Clostridium difficile infection in orthopaedic patients

In a review of the results of toxin assays, twenty-five orthopaedic patients who had a Clostridium difficile infection and associated diarrhea were identified. The infection was due to the use of antibiotics in all but one patient. Seventeen patients had received the antibiotics prophylactically. The two most commonly implicated antibiotics were cefazolin and clindamycin, because those drugs had been commonly used for prophylaxis at the study institutions. However, other antibiotics were implicated. There was a positive correlation between the delay in diagnosis and the severity of the illness. A white blood-cell count of more than 20 x 10(9) per liter indicated severe disease in our survey. The possibility of Clostridium difficile infection should be considered in patients who have signs and symptoms that mimic those of intestinal obstruction. Patients who have an unexplained fever or high white blood-cell count and in whom diarrhea develops in the postoperative period should be treated immediately with metronidazole, and a specimen of stool should be obtained for an assay for Clostridium difficile toxin. If the diagnosis of Clostridium difficile infection is confirmed by the presence of toxin in the stool and the patient has persistent, severe diarrhea, oral administration of vancomycin should be added to the regimen. The duration of antibiotic prophylaxis should be minimized to decrease the risk of Clostridium difficile colitis.     

Clostridium difficile infection and gut microbiota

Clostridium difficile infection (CDI) is associated with disturbance of intestinal microbiota. Microbiota of CDI patients usually shows decreased diversity, increase of facultative anaerobes, and decreased levels of bifidobacteria, Bacteroidetes, Lachnospiraceae, and butyrate-producing bacteria. Studies including symptomatic, asymptomatic, recurrent, and fecal therapy-treated patients could result in the recognition of microbial markers for CDI risk or could provide the combination of beneficial microbes for a C. difficile-specific probiotic.     

Antibiotic therapy for Clostridium difficile infection

Antibiotic treatment of Clostridium difficile infection (CDI) in adults in the United States has been guided by the 2010 joint guidelines from the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA), but three new sets of guidelines became available in 2013, including one from the American College of Gastroenterology and two from Europe. This article will put these guidelines in perspective, review their recommendations, and cite the data from key primary references. Although varied definitions of disease severity are used, metronidazole is generally recommended for a first or second episode of non-severe CDI, low-dose oral vancomycin is preferred for severe CDI, and the combination of high-dose oral vancomycin plus intravenous metronidazole is reserved for complicated CDI. The roles of fidaxomicin and other measures are also discussed. However, the many caveats within the recommendations underscore the importance of clinical judgment in treating this evolving disease.     

Surgery for fulminant Clostridium difficile infection

Fulminant Clostridium difficile infection is an important clinical entity for surgeons given the increasing incidence and severity of the disease worldwide. Indications for surgery have not been standardized, but a worsening clinical picture from serial examination, laboratory evaluation, or overall clinical status appears to warrant surgical intervention. Total abdominal colectomy with end ileostomy confers a modest survival advantage but historical mortality rates range from 35% to 80% in small series. Diverting loop ileostomy has recently emerged as a possible alternative with decreased mortality rates and the advantage of preserving the colon.     

The outcome of surgery in fulminant Clostridium difficile colitis

BACKGROUND: The clinical presentation of Clostridium difficile infection ranges from asymptomatic carriage, colitis with or without pseudomembranes, to fulminant colitis. Although not common, fulminant C. difficile colitis can result in bowel perforation and peritonitis with a high mortality rate. Colectomy is often indicated in these cases. METHODS: We retrospectively analysed the outcome of 14 patients who underwent surgery for fulminant C. difficile colitis in the period 1996-2003 in our Unit. RESULTS: The indications for surgery were systemic toxicity and peritonitis (n = 10), radiological and clinical evidence of progressive toxic colonic dilatation (n = 3) and progressive colonic dilatation with bowel perforation (n = 1). C. difficile infection as the cause of colitis was diagnosed pre-operatively in seven (50%) patients, six of whom underwent a total colectomy and one a right hemicolectomy. Overall mortality in our series was 35.7%. Total colectomy was associated with a lower mortality rate of 11.1% (1/9) when compared with left hemicolectomy was 100% (4/4) (P = 0.01). One patient who underwent a right hemicolectomy (on the basis of deceptively normal external appearance of the rest of the colon intra-operatively) survived after a prolonged hospital stay. CONCLUSIONS: Early or pre-operative microbiological diagnosis of C. difficile infection can be difficult in patients with a fulminant presentation. Those patients with C. difficile colitis, who develop signs of toxicity, peritonitis or perforation, should undergo a total colectomy as the operation of choice.     

