following stoma formation: a literature reviewFiona Brown20 April 2017 | Gastrointestinal Nursing, Vol. 15, No. 3Analysing the role of support wear, clothing and accessories in maintaining ostomates' quality of lifeDebbie Johnson, Linda Readding, Claire Ryan21 September 2015 | Gastrointestinal Nursing, Vol. 13, No. 7Journal ScanOsman K, Ahmed MH, Hamad MA (2011) Emergency colectomy for fulminant Clostridium difficile colitis: Striking the right balance. Scand J Gastroenterol46(10): 1222–7Nikki Welyczko16 August 2013 | Gastrointestinal Nursing, Vol. 9, No. 9Journal ScanDavenport R (2011) Stoma Pouch noise: meeting patients needs. Br J Nurs20(15): 908Nikki Welyczko16 August 2013 | Gastrointestinal Nursing, Vol. 9, No. 9 11 August 2011Volume 20Issue 15ISSN (print): 0966-0461ISSN (online): 2052-2819 Metrics History Published online 16 August 2013 Published in print 11 August 2011 Information© MA Healthcare LimitedPDF download

Predictors of Fatal Outcome after Colectomy for Fulminant Clostridium difficile Colitis: A 10-Year Experience

Surgical treatment of fulminant Clostridium difficile colitis has high mortality rates. Identification of a set of preoperative characteristics that could predict outcome after surgery is necessary to optimize clinical management and guide surgical timing. Data were retrospectively collected on patients operated on for C. difficile colitis between 2000 and 2010 at our institution. Statistical analysis was performed to identify predictors of mortality. We reviewed the records of 13 inpatients diagnosed as having C. difficile colitis and who underwent colectomy during the same admission. The in-hospital mortality rate for patients undergoing colectomy for colitis was 46.2 per cent. Independent predictors of mortality included the following: white blood cell count (34,600/μL or greater), hypoalbuminemia (1.5 g/dL or less), septic shock with requirements of vasopressors, and respiratory failure. Patients who underwent colectomy earlier (mean time from presentation to surgery 2.4 ± 1.5 days) had decreased mortality (P = 0.019).). Longer length of hospital stay to the time of diagnosis was associated with higher rates of fatal outcome (P = 0.031). Parameters without significant difference (P > 0.05) included patient age, presenting symptoms, other comorbidities, creatinine levels, and CT scan findings. Identified factors can predict unfavorable outcomes after colectomy. Aggressive surgical intervention early in the course of the disease might be associated with improved survival.

In-Hospital and 6-Month Mortality Rates After Open Elective vs Open Emergent Colectomy in Patients Older Than 80 Years

There are few reports of long-term outcomes in elderly patients after open colectomy. This study aimed to determine the in-hospital and 6-month outcomes and identify the variables associated with mortality after colectomy in patients ≥ 80 years of age. The charts of patients ≥ 80 years of age, who underwent open colectomy, were analyzed. Data included indications for operation, underlying diagnoses, preoperative functional status, type of procedure, length of procedure, length of stay, ASA grade, complications, and in-hospital and 6-month mortality rates. Univariate and multivariate logistic regression analyses were conducted to ascertain risk factors for mortality. P values of < .05 were considered significant. The main outcome measures were in-hospital and 6-month mortality. One hundred sixty-two patients ≥ 80 years of age underwent colectomy: 99 patients emergently; 63, electively. Postoperative acute renal failure (3% vs 19%, P = .0032) and in-hospital deaths were significantly higher (4.7% vs 28%, P = .0002) among the patients undergoing emergent colectomies. The mortality rate among emergent cases rose from 28% in-hospital to 52% at 6 months. Mortality among the elective cases increased similarly from 4.7% to 28.5%. Admission from a nursing facility was associated with higher in-hospital mortality (47.6% vs 14.9%, P = .0005). Discharge to a skilled nursing facility was associated with a higher 6-month mortality rate compared with discharge to home (40% vs 17%). Length of procedure, postoperative complications, perioperative blood transfusion, and emergent indications for operation independently predicted in-hospital mortality. Postoperative complications and emergent diagnosis independently predicted 6-month mortality. The 6-month mortality rate varied according to the underlying diagnosis as follows: fulminant Clostridium difficile colitis (86%); ischemic colitis (60%); gastrointestinal bleeding (37%), and volvulus (40%). This study was limited by its retrospective nature. Emergent open colectomy in elderly patients is associated with a high morbidity and mortality rate. The mortality rate rises by >20% in both elective and emergent cases at discharge to 6 months. Length of procedure, postoperative complications, and colectomy for emergent indications predicted mortality.

