<Emphasis Type="Italic">Clostridium difficile</Emphasis> Infection: A Surgical Disease in Evolution

Introduction  Several recent publications suggest an increase in the incidence of Clostridium difficile colitis. However, such studies commonly lack denominators over which to index this rise. There is also concern in the literature that disease virulence is increasing. Methods  Billing, admission, operative, and infection databases at a single tertiary care center identified patients admitted from 1990 to 2006 with a diagnosis of C. difficile infection. Grouped by era, case numbers were indexed against overall hospital, operative, and laboratory volumes. C. difficile colectomy cases were individually examined and analyzed. Results  The number of hospitalized patients diagnosed with C. difficile colitis increased in a linear fashion during the study period (1990, 14 cases; 2006, 927 cases). The colectomy per C. difficile case ratio did not change over the study period (era 1, 0.17%; era 2, 0.20%; era 3, 0.16%). Thirteen patients underwent colectomy with 54% surviving. The increase in patients admitted with a diagnosis of C. difficile was significantly associated with hospital volume (p = 0.04), operative volume (p < 0.001), and lab testing volume (p = 0.008). Conclusion  The number of C. difficile patients admitted to our hospital is rising at an alarming rate. This reflects national trends and urgent action seems warranted to prevent a C. difficile epidemic. Originally Presented at: Digestive Disease Week, May 2007, Washington D.C.     

Clostridium difficile enteritis: A report of two cases and systematic literature review

Clostridium difficile (C. difficile) is the most common cause of healthcare associated infectious diarrhea. In the last decade, the incidence of C. difficile infection has increased dramatically. The virulence of C. difficile has also increased recently with toxigenic strains developing. C. difficile is generally a disease of the colon and presents with abdominal pain and diarrhea due to colitis. However, C. difficile enteritis has been reported rarely. The initial reports suggested mortality rates as high as 66%. The incidence of C. difficile enteritis appears to be increasing in parallel to the increase in colonic infections. We present two cases of patients who had otherwise uneventful abdominal surgery but subsequently developed C. difficile enteritis. Our literature review demonstrates 81 prior cases of C. difficile enteritis described in case reports. The mortality of the disease remains high at approximately 25%. Early recognition and intervention may reduce the high mortality associated with this disease process.     

Pseudomembranous colitis: how useful is endoscopy?

Summary Clostridium difficile colitis may be diagnosed either by endoscopy or by laboratory tests. To determine the role of endoscopy, we reviewed 59 cases of confirmed C. difficile colitis. In all patients, the etiology was confirmed by stool tests. Twenty-nine underwent lower gastrointestinal endoscopy. In 16 (55%) there was endoscopic confirmation of pseudomembranes while 4 (14%) had only nonspecific colitis. There was no apparent difference in the rate of detection of pseudomembranes between rigid sigmoidoscopy (57%), flexible sigmoidoscopy (50%), and colonoscopy (50%). Vancomycin and metronidazole were equally effective therapy but treatment with vancomycin cost more than 250 times that for metronidazole. There were no patients in whom the diagnosis was made by endoscopy alone. Endoscopy was costly and insensitive, while noninvasive stool tests were cheap and accurate. We conclude that endoscopy should be relegated to a secondary role in the workup of antibiotic-associated diarrhea.     

Clostridium difficile‐related pancolitis in lung‐transplanted patients with cystic fibrosis

Patriarchi F, Rolla M, Maccioni F, Menichella A, Scacchi C, Ambrosini A, Costantino A, Quattrucci S. Clostridium difficile‐related pancolitis in lung‐transplanted patients with cystic fibrosis.
Clin Transplant 2011: 25: E46–E51. © 2010 John Wiley & Sons A/S. Abstract: C. difficile (C. d.) is the main cause of antibiotic‐associated diarrhea and colitis. It is shown in literature a high asymptomatic carriage rate of C. d. in patients with cystic fibrosis (CF), though C. d.‐related colitis is an uncommon complication in these patients, despite the use of multiple high‐dose antibiotic regimes and the frequency of hospital admissions. Lung transplantation with the associated immunosuppression and aggressive antibiotic therapy may increase the risk of the clinical manifestation of C. d. In this paper, we describe three cases of severe C. d. colitis in patients with CF following lung transplantation and illustrate our experience in the diagnosis and management of these patients.     

