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Clin Colon Rectal Surg 2012; 25(04): 204-209
DOI: 10.1055/s-0032-1329390
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Surgical Management of Clostridium difficile Colitis

Ann K. Seltman
1   Colon and Rectal Surgery Associates Ltd., St. Paul, Minnesota
2   Division of Colon and Rectal Surgery, University of Minnesota, St. Paul, Minnesota
› Author Affiliations
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Publication History

Publication Date:
21 November 2012 (online)

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Abstract

Clostridium difficile infection (CDI) will progress to fulminant disease in 3 to 5% of cases. With the emergence of hypervirulent, multidrug-resistant strains, the incidence and severity of disease are continuing to rise. Prompt identification, early resuscitation, and treatment are critical in preventing morbidity and mortality in this increasingly common condition. Discontinuation of antibiotics and treatment with oral vancomycin and intravenous or oral metronidazole are first-line treatments, but complicated cases may require surgery. Subtotal colectomy with ileostomy remains the standard of care when toxic megacolon, perforation, or an acute surgical abdomen is present, but mortality rates are high. Recognition of risk factors for fulminant CDI and earlier surgical intervention may decrease mortality from this highly lethal disease.

Keywords

Clostridium difficile - pseudomembranous colitis - colectomy
 

  • References

  • 1 Bartlett JG, Chang TW, Gurwith M, Gorbach SL, Onderdonk AB. Antibiotic-associated pseudomembranous colitis due to toxin-producing clostridia. N Engl J Med 1978; 298 (10) 531-534
    CrossrefPubMedGoogle Scholar
  • 2 Bartlett JG, Moon N, Chang TW, Taylor N, Onderdonk AB. Role of Clostridium difficile in antibiotic-associated pseudomembranous colitis. Gastroenterology 1978; 75 (5) 778-782
    CrossrefPubMedGoogle Scholar
  • 3 Butler M, Bliss D, Drekonja D , et al. Effectiveness of early diagnosis, prevention, and treatment of Clostridium difficile infection. Rockville, MD: U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality; 2011
    Google Scholar
  • 4 Dallal RM, Harbrecht BG, Boujoukas AJ , et al. Fulminant Clostridium difficile: an underappreciated and increasing cause of death and complications. Ann Surg 2002; 235 (3) 363-372
    CrossrefPubMedGoogle Scholar
  • 5 Sailhamer EA, Carson K, Chang Y , et al. Fulminant Clostridium difficile colitis: patterns of care and predictors of mortality. Arch Surg 2009; 144 (5) 433-439 , discussion 439–440
    CrossrefPubMedGoogle Scholar
  • 6 Neal MD, Alverdy JC, Hall DE, Simmons RL, Zuckerbraun BS. Diverting loop ileostomy and colonic lavage: an alternative to total abdominal colectomy for the treatment of severe, complicated Clostridium difficile associated disease. Ann Surg 2011; 254 (3) 423-427 , discussion 427–429
    CrossrefPubMedGoogle Scholar
  • 7 Leclair MA, Allard C, Lesur O, Pépin J. Clostridium difficile infection in the intensive care unit. J Intensive Care Med 2010; 25 (1) 23-30
    CrossrefPubMedGoogle Scholar
  • 8 Kuehne SA, Cartman ST, Heap JT, Kelly ML, Cockayne A, Minton NP. The role of toxin A and toxin B in Clostridium difficile infection. Nature 2010; 467 (7316) 711-713
    CrossrefPubMedGoogle Scholar
  • 9 Bacci S, Mølbak K, Kjeldsen MK, Olsen KE. Binary toxin and death after Clostridium difficile infection. Emerg Infect Dis 2011; 17 (6) 976-982
    CrossrefPubMedGoogle Scholar