Outcomes of emergency colectomy for fulminant Clostridium difficile colitis

Introduction Clostridium difficile has become increasingly a common cause of nosocomial infection with increasing antibiotic usage. Recently there has been an increase in the incidence of patients undergoing colectomy for fulminant C. difficile colitis (FCDC). Early surgical consultation is necessary to avoid delay in diagnosis. We present a retrospective review of the outcomes of colectomies for FCDC at our large district general hospital. Materials and methods Over a twenty one month period, from January 2007 to September 2009, a total number of 20 patients underwent exploratory laparotomy for FCDC. A retrospective analysis of patients’ case notes, was carried out retrieving all relevant. Data on haematology, biochemistry and imaging were extracted from the trust’s on-line clinical databases. Results A total number of 528 diagnosed cases with C. difficile infection were identified. Of these, twenty patients underwent colectomy for FCDC (3.7%). All patients had received antibiotics prior to symptoms development. 45% of patients had multiple antibiotics. 35% of patients developed FCDC after having three doses of prophylactic antibiotic (Cefuroxime) for a surgical procedure. Time from referral to having surgery varied. Seventeen patients received subtotal colectomy and end ileostomy in a single operation. Mortality rate was 40%. Conclusion Emergency colectomy for FCDC is associated with high mortality rate. The majority of patients who have significant co-morbidities (75%) did not survive following emergency colectomy. Therefore, it is crucial to identify those patients early in their disease course before they progress into FCDC and organ failure.

Surgical aspects of fulminant Clostridium difficile Colitis

Background Clostridium difficile–associated disease (CDAD) is responsible for the majority of nosocomial diarrhea, and fulminant C difficile colitis can have mortality upwards of 80%. Early identification and treatment of fulminant C difficile colitis is critical to patient care, but timing of surgical intervention remains difficult. This review summarizes the epidemiology, predictors of development, and management of fulminant C difficile colitis. Methods A literature search was conducted between January 1989 and May 2009 using the keywords “clostridium difficile colitis” or “fulminant clostridium difficile colitis” and “surgery.” Articles not in English, those not involving human subjects, and case reports were excluded. Conclusion Early diagnosis and treatment with subtotal colectomy and end ileostomy is critical in reducing the mortality associated with fulminant colitis. Patients who have a history of inflammatory bowel disease (IBD), recent surgery, prior treatment with intravenous immunoglobulin (IVIG), vasopressor requirements, leukocytosis, or increased lactate should have early surgical consultation and operative intervention.

Colectomy for Fulminant Clostridium difficile Colitis: Predictors of Mortality

The purpose of this study was to define clinical and radiographic variables associated with postoperative mortality after urgent colectomy for fulminant Clostridium difficile colitis. Data were obtained regarding patients undergoing colectomy for fulminant C. difficile colitis at two institutions (1997-2005). Univariate analysis of factors predicting 30-day mortality was performed using chi2 and Student's t tests. Multivariable logistic regression was done to include all variables whose P value was < 0.20. Clinical variables analyzed included: age, gender, recent operation, comorbidities, preoperative multisystem organ failure, vasopressors, symptom duration, time to surgery, serum albumin, change in serum albumin, serum creatinine, white blood cell count, and extent of colectomy. Computed tomography variables included: ascites, megacolon, and extent of colitis. Thirty-five patients (mean age 70 years, 46% male) underwent urgent colectomy for C. difficile colitis. The 30-day mortality rate was 45.7 per cent (16/35). The only clinical variable associated with mortality was preoperative multisystem organ failure (nonsurvivors 9/16 vs survivors: 4/19; P = 0.037). None of the three patients undergoing partial colectomy survived, although the difference in survival versus those undergoing subtotal colectomy was not significant. Patients with fulminant C. difficile colitis undergoing colectomy have a high mortality rate. Preoperative presence of multisystem organ failure was independently predictive of mortality.

Fulminant Clostridium difficile Colitis

There exist predictors of mortality and the need for colectomy among patients with fulminant Clostridium difficile colitis. Retrospective study. Academic tertiary referral center. We reviewed the records of 4796 inpatients diagnosed as having C difficile colitis from January 1, 1996, to December 31, 2007, and identified 199 (4.1%) with fulminant C difficile colitis, as defined by the need for colectomy or admission to the intensive care unit for C difficile colitis. Risk of inpatient mortality was determined by multivariate analysis according to clinical predictors, colectomy, and medical team. The inhospital mortality rate for fulminant C difficile colitis was 34.7%. Independent predictors of mortality included the following: (1) age of 70 years or older, (2) severe leukocytosis or leukopenia (white blood cell count, >or=35 000/microL or <4000/microL) or bandemia (neutrophil bands, >or=10%), and (3) cardiorespiratory failure (intubation or vasopressors). When all 3 factors were present, the mortality rate was 57.1%; when all 3 were absent, the mortality rate was 0%. Patients who underwent colectomy had a trend toward decreased mortality rates (odds ratio, 0.49; 95% confidence interval, 0.21-1.1; P = .08). Among patients admitted primarily for fulminant C difficile colitis, care in the surgical department compared with the nonsurgical department resulted in a higher rate of operation (85.1% vs 11.2%; P < .001) and lower mortality rates (12.8% vs 39.3%; P = .001). Patients admitted directly to the surgical department had a shorter mean (SD) interval from admission to operation (0 vs 1.7 [2.8] days; P = .001). Despite awareness and treatment, fulminant C difficile colitis remains a highly lethal disease. Reliable predictors of mortality exist and should be used to prompt aggressive surgical intervention. Survival rates are higher in patients who were cared for by surgical vs nonsurgical departments, possibly because of more frequent and earlier operations.

Early colectomy may be associated with improved survival in fulminant Clostridium difficile colitis: an 8-year experience

Background We hypothesized that colectomy for fulminant Clostridium difficile colitis (CDC) before organ failure would be associated with decreased mortality. Methods Data were retrospectively collected on patients operated on for CDC between 2000 and 2007. Variables examined included age, sex, immunodeficiency, recurrent CDC, vasopressor requirement, acute respiratory failure, acute renal failure, white blood cell count, and stress ulcer prophylaxis. Univariate and multivariate analyses were performed to identify predictors of mortality. Results During this period, 6,841 patients were diagnosed with CDC and 69 patients underwent surgery. Independent predictors of mortality were age >65 years (odds ratio [OR] 6.8, confidence interval [CI] 1.4–32.3, P = .016), acute respiratory failure (OR 5.4, CI 1.6–18.1, P = .007), and acute renal failure (OR 3.8, CI 1.1–13.1, P = .035). Conclusions Colectomy before the development of organ failure is associated with decreased mortality in patients with fulminant CDC, especially in those >65 years old.

Long-Term Follow-Up of Patients with Fulminant Clostridium difficile Colitis

PurposeThe purpose of this study was to determine the long-term survival rate, rate of gastrointestinal continuity restoration, and rate of recurrence following an attack of fulminant Clostridium difficile colitis. Material and MethodsFulminant C. difficile colitis was defined as any patient who had a bout of C. difficile colitis and required surgical intervention after failing medical therapy. These patients were found through a pathological database search. Follow-up phone calls were made to any patient who survived at least 30 days after being discharged from the hospital following surgical intervention (long-term survivor group). ResultsA total of 49 patients were involved in the study. The 30-day mortality rate was 57% (28/49), with an in-hospital mortality rate of 49%. The 5-year survival rate for the long-term survival group was 38% (8/21) and 16.3% for all patients. Gastrointestinal continuity was restored in 20% of the patients. There was one documented recurrence of C. difficile colitis ConclusionPatients who have a bout of fulminant C. difficile colitis have a poor prognosis of surviving longer than 5 years. Restoring gastrointestinal continuity is uncommon and usually reserved for patients with few co-morbidities. Recurrent C. difficile colitis after surgical resection is a rare occurrence

