Clostridium difficile colitis: A clinical review

doi:10.1016/j.amjsurg.2016.10.035

The American Journal of Surgery

Volume 213, Issue 3, March 2017, Pages 565-571

https://doi.org/10.1016/j.amjsurg.2016.10.035 Get rights and content

Abstract

Background

Clostridium difficile colitis is an important cause of morbidity and mortality in the surgical patient. In recent years, Clostridium difficile infections have shown marked increases in frequency, severity, and resistance to standard treatment. With urgent operative interventions and novel endoscopic approaches, pseudomembranous colitis is being seen more commonly in surgical practices.

Data sources

In this paper, we will review a number of papers from the literature. We will discuss the epidemiology, evaluation and treatment of Clostridium difficile infection. Fulminant colitis may require emergency operation. For the surgical endoscopist, fecal microbiota transplantation restores the gastrointestinal flora, and has been shown to be effective in more than 80% of patients.

Conclusion

Section snippets

Epidemiology

The frequency of CDI infection increased from 4.5 CDI cases per 1000 discharges in 2001 to 8.2 in 2010 with a mortality rate of around 7%.² A population-based study by Lessa et al. estimated almost a half million cases in the United States in 2011, with 83,000 recurrences and 29,300 deaths.³

Clostridium difficile infection is triggered by toxin production from the bacteria. Normal bacterial flora is disrupted, the colon is colonized with the Clostridium difficile bacteria, and toxins are

Diagnosis

Diagnosis of CDI requires the presence of diarrhea (at least 3 unformed stools in 24 h) or radiographic evidence of ileus or toxic megacolon, in addition to positive stool testing for Clostridium difficile toxin or colonoscopic or pathologic findings showing pseudomembranes.⁹

Pseudomembranes are pathognomonic of the disease, but are present in only about 50% of patients who are toxin-assay positive. As many as 70% of patients may present with rectal sparing, and 10% may have pseudomembranes

Clinical features

The signs and symptoms of CDI range from self-limited diarrhea to a combination of symptoms which may include fever, elevated white blood cell count, abdominal pain and/or distention, and tachycardia. With worsening disease, patients may progress to renal failure, shock, intensive care unit admission, and an acute surgical abdomen. Several grading scales have been published to enable the clinician to identify the appropriate therapy for a patient with active infection (See Table 1, Table 2).

Medical management

Treatment of Clostridium difficile infection involves discontinuation of the offending antibiotic, whenever possible. Antiperistaltic agents should be avoided, at least until antibiotic therapy is well underway. Resuscitation should be initiated for patients with more advanced disease.

Metronidazole is the drug of choice for mild infection (500 mg by mouth three times a day for 10–14 days), while vancomycin should be used for more severe episodes (125 mg by mouth four times daily for 10–14 days).

Fecal microbiota transplantation

A form of fecal microbiota transplantation (FMT) has been used in Chinese medicine for at least 1700 years for the treatment of various gastrointestinal ailments.²⁵ More recently, Eiseman, in 1958, described the use of fecal enemas in the treatment of four patients with Clostridium difficile colitis.²⁶ Since that time, there have been sporadic reports in the literature, with a marked increase in the number of publications in the last several years, as reported by the NIH clinical trials

Surgical treatment

When medical therapy fails to improve patient status, surgical consultation should be obtained. Unfortunately, in most cases, this is a time of crisis.

Abdominal colectomy is the treatment of choice for severely ill patients. Patients with megacolon, perforation or an acute abdomen should have an emergency colectomy. A review of the Nationwide Inpatient Sample from 2001 to 2010 by Halabi et al. found a colectomy rate of hospitalized patients of 0.7% with an overall mortality rate of 30.7% for

Clostridium difficile infection in inflammatory bowel disease

Clostridium difficile infections have a marked significance in the population with coincidental diagnosis of inflammatory bowel disease (IBD). Review of isolated case studies collected over several decades has concluded that CDI negatively impacts the natural course of IBD. This includes increased disease flares, increased morbidity, and increased length of hospitalization.⁶¹ Unfortunately, the nature of immunosuppressive therapy often makes the diagnosis of CDI difficult in this population, as

Conclusion

Clostridium difficile infection is a major cause of healthcare-related diarrhea leading to increased morbidity and mortality in surgical patients. Increases in failure rates and resistance to current treatments have been clinical and economical challenges in the healthcare setting. New developments in pharmacologic agents, surgical management and other strategies have been developed to improve management of CDI.

Medical management of CDI is dependent on the severity of the infection.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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