Fulminant Clostridium difficile Colitis: Patterns of Care and Predictors of Mortality | Gastroenterology | JAMA Surgery | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address 18.204.227.34. Please contact the publisher to request reinstatement.
1.
Kelly  CPPothoulakis  CLaMont  JT Clostridium difficile colitis.  N Engl J Med 1994;330 (4) 257- 261PubMedGoogle ScholarCrossref
2.
McDonald  LCOwings  MJernigan  DB Clostridium difficile infection in patients discharged from US short-stay hospitals, 1996-2003.  Emerg Infect Dis 2006;12 (3) 409- 415PubMedGoogle ScholarCrossref
3.
Schroeder  MS Clostridium difficile-associated diarrhea.  Am Fam Physician 2005;71 (5) 921- 928PubMedGoogle Scholar
4.
Wysowski  DK Increase in deaths related to enterocolitis due to Clostridium difficile in the United States, 1999-2002.  Public Health Rep 2006;121 (4) 361- 362PubMedGoogle Scholar
5.
Longo  WEMazuski  JEVirgo  KSLee  PBahadursingh  ANJohnson  FE Outcome after colectomy for Clostridium difficile colitis.  Dis Colon Rectum 2004;47 (10) 1620- 1626PubMedGoogle ScholarCrossref
6.
Dallal  RMHarbrecht  BGBoujoukas  AJ  et al.  Fulminant Clostridium difficile: an underappreciated and increasing cause of death and complications.  Ann Surg 2002;235 (3) 363- 372PubMedGoogle ScholarCrossref
7.
 International Classification of Diseases, Ninth Revision.  Washington, DC Public Health Service, US Dept of Health and Human Services1988;
8.
Hall  JFBerger  D Outcome of colectomy for Clostridium difficile colitis: a plea for early surgical management.  Am J Surg 2008;196 (3) 384- 388PubMedGoogle ScholarCrossref
9.
Vincent  JLMoreno  RTakala  J  et al.  The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure.  Intensive Care Med 1996;22 (7) 707- 710PubMedGoogle ScholarCrossref
10.
Kyne  LHamel  MBPolavaram  RKelly  CP Health care costs and mortality associated with nosocomial diarrhea from Clostridium difficile Clin Infect Dis 2002;34 (3) 346- 353PubMedGoogle ScholarCrossref
11.
Loo  VGPoirier  LMiller  MA  et al.  A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality.  N Engl J Med 2005;353 (23) 2442- 2449PubMedGoogle ScholarCrossref
12.
Lipsett  PASamantaray  DKTam  MLBartlett  JGLillemoe  KD Pseudomembranous colitis: a surgical disease?  Surgery 1994;116 (3) 491- 496PubMedGoogle Scholar
13.
Koss  KClark  MASanders  DSMorton  DKeighley  MRGoh  J The outcome of surgery in fulminant Clostridium difficile colitis.  Colorectal Dis 2006;8 (2) 149- 154PubMedGoogle ScholarCrossref
14.
Lamontagne  FLabbe  ACHaeck  O  et al.  Impact of emergency colectomy of survival of patients with fulminant Clostridium difficile colitis during an epidemic caused by a hypervirulent strain.  Ann Surg 2007;245 (2) 267- 272PubMedGoogle ScholarCrossref
15.
Byrn  JCMaun  DCGingold  DSBaril  DTOzao  JJDivino  CM Predictors of mortality after colectomy for fulminant Clostridium difficile colitis.  Arch Surg 2008;143 (2) 150- 154PubMedGoogle ScholarCrossref
16.
McDonald  LC Clostridium difficile: responding to a new threat from an old enemy.  Infect Control Hosp Epidemiol 2005;26 (8) 672- 675PubMedGoogle ScholarCrossref
17.
Ali  SOWelch  JPDring  RJ Early surgical intervention for fulminant pseudomembranous colitis.  Am Surg 2008;74 (1) 20- 26PubMedGoogle Scholar
18.
Pépin  JValiquette  LAlary  ME  et al.  Clostridium difficile-associated diarrhea in a region of Quebec from 1991 to 2003: a changing pattern of disease severity.  CMAJ 2004;171 (5) 466- 472PubMedGoogle ScholarCrossref
Paper
May 18, 2009

Fulminant Clostridium difficile Colitis: Patterns of Care and Predictors of Mortality

Author Affiliations

Author Affiliations: Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care (Drs Sailhamer, Zacharias, Spaniolas, Tabbara, Alam, DeMoya, Velmahos, and Carson), and General Medicine Division, Division of Biostatistics (Dr Chang), Massