Risk factors for the development of fulminant Clostridium difficile colitis

Greenstein, Alexander J.; Byrn, John C.; Zhang, Linda P.; Swedish, Kristin A.; Jahn, Alice E.; Divino, Celia M.

doi:10.1016/j.surg.2007.12.008

Cited by 86 publications

(64 citation statements)

References 19 publications

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“…This was a reasonable length of time to give patients to respond to oral therapy and is comparable to that found by Greenstein et al 7 at 4.6 days. Eight patients developed C. difficile infection requiring colectomy, while recovering from surgery they had undergone in the same admission.…”

Section: Discussionsupporting

confidence: 86%

Emergency subtotal colectomy for fulminant Clostridium difficile colitis – is a surgical solution considered for all patients?

Gash

Brown

Pullyblank

2010

annals

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Ann R Coll Surg Engl 2010; 92: 56-60 56Clostridium difficile is the most common cause of hospitalacquired diarrhoea and has been a serious problem in the UK. Infection produces a spectrum of disease, from mild abdominal pain and diarrhoea, to fulminant pseudomembranous colitis. This nosocomial infection associated with antibiotic use, causes more deaths per year than methicillin-resistant Staphylococcus aureus (MRSA). In 2007, there were 49,785 reported cases of C. difficile infection in England.1 The UK Government is now investing £230 million per year in order to cut C. difficile related deaths. 2In 2007, C. difficile infection was documented on 8324 death certificates in England and Wales. This was an increase of 28%, from 6480, in the previous year. It was recorded as the underlying cause of death in 4056 of these cases and mentioned on a further 4268 certificates.3 Our own trust saw a rise in C. difficile related deaths from 13 in 2001 to 158 in 2007. 3 This was partly due to an increase in reporting, as C. difficile deaths were not accurately reported until 2007. Nationally, between 2004 and 2007, there was a rising incidence of the 027-ribotype strain of C. difficile and in our trust, a growing number of patients developed fulminant colitis. With an increasing number of these patients requiring subtotal colectomy for pseudomembranous colitis, we reviewed a series of these cases. Patients and MethodsThis study was a retrospective analysis of patients who underwent a subtotal colectomy for fulminant C. difficile colitis in a large hospital trust, over a period of 18 months, Clostridium difficile has been an increasing problem in UK hospitals. At the time of this study, there was a high incidence of C. difficile within our trust and a number of patients developed acute fulminant colitis requiring subtotal colectomy. We review a series of colectomies for C. difficile, examining the associated morbidity and mortality and the factors that predispose to acute fulminant colitis. PATIENTS AND METHODS This is a retrospective study of patients undergoing subtotal colectomy for C. difficile colitis in an NHS trust over 18 months. Case notes were reviewed for antibiotic use, duration of diarrhoea, treatment, blood results, preoperative imaging and surgical morbidity and mortality. RESULTS A total of 1398 patients tested positive for C. difficile in this period. Of these, 18 (1.29%) underwent colectomy. All were emergency admissions, 35% medical, 35% surgical, 24% neurosurgical and 6% orthopaedic. In the cohort, 29% were aged less than 65 years. Patients had a median of three antibiotics (range, 1-6), for a median of 10 days (range, 0-59 days). Median length of stay prior to C. difficile diagnosis was 13 days. Subtotal colectomy was performed a median of 4 days (range, 0-23 days) after diagnosis. Postoperative mortality was 53% (9 of 17). The median C-reactive protein level for those who died was 302 mg/l, in contrast to 214 mg/l in the survival group. Whilst 62% of all C. difficile cases were medical, the colectomy...

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Section: Discussionsupporting

confidence: 86%

Emergency subtotal colectomy for fulminant Clostridium difficile colitis – is a surgical solution considered for all patients?

Gash

Brown

Pullyblank

2010

annals

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“…43,45,46 Fulminant CDI can be defined as disease that progresses rapidly to cause systemic manifestations, including marked leukocytosis, hypotension, renal failure, and anasarca. [47][48][49][50][51] In practice, fulminant and refractory disease often overlap, their management is challenging, and their incidence is rising. Fulminant CDI may present with abdominal pain and tenderness, colonic distension, and signs of sepsis including fever, leukocytosis, hypotension, and lactic acidosis.…”

Section: Refractory CDImentioning

confidence: 99%

“…Fulminant CDI may present with abdominal pain and tenderness, colonic distension, and signs of sepsis including fever, leukocytosis, hypotension, and lactic acidosis. [47][48][49][50][51] Diarrhea may be absent or minimal due to ileus, and this factor may obscure a diagnosis of CDI and instead suggest diagnoses such as ischemic bowel or a perforated viscus. 49 In this situation, gentle flexible sigmoidoscopy or colonoscopy (without attempting a full bowel preparation and with minimal air insufflation) can be invaluable in immediately identifying pseudomembranous colitis and thereby informing medical and surgical management.…”

Section: Refractory CDImentioning

confidence: 99%

A 76-Year-Old Man With Recurrent Clostridium difficile–Associated Diarrhea

Kelly

2009

JAMA

102

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“…Leukocytosis is common in CDI patients, and white blood cell (WBC) counts can be as high as 40,000 cells/mm 3 . WBC counts above 16,000 cells/mm 3 are predictive of severe disease (28,29). Interestingly, the cause of death in this illness is still not known; however, severely ill patients exhibit symptoms of systemic complications.…”

Section: Clinical Significancementioning

confidence: 99%

Variations in Virulence and Molecular Biology among Emerging Strains of Clostridium difficile

Hunt

Ballard

2013

Microbiol Mol Biol Rev

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SUMMARY Clostridium difficile is a Gram-positive, spore-forming organism which infects and colonizes the large intestine, produces potent toxins, triggers inflammation, and causes significant systemic complications. Treating C. difficile infection (CDI) has always been difficult, because the disease is both caused and resolved by antibiotic treatment. For three and a half decades, C. difficile has presented a treatment challenge to clinicians, and the situation took a turn for the worse about 10 years ago. An increase in epidemic outbreaks related to CDI was first noticed around 2003, and these outbreaks correlated with a sudden increase in the mortality rate of this illness. Further studies discovered that these changes in CDI epidemiology were associated with the rapid emergence of hypervirulent strains of C. difficile , now collectively referred to as NAP1/BI/027 strains. The discovery of new epidemic strains of C. difficile has provided a unique opportunity for retrospective and prospective studies that have sought to understand how these strains have essentially replaced more historical strains as a major cause of CDI. Moreover, detailed studies on the pathogenesis of NAP1/BI/027 strains are leading to new hypotheses on how this emerging strain causes severe disease and is more commonly associated with epidemics. In this review, we provide an overview of CDI, discuss critical mechanisms of C. difficile virulence, and explain how differences in virulence-associated factors between historical and newly emerging strains might explain the hypervirulence exhibited by this pathogen during the past decade.

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Risk factors for the development of fulminant Clostridium difficile colitis

Cited by 86 publications

References 19 publications

Emergency subtotal colectomy for fulminant Clostridium difficile colitis – is a surgical solution considered for all patients?

Emergency subtotal colectomy for fulminant Clostridium difficile colitis – is a surgical solution considered for all patients?

A 76-Year-Old Man With Recurrent Clostridium difficile–Associated Diarrhea

Variations in Virulence and Molecular Biology among Emerging Strains of Clostridium difficile

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