Overview and changing epidemiology of Clostridium difficile infection

There has been an increase in Clostridium difficile infection (CDI) incidence, severity, and mortality during the last decade. Although the elderly receiving antibiotic therapy are the most common group at risk for infection, CDI occurs in all age groups, and recent data indicate that CDI is emerging in groups that have been traditionally considered at low risk for infection. Additionally, approximately one-third of all CDI cases are now considered to be community associated in the U.S. New information is emerging on risk factors for an initial episode of CDI as well as recurrent disease. Increases in the burden of disease and severe outcomes related to CDI has been associated with the emergence of a new epidemic strain, restriction enzyme analysis BI, North American Pulsed-Field Type 1, and PCR Ribotype 027 (BI/NAP1/027) as well as other emerging strains. This article explores the changing epidemiology of CDI based on the latest available data as well as the recent developments in diagnosis and infection control.     

The morbidity of Clostridium difficile infection after elective colonic resection-results from a national population database

Background

Clostridium difficile (CD), a gram-positive rod bacterium, resides normally within the human colon. Antibiotic treatment alters normal colonic flora, potentiating abnormal overgrowth of CD.

Methods

This study examined the 2004 to 2006 Nationwide Inpatient Sample to determine outcomes of CD colitis after 695,010 elective colonic resections.

Results

CD infection, occurring in 1.4% of patients, was associated with higher pulmonary (12.1% vs 6.4%) and gastrointestinal (12.8% vs 10.5%) complications as well as an increased length of stay (22.6 vs 10.9 days) and mortality (16.2% vs 4.9%; all P < .001). CD colitis patients more frequently held Medicare insurance (68% vs 51%) and underwent small segmental colonic resection as opposed to a defined anatomic resection (20.0% vs 9.9%; P < .001). An underlying diagnosis of colon cancer was associated with a lower incidence of CD colitis (odds ratio, .71; 95% confidence interval, .59–.84; P < .001).

Conclusions

CD colitis is associated with worse outcomes after elective colonic resection.     

Clinical and radiographic findings in the patient with Clostridium difficile infection

Though Clostridium difficile can be found in the colon of asymptomatic patients, it is well known to exhibit pathogenic behavior in the setting of an altered colonic bacterial flora. This leads to a broad spectrum of disease states ranging from simple diarrhea to toxic colitis. The focus of this article is to detail the factors associated with the clinical presentation of C. difficile infection and to describe radiographic adjuncts to diagnosing the severity of C. difficile infection.     

Adrenal surgery in the pediatric population

Adrenal tumors in children may be benign or malignant. In addition, both benign and malignant tumors may be hormonally active, leading to hypertension, metabolic crises, and endocrinopathies. These tumors may be found incidentally or secondary to signs and symptoms of the aforementioned disorders. Both a metabolic and a radiographic work-up are required before treatment of an adrenal tumor. The primary therapy for most adrenal lesions is surgical, though some are treated medically or require chemotherapy before excision. Laparoscopy has become the surgical approach of choice in both adult and pediatric patients with localized disease. Open surgical approaches remain necessary in patients with extensive locally invasive or metastatic disease.     

Role of endoscopy in the assessment and treatment of Clostridium difficile infection

As our ability to diagnose and treat Clostridium difficile infections (CDI) has improved over time, the role that endoscopy plays in the management of these patients has evolved. We reviewed the medical literature to describe the role of endoscopy in the management of CDI. A search of PubMed, Ovid, and the Cochrane Library was performed. Abstracts were reviewed to determine their scientific merit and relevance. The selected articles and relevant embedded references from the primary articles were also examined, with recommendations based on consensus conclusions of the data. A total of 80 articles were reviewed and analyzed for this article. Endoscopy once played a very prominent role in the diagnosis and management of C. difficile infections. It now serves as a tool in complicated cases to evaluate for other pathology and to asses for disease severity, while providing a therapeutic option for select patients.     

Clostridium difficile in urology

INTRODUCTION

The objective was to determine the incidence of Clostridium difficile infection in a UK urology ward from 2000 to 2005, and correlate and compare the data with other specialty wards and national figures.

PATIENTS AND METHODS

Urology patients with a positive stool culture for C. difficile between 2000 and 2005 were identified from a hospital database. The medical records of these patients were reviewed and data such as antibiotic use, urological diagnosis and elective/emergency status of the patient were recorded and analysed. The number of C. difficile cases on an elderly care ward, an acute medical ward and an acute surgical ward were also recorded for this period. Data on the number of admissions and occupied bed-days on all 4 wards were compared.

RESULTS

There were 33 cases of C. difficile on the urology ward between 2000 and 2005. The incidence of this infection varied between 10.2 and 48.4 cases per 10,000 patient episodes (mean 21.0). There was a significant difference between the number of C. difficile cases per 1000 patient days between the urology ward and the acute medical ward (P = 0.002) and the elderly care ward (P = 0.03).

CONCLUSIONS

There is no evidence to suggest that there has been an increase in the incidence of C. difficile in a UK urology ward. The rates on the urology ward were lower than the national average, and significantly lower than those rates on an acute medical ward and an elderly care ward. There is a 0.21% chance of a patient testing positive for C. difficile during their stay on a urology ward.