Clostridium difficile enteritis: A new role for an old foe

BackgroundSmall bowel involvement of Clostridium difficile is increasingly encountered. Data on many management aspects are lacking.AimTo synthesis existing reports and assess the frequency, pathophysiology, outcomes, risk factors, diagnosis and management of C. difficle enteritis.MethodsA systematic review of the literature was conducted to evaluate evidence regarding frequency, pathophysiology, risk factors, optimal diagnosis, management and outcomes for C. difficle enteritis. Three major databases (PubMed, MEDLINE and the Cochrane Library) were searched. The review included original articles reporting C. difficle enteritis from January 1950 to December 2012.ResultsC. difficle enteritis is rare but increasingly encountered. Presentation is variable and distinct predisposing factors include emergency surgery, white race and increased age. Diagnosis generally involves a sensitive but often non specific screening test for C. difficile antigens. Oral metronidazole represents first line therapy and surgery may be required for complications. Outcomes are inconsistent but may be improving.ConclusionsA high index of clinical suspicion, early diagnosis and treatment are vital. Further prospective studies are needed to determine the significance of asymptomatic small bowel C. difficile infections.     

Association of IgA nephropathy with Clostridium difficile colitis

Immunoglobulin A (IgA) nephropathy, the most common cause of glomerulonephritis worldwide, is usually idiopathic in origin and renal limited. Secondary IgA nephropathy has been associated with systemic disease, including such gastrointestinal tract disturbances as celiac sprue and inflammatory bowel disease. We describe gross hematuria and reversible acute renal failure from IgA nephropathy in a patient with cephalosporin-induced Clostridium difficile colitis. In addition to mesangial IgA and C3 deposition, renal histological examination showed glomerular bleeding, intratubular red blood cell casts, and acute tubular necrosis. To the best of our knowledge, this is the first report of an association between IgA nephropathy and C difficile colitis.     

Recurrent Clostridium difficile colitis in cystic fibrosis: An emerging problem

ObjectiveTo examine the incidence of recurrent Clostridium difficile infection in patients with cystic fibrosis (CF), including patients who had undergone lung transplantation, and review clinical findings in hospitalized patients with C. difficile colitis.MethodsA retrospective chart review was performed to examine the clinical presentation and management of patients with cystic fibrosis (CF) who received care at the University of Wisconsin Hospital and Clinics (UWHC) from 1994 to 2011 and were prospectively identified with C. difficile colitis.ResultsTen cases of C. difficile associated disease (CDAD) occurred in patients with CF followed by our Adult CF Center over a period of 17 years, and 4 patients were bilateral lung transplant recipients. Two of the lung transplant recipients had recurrent CDAD that lead to fulminant pancolitis, surgical intervention, and shock. Two patients in the non-transplant group experienced recurrent C. difficile infection that led to fulminant pancolitis with associated systemic inflammatory response syndrome and required colectomy.ConclusionsC. difficile colitis can cause life threatening illness in patients with CF, and symptoms may be subtle and/or atypical and lead to significant delay in diagnosis. Patients with recurrent C. difficile colitis are at high risk of fatal outcome, and empiric therapy should be considered for patients with previous C. difficile colitis even in the absence of disease when broad-spectrum antibiotics are given to treat bacterial infection.     

Role of intraoperative prograde colonic lavage and a decompressive loop ileostomy in the management of transmural amoebic colitis

A prospective analysis is presented of a selected group of 45 consecutive patients with transmural amoebic colitis treated by laparotomy, colonic lavage and ileostomy (phase 1 surgery) over 3 years. The diagnosis of amoebic colitis and amoebic perforation of the bowel were difficult and therefore all patients with 'acute abdomen' had proctosigmoidoscopy and a trial of metronidazole for 24-48 h before laparotomy. At laparotomy, adhesive wraps were present in all patients; 13 perforations were exposed by inadvertent disturbance of adhesive wraps but were successfully closed by suture to any available organ in close proximity, such as the omentum or small bowel. Four patients (9 per cent) died after phase 1 surgery. After 6 weeks when the acute disease had healed, 33 of the remaining 41 patients (80 per cent) required closure of ileostomy only, five had resection of stricture and three (7 per cent) needed stricturoplasty (phase 2 surgery). Two patients (5 per cent) died after phase 2 surgery. Thus, in surgery for transmural amoebic colitis adhesive wraps should not be disturbed as they mechanically protect the peritoneal cavity from faecal soiling when perforation occurs. The colon should be emptied by lavage and the faecal stream diverted to avoid secondary bacterial effects.     

Outcomes of emergency colectomy for fulminant Clostridium difficile colitis

IntroductionClostridium 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 methodsOver 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.ResultsA 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%.ConclusionEmergency 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.     

Assessment of the potential risk of infection associated with Clostridium difficile from porcine xenografts

Bakri MM, Sutherland AD, Brown DJ, Vesely P, Crossan C, Scobie L. Assessment of the potential risk of infection associated with Clostridium difficile from porcine xenografts.
Xenotransplantation 2009; 16: 472–476. © 2009 John Wiley & Sons A/S. Abstract: There are numerous concerns over the potential for transfer of pathogens between species during clinical xenotransplantation, and although current clinical application is limited, porcine xenografts have been previously used to treat patients with severe burns. Donor animals providing the xenografts are sourced from a healthy commercial herd, however, as pigs are a known source of zoonotic agents, a number of diseases are required to be excluded from pigs used for xenotransplantation purposes. Many studies have indicated the relevance of viral zoonoses, however, little has been done with regard to the potential for transfer of pathogens related to health care associated infections. Clostridium difficile is a major cause of neonatal enteritis in pigs and an important feature of this organism is that pigs can be asymptomatic carriers. This study has examined the incidence of C. difficile PCR ribotypes present in healthy donor pigs to determine if pig faeces, and in particular, contamination of skin with faecal matter, is a potential route for the transfer of C. difficile. Animals were found to have human ribotype 017 present in the faecal matter, however, no C. difficile was isolated from skin samples taken from the same animals. In addition, due to the risk factors associated with C. difficile infection, the antimicrobial susceptibility of the C. difficile isolates has been determined.     

Colectomy and ileostomy in the management of ulcerative colitis

For 30 years, colectomy with ileostomy has been the mainstay of the surgical treatment for ulcerative colitis. Between 1963 and 1985, 535 patients with inflammatory bowel disease were admitted to the Royal Prince Alfred Hospital in Sydney, Australia; 471 had ulcerative colitis and 64 Crohn's colitis. One hundred and eight-six of these patients underwent colonic resection. The proportion of patients who underwent surgery was the same for both disorders. There have been no deaths resulting from the surgical management of inflammatory bowel disease at our hospital since 1965. These patients should be treated safely by standard means before the more elaborate sphincter-saving procedures, currently recommended, are tried.     

Prevalence of clostridium difficile in excluded colons

Clostridium difficile infection is associated with substantial morbidity and mortality, increased duration of hospitalization, and a marked economic impact. Several case reports and case series have described C. difficile infection in excluded bowels or immediately after reversal of defunctioning ileostomy. The aim of this prospective study is to detect whether the excluded colon is associated with a higher rate of C. difficile colonization than the normal population, which may increase the risk of C. difficile infection. Patients with defunctioning loop ileostomy, undergoing closure of ileostomy to restore bowel continuity, were prospectively recruited. Two stool samples were collected from the ileostomy effluent before closure of ileostomy and two after the procedure including the first bowel movement. All samples were cultured for C. difficile and analyzed for toxins A and B by a Premier EIA test. Demographic data and possible confounding factors were observed and recorded. Twenty-fine adult patients were recruited to this study; five patients were subsequently excluded. Two patients had positive stool cultures for C. difficile in the postoperative samples and another patient developed clinical pseudomembranous colitis with positive toxin. This indicates a possible colonization rate of 3 to 38 per cent (95% confidence interval). Four observed cases out of the 20 subjects taking part in this study would confidently conclude that C. difficile colonization in the excluded colon is 6 to 44 per cent, i.e., higher than the incidence in the healthy adult population, which is 3 per cent. However, the findings of this study prompt larger and well-powered studies to confirm these findings.     

Fecal microbiota transplantation for the treatment of recurrent and severe Clostridium difficile infection in solid organ transplant recipients: A multicenter experience

Fecal microbiota transplant (FMT) is recommended for Clostridium difficile infection (CDI) treatment; however, use in solid organ transplantation (SOT) patients has theoretical safety concerns. This multicenter, retrospective study evaluated FMT safety, effectiveness, and risk factors for failure in SOT patients. Primary cure and overall cure were defined as resolution of diarrhea or negative C difficile stool test after a single FMT or after subsequent FMT(s) ± anti‐CDI antibiotics, respectively. Ninety‐four SOT patients underwent FMT, 78% for recurrent CDI and 22% for severe or fulminant CDI. FMT‐related adverse events (AE) occurred in 22.3% of cases, mainly comprising self‐limiting conditions including nausea, abdominal pain, and FMT‐related diarrhea. Severe AEs occurred in 3.2% of cases, with no FMT‐related bacteremia. After FMT, 25% of patients with underlying inflammatory bowel disease had worsening disease activity, while 14% of cytomegalovirus‐seropositive patients had reactivation. At 3 months, primary cure was 58.7%, while overall cure was 91.3%. Predictors of failing a single FMT included inpatient status, severe and fulminant CDI, presence of pseudomembranous colitis, and use of non‐CDI antibiotics at the time of FMT. These data suggest FMT is safe in SOT patients. However, repeated FMT(s) or additional antibiotics may be needed to optimize rates of cure with FMT.     

