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Invited Critique
May 18, 2009

Fulminant Clostridium difficile Colitis—Invited Critique

Arch Surg. 2009;144(5):439-440. doi:10.1001/archsurg.2009.53

This review confirms the substantial mortality associated with fulminant C difficile colitis (FCDC). Independent predictors of mortality are similar to results from other reviews: advanced patient age (≥70 years), profound leukocytosis (≥35 000/μL), and the need for cardiopulmonary support. Nearly half of those who required colectomy were experiencing multisystem organ failure prior to surgery.

The fact that patients admitted to the surgical department experienced a better outcome is noteworthy. The authors speculate that improved survival in this cohort may reflect both the increased rate of urgent colectomy and the shorter interval between admission and operation for patients in the surgical department, a factor that has been associated with improved survival in other series. This subset analysis excludes 63 patients who developed FCDC while hospitalized for other medical problems. According to the report, 29 of these 63 patients were treated in the surgery department. Treatment outcome in these 29 patients could be germane to any comparison of differences in treatment strategy and patient outcome.

The study provides little insight into alternative strategies for improvement of the dismal outcome associated with FCDC. It comes as no surprise that results are poor when elderly patients with acute respiratory failure and/or hemodynamic instability require urgent colectomy. Ideally, surgery should be undertaken before these complications develop. Increased patient age, immunosuppression, hypoalbuminemia, significant leukocytosis, and increased serum lactate levels have all been shown, in this or other reviews, to correlate with the need for operation and with ultimate treatment outcome. Nevertheless, there is no absolute threshold in any of these categories and no finding on CT scan, short of pneumoperitoneum, that predicts the need for operation with certainty for an individual patient.

Epidemic outbreaks of FCDC have been attributed to the emergence of a more virulent strain of the organism (NAP-1/027). The proportion of sporadic cases of FCDC caused by NAP-1/027 is uncertain. Currently there is no way to rapidly identify infections caused by this strain, to our knowledge. Whether this information would influence indications for operation in patients with FCDC remains speculative.

Until more precise criteria for surgical intervention are identified, patients with FCDC should be managed in similar fashion to patients with other forms of toxic colitis. After resuscitative measures have been initiated, medical therapy for the specific cause of the disease should be instituted. For FCDC this should include the use of intravenous metronidazole as well as oral vancomycin. Although vancomycin is more effective, delivery of the drug to the colon can be impaired when the disease is complicated by a paralytic ileus. Intravenous administration of metronidazole may produce therapeutic levels in the colonic lumen as a result of biliary and intestinal excretion. Active involvement by surgeons in the assessment and treatment of these patients is crucial. Any sign of further clinical deterioration or absence of objective improvement within 24-48 hours should be indications for urgent laparotomy. Total abdominal colectomy with ileostomy and preservation of the rectum is the procedure of choice, regardless of the appearance of the colon at laparotomy.

Correspondence: Dr Murray, Chief, Division of Colon and Rectal Surgery, Department of Surgery, Dartmouth Hitchcock Medical Center, One Medical Center Dr, Lebanon, NH 03756 (john.j.murray@hitchcock.org).

Financial Disclosure: None reported.

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