  • 10 Cohen SH, Gerding DN, Johnson S , et al; Society for Healthcare Epidemiology of America; Infectious Diseases Society of America. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA). Infect Control Hosp Epidemiol 2010; 31 (5) 431-455
    CrossrefPubMedGoogle Scholar
  • 11 VerLee KE, Finks JL, Wilkins MJ, Wells EV. Michigan Clostridium difficile hospital discharges: frequency, mortality, and charges, 2002–2008. Public Health Rep 2012; 127 (1) 62-71
    PubMedGoogle Scholar
  • 12 Gravel D, Miller M, Simor A , et al; Canadian Nosocomial Infection Surveillance Program. Health care-associated Clostridium difficile infection in adults admitted to acute care hospitals in Canada: a Canadian Nosocomial Infection Surveillance Program Study. Clin Infect Dis 2009; 48 (5) 568-576
    CrossrefPubMedGoogle Scholar
  • 13 Jarvis WR, Schlosser J, Jarvis AA, Chinn RY. National point prevalence of Clostridium difficile in US health care facility inpatients, 2008. Am J Infect Control 2009; 37 (4) 263-270
    CrossrefPubMedGoogle Scholar
  • 14 Lamontagne F, Labbé AC, Haeck O , et al. Impact of emergency colectomy on survival of patients with fulminant Clostridium difficile colitis during an epidemic caused by a hypervirulent strain. Ann Surg 2007; 245 (2) 267-272
    CrossrefPubMedGoogle Scholar
  • 15 Bauer MP, Notermans DW, van Benthem BH , et al; ECDIS Study Group. Clostridium difficile infection in Europe: a hospital-based survey. Lancet 2011; 377 (9759) 63-73
    CrossrefPubMedGoogle Scholar
  • 16 Longo WE, Mazuski JE, Virgo KS, Lee P, Bahadursingh AN, Johnson FE. Outcome after colectomy for Clostridium difficile colitis. Dis Colon Rectum 2004; 47 (10) 1620-1626
    CrossrefPubMedGoogle Scholar
  • 17 Nair S, Yadav D, Corpuz M, Pitchumoni CS. Clostridium difficile colitis: factors influencing treatment failure and relapse—a prospective evaluation. Am J Gastroenterol 1998; 93 (10) 1873-1876
    PubMedGoogle Scholar
  • 18 Baxter R, Ray GT, Fireman BH. Case-control study of antibiotic use and subsequent Clostridium difficile-associated diarrhea in hospitalized patients. Infect Control Hosp Epidemiol 2008; 29 (1) 44-50
    CrossrefPubMedGoogle Scholar
  • 19 Khanna S, Pardi DS, Aronson SL , et al. The epidemiology of community-acquired Clostridium difficile infection: a population-based study. Am J Gastroenterol 2012; 107 (1) 89-95
    CrossrefPubMedGoogle Scholar
  • 20 Dharmarajan T, Sipalay M, Shyamsundar R, Norkus E, Pitchumoni C. Co-morbidity, not age predicts adverse outcome in Clostridium difficile colitis. World J Gastroenterol 2000; 6 (2) 198-201
    PubMedGoogle Scholar
  • 21 Seder CW, Villalba Jr MR, Robbins J , et al. Early colectomy may be associated with improved survival in fulminant Clostridium difficile colitis: an 8-year experience. Am J Surg 2009; 197 (3) 302-307
    CrossrefPubMedGoogle Scholar
  • 22 Bavishi C, Dupont HL. Systematic review: the use of proton pump inhibitors and increased susceptibility to enteric infection. Aliment Pharmacol Ther 2011; 34 (11-12) 1269-1281
    CrossrefPubMedGoogle Scholar
  • 23 Stevens V, Dumyati G, Brown J, Wijngaarden E. Differential risk of Clostridium difficile infection with proton pump inhibitor use by level of antibiotic exposure. Pharmacoepidemiol Drug Saf 2011; 20 (10) 1035-1042
    CrossrefPubMedGoogle Scholar
  • 24 Kim YG, Graham DY, Jang BI. Proton pump inhibitor use and recurrent Clostridium difficile-associated disease: a case-control analysis matched by propensity score. J Clin Gastroenterol 2012; 46 (5) 397-400
    CrossrefPubMedGoogle Scholar
  • 25 Ananthakrishnan AN, Issa M, Binion DG. Clostridium difficile and inflammatory bowel disease. Gastroenterol Clin North Am 2009; 38 (4) 711-728
    CrossrefPubMedGoogle Scholar
  • 26 Ananthakrishnan AN, Guzman-Perez R, Gainer V , et al. Predictors of severe outcomes associated with Clostridium difficile infection in patients with inflammatory bowel disease. Aliment Pharmacol Ther 2012; 35 (7) 789-795
    CrossrefPubMedGoogle Scholar
  • 27 Navaneethan U, Mukewar S, Venkatesh PG, Lopez R, Shen B. Clostridium difficile infection is associated with worse long term outcome in patients with ulcerative colitis. J Crohn's Colitis 2012; 6 (3) 330-336
    PubMedGoogle Scholar
  • 28 Byrn JC, Maun DC, Gingold DS, Baril DT, Ozao JJ, Divino CM. Predictors of mortality after colectomy for fulminant Clostridium difficile colitis. Arch Surg 2008; 143 (2) 150-154 , discussion 155
    CrossrefPubMedGoogle Scholar
  • 29 Zahariadis G, Connon JJ, Fong IW. Fulminant Clostridium difficile colitis without diarrhea: lack of emphasis in diagnostic guidelines. Am J Gastroenterol 2002; 97 (11) 2929-2930
    CrossrefPubMedGoogle Scholar
  • 30 Nelson RL, Kelsey P, Leeman H , et al. Antibiotic treatment for Clostridium difficile-associated diarrhea in adults. Cochrane Database Syst Rev 2011; (9) CD004610
    PubMedGoogle Scholar
  • 31 Louie TJ, Miller MA, Mullane KM , et al; OPT-80-003 Clinical Study Group. Fidaxomicin versus vancomycin for Clostridium difficile infection. N Engl J Med 2011; 364 (5) 422-431
    CrossrefPubMedGoogle Scholar
  • 32 Cornely OA, Crook DW, Esposito R , et al; OPT-80-004 Clinical Study Group. Fidaxomicin versus vancomycin for infection with Clostridium difficile in Europe, Canada, and the USA: a double-blind, non-inferiority, randomised controlled trial. Lancet Infect Dis 2012; 12 (4) 281-289
    CrossrefPubMedGoogle Scholar
  • 33 Mattila E, Anttila VJ, Broas M , et al. A randomized, double-blind study comparing Clostridium difficile immune whey and metronidazole for recurrent Clostridium difficile-associated diarrhoea: efficacy and safety data of a prematurely interrupted trial. Scand J Infect Dis 2008; 40 (9) 702-708
    CrossrefPubMedGoogle Scholar
  • 34 Kelly CR, de Leon L, Jasutkar N. Fecal microbiota transplantation for relapsing Clostridium difficile infection in 26 patients: methodology and results. J Clin Gastroenterol 2012; 46 (2) 145-149
    CrossrefPubMedGoogle Scholar
  • 35 Mattila E, Uusitalo-Seppälä R, Wuorela M , et al. Fecal transplantation, through colonoscopy, is effective therapy for recurrent Clostridium difficile infection. Gastroenterology 2012; 142 (3) 490-496
    CrossrefPubMedGoogle Scholar
  • 36 Gash K, Brown E, Pullyblank A. Emergency subtotal colectomy for fulminant Clostridium difficile colitis—is a surgical solution considered for all patients?. Ann R Coll Surg Engl 2010; 92 (1) 56-60
    CrossrefPubMedGoogle Scholar
  • 37 Hall JF, Berger D. Outcome of colectomy for Clostridium difficile colitis: a plea for early surgical management. Am J Surg 2008; 196 (3) 384-388
    CrossrefPubMedGoogle Scholar
  • 38 Koss K, Clark MA, Sanders DS, Morton D, Keighley MR, Goh J. The outcome of surgery in fulminant Clostridium difficile colitis. Colorectal Dis 2006; 8 (2) 149-154
    CrossrefPubMedGoogle Scholar
  • 39 Pepin J, Vo TT, Boutros M , et al. Risk factors for mortality following emergency colectomy for fulminant Clostridium difficile infection. Dis Colon Rectum 2009; 52 (3) 400-405
    CrossrefPubMedGoogle Scholar
  • 40 Ali SO, Welch JP, Dring RJ. Early surgical intervention for fulminant pseudomembranous colitis. Am Surg 2008; 74 (1) 20-26
    PubMedGoogle Scholar
  • 41 Dudukgian H, Sie E, Gonzalez-Ruiz C, Etzioni DA, Kaiser AM. C. difficile colitis—predictors of fatal outcome. J Gastrointest Surg 2010; 14 (2) 315-322
    CrossrefPubMedGoogle Scholar