TOTAL COLECTOMY FOR CROHN’S DISEASE

Background : Total colectomy for Crohn’s disease of the colon may be restorative with ileorectal anastomosis or with an ileostomy and rectal stump. The present paper retrospectively audits the results of total colectomy and in particular assesses the number of patients who had a permanent ileostomy and whether this was related to disease in the rectum at the time of the original operation. Methods : A retrospective case note review was undertaken of patients operated upon between 1968 and 1994. Results : Thirty-eight patients were identified (mean age 35 years; range 17–65 years). One patient died perioperatively from an anastomotic leak. Median follow-up for the remaining patients was 7 years (range 1–29 years). Ileorectal anastomosis was performed in 17 patients and total colectomy and ileostomy in 20 patients. Indications for surgery were failure of medical treatment (61%); toxic colitis (18%); abscess (8%); perforation (5%); large bowel obstruction (5%); and colovesical fistula (3%). Subsequent proctectomy (14 patients, 38%) was more likely with subtotal colectomy and ileostomy (nine patients, 45%) than ileorectal anastomosis (five patients, 29%). This was not statistically significant (P = 0.33). Additionally, seven patients had diversion of the rectum making 21 with an ileostomy (57%). Rectal involvement at the time of the original procedure significantly increased the likelihood of permanent ileostomy (P = 0.001). The presence of anal disease did not increase the prospect of ileostomy. One patient died with advanced adenocarcinoma in a defunctioned rectum. Conclusions : A permanent ileostomy after total colectomy for Crohn’s disease is common and significantly more likely with rectal involvement.     

Safety of the temporary loop ileostomy

Objective To evaluate the complications of the temporary loop ileostomy. Method A retrospective study of 222 consecutive patients with low anterior resection, ileal pouch‐anal anastomosis or continent ileostomy and a diverting loop ileostomy routinely fashioned during the primary operation. The loop ileostomy was closed in 213 patients (96%) during the minimum follow‐up period of 15 months. Results Four patients (2%) required preterm closure of the ostomy due to stomal retraction (n = 3) or bowel obstruction (n = 1). Four patients were readmitted due to transient bowel obstruction that resolved without surgery. After closure of the loop ileostomy a total of 27 patients (13%) had complications. In 7 patients emergency re‐operation was done due to small bowel obstruction (n = 5) or intra‐abdominal abscess (n = 2). Elective re‐operation was done in 5 patients for hernia at the site of the previous stoma. Despite the use of a loop ileostomy there was 1 postoperative death after the initial operation in consequence of anastomotic leakage. There was 1 death in consequence of closure of the loop ileostomy after 3 weeks due to intra‐abdominal sepsis and heart failure. Conclusion In this series closure of the ostomy wasassociated with one death (0.5%) and overall ostomy‐related morbidity included the need to re‐operate in 6%.     

Pouch ileitis in excluded reservoir: an unusual complication of restorative proctocolectomy for ulcerative colitis

One case of pouch ileitis after restorative proctocolectomy for ulcerative colitis is described. Diagnosis was made by endoscopy, histology and electron microscopy. The most prominent feature was intense inflammation of the mucosa and submucosa, with atrophy of the villi, and colonic metaplasia, occurring before closure of the loop ileostomy. The patient improved after a course of metronidazole therapy, but ileostomy closure was postponed. It appears that the ileum mucosa of patients with ulcerative colitis is highly prone to the development of inflammation and careful, regular follow-up is recommended.     

Three-step ileal pouch-anal anastomosis under total laparoscopic approach for acute or severe colitis complicating inflammatory bowel disease

BACKGROUND: A two- or three-step procedure is mandatory for restorative proctocolectomy in patients presenting with severe or acute colitis complicating inflammatory bowel disease (IBD). The aim of this study was to analyze the feasibility of a total laparoscopic approach for consecutive subtotal colectomy (STC) and secondary ileal pouch-anal anastomosis (IPAA). STUDY DESIGN: All patients underwent a three-step procedure that included first, a laparoscopic STC with ileostomy and sigmoidostomy; second, a laparoscopic proctectomy and IPAA, and third, closure of the temporary ileostomy. RESULTS: Eighteen consecutive patients (7 women and 11 men), with a mean age of 39+/-14 years (range 15 to 59 years) were included. Mean lengths of the procedures were 252+/-59 minutes for STC, and 286+/-46 minutes for IPAA, respectively. Two patients (11%) after laparoscopic IPAA required conversion into laparotomy. No patient died postoperatively. Four patients had reoperations after laparoscopic IPAA for intraperitoneal hemorrhage by laparotomy (n=2) and by a transanal approach for anastomotic leakage (n=2). The overall morbidity rate was 33% (12 of 36 procedures). Mean hospital stay was 8+/-2 days after STC, and 10+/-2 days after IPAA. After a mean follow up of 13 months, all patients underwent intestinal continuity restoration. CONCLUSIONS: Our study suggests that a total laparoscopic approach is feasible and safe in inflammatory bowel disease patients with acute or severe colitis, not only for STC but also for IPAA after STC, with no mortality and an acceptable morbidity rate.     