Clinical Review of the Management of FulminantClostridium difficileInfection

Clostridium difficile infection (CDI) is a frequent cause of morbidity and mortality among elderly hospitalized patients. A small but increasing number of patients have developed fulminant CDI, and a significant number of these patients require emergency colectomy. In this review, we discuss the risk factors, pathophysiology, diagnosis, and management of fulminant CDI. A literature search (Medline, Embase, Cochrane Library, Biosis, Science Citation Index, Ovid Journals) was performed from the period between January 1980 and June 2008 using the key words "Clostridium difficile,""pseudomembranous enterocolitis,""colectomy,""acute abdomen,""antibiotic-associated diarrhea," or "fulminant Clostridium difficile colitis." Articles not in English or not related to human subjects were excluded. For this review, we analyzed the articles identified in our original search and those articles cited in the original review articles. No randomized trials were found on the surgical management of fulminant CDI and only retrospective studies with a minimum of five patients were used in the review. With respect to medical treatment, we based our review on guideline articles, systematic reviews, and available randomized trials. Both the incidence and severity of CDI are increasing. Fulminant CDI is underappreciated as a life-threatening disease because of a lack of awareness of its severity and its nonspecific clinical syndrome. Early diagnosis and treatment are essential for a good outcome, and early surgical intervention should be used in patients who are unresponsive to medical therapy. The surgical procedure of choice is a total abdominal colectomy with end ileostomy, although the mortality rate remains high.

Nitazoxanide (Alinia®) as a Rescue Treatment for Refractory Fulminant Clostridium difficile Colitis

Nitazoxanide (Alinia®) as a Rescue Treatment for Refractory Fulminant Clostridium difficile Colitis

Outcome of colectomy for Clostridium difficile colitis: a plea for early surgical management

Background Fulminant Clostridium difficile colitis is a common nosocomial infection that occurs with increasing frequency. Methods A total of 3,237 consecutive cases of C difficile cytotoxin–positive stool samples from 1998 to 2006 were reviewed. Commonly referenced indicators for surgical intervention were gathered on the day of surgery. The preoperative characteristics of patients surviving subtotal colectomy were compared with those who did not survive. Results Thirty-six patients underwent colectomy. Twenty-three patients (64%) were discharged from the hospital alive. Preoperative intubation and vasopressor requirement were risk factors for in-hospital mortality (odds ratio [OR], 7.15; 95% confidence interval [95% CI], 1.28–39.8 and OR, 6.0; CI, 1.08–33, respectively). Patients who had a recent surgical procedure had a lower in-hospital mortality rate (OR, .11; 95% CI, .02–.52). Conclusions Fulminant C difficile colitis is associated with a high mortality rate. Development of a vasopressor requirement or need for intubation are ominous signs and should lead to rapid surgical intervention.

Risk factors for the development of fulminant Clostridium difficile colitis

The development of fulminant Clostridium difficile colitis (FCDC) requires prompt operative intervention and is associated with a high mortality rate. The aim of this study was to use a case-control design to define the clinical and laboratory parameters that predict which patients with Clostridium difficile infection are most likely to progress to FCDC. Cases from 1994 to 2006 with documented in-hospital progression of Clostridium difficile infection to FCDC were matched retrospectively at the start of medical therapy by age, sex, and intensive care unit (ICU) status to controls with Clostridium difficile infection who did not develop FCDC. Chi-Square and multivariable logistic regression were used to identify risk factors for progression to FCDC. A total of 35 patients with FCDC were matched to 70 controls with Clostridium difficile infection who did not develop FCDC. The patients with FCDC underwent colectomy after an average of 4.6 days of medical therapy and had a mortality rate of 40%. On multivariate analysis, independent risk factors for the development of FCDC were a WBC > 16,000 cells/mm(3) (P < .01) at initiation of therapy, operative therapy within the last 30 days (P = .03), a history of inflammatory bowel disease (P = .04), and a history of intravenous immunoglobulin treatment (P < .01). Leukocytosis, recent prior operative therapy, and a history of inflammatory bowel disease and intravenous immunoglobulin treatment were negative prognostic indicators for patients with Clostridium difficile infection. The presence of these factors merits close observation for progression to FCDC and acceleration of the planning process for operative intervention.

Predictors of Mortality After Colectomy for Fulminant Clostridium difficile Colitis—Invited Critique

Predictors of Mortality After Colectomy for Fulminant Clostridium difficile Colitis—Invited Critique