Prise en charge d’une colite aigüe grave

Acute severe colitis is a classic complication of inflammatory bowel disease, especially of ulcerative colitis. It is a short-term life-threatening medical and surgical emergency. Acute severe ulcerative colitis diagnosis is based on clinical and biological criteria. The first medical evaluation should identify serious complications that require surgery in emergency and exclude a bowel infection (especially Clostridium Difficile or cytomegalovirus infections). In acute severe colitis, intravenous corticosteroids are the conventionnal medical treatment. However, roughly one third of patients are resistant to the treatment. Ciclosporin and infliximab are potential rescue treatments in this case, with a similar efficacy. Colectomy remains the best option in case of complicated acute severe colitis and should be discussed as an option at each stage of the treatment.     

Determining the optimal surgical timing of fulminant Clostridium difficile colitis by using four objective factors and computed tomography findings: A case report

Introduction and importanceClostridium difficile colitis is increasingly seen in everyday clinical situations, and most cases are treated with antibiotics. Fulminant C. difficile colitis (FCDC) is rare; however, it is extremely virulent, and understanding its appropriate surgical treatment is critical. The surgical timing is controversial because of the lack of concrete decision-making factors. We report a case of FCDC with a favourable outcome, which was achieved by using four objective factors and computed tomography (CT) findings.Case presentationA patient with head trauma developed pneumonia at 2 days post-admission. He was prescribed with antibiotics. Fever and leucocytosis persisted on hospital day 10. Clostridium was detected in the stool on day 12, and metronidazole was administered. His condition did not improve; thus, he was started on vancomycin on day 14. The marked deterioration in the four laboratory parameters (white blood cell, albumin [Alb], creatinine, and body temperature) on day 15 and CT findings contributed to the decision to perform emergency subtotal colectomy and ileostomy. His condition improved dramatically postoperatively.Clinical discussionMany factors of FCDC are already suggested for surgical intervention in the guidelines; however, they are often seen at the late stage of FCDC. Early detection of FCDC is the key to favourable surgical outcome. Following the trend of these objective factors guides in making appropriate surgical decisions.ConclusionFocusing on the four objective factors and CT findings of FCDC could help surgeons detect FCDC at an early stage and decide the optimal surgical timing.     

Does an ileoanal pouch offer a better quality of life than a permanent ileostomy for patients with ulcerative colitis?

Although an ileoanal pouch is frequently offered to patients with ulcerative colitis, it is still not clear to what extent this operation offers advantages over a permanent ileostomy. The aim of this study was to determine whether patients with a pouch have less morbidity and a better quality of life than a matched group of patients with a Brooke ileostomy. Nineteen patients (12 males and 7 females, median age 41 years) who had undergone total colectomy and ileoanal pouch formation for ulcerative colitis were individually matched with patients who had had a panproctocolectomy and ileostomy; patients were matched for disease process, sex, age, socioeconomic status, and time since surgery. Quality of life was assessed using the Short-Form 36 version 2 questionnaire, the inflammatory bowel disease questionnaire, and a few additional questions on perception of body image. The scores were compared using the nonparametric Wilcoxon signed-rank test for paired samples. The number and type of postoperative complications, as well as the number of operative stages, were recorded prospectively. Restorative proctocolectomy was associated with a significantly better perception of body image than a permanent stoma, although quality of life in general was similar in both groups. Patients with a pouch had more long-term complications than patients with an ileostomy within the same period of time (52.6% vs. 26.3%). The median number of stages for pouch construction was two, compared to a median of one stage for an ileostomy (P < 0.0001). Because of the high long-term complication rate and the relatively small quality-of-life advantage associated with restorative proctocolectomy, patients need to be counseled thoroughly before agreeing to this operation. Presented at the Millenium Joint Scientific Meetings of the Association of Surgeons of Great Britain and Ireland and the Surgical Research Society, Cardiff, Wales, May 23–26, 2000; and published as an abstract in British Journal of Surgery 2000;87(Suppl 1):47. Supported by an educational grant from ConvaTec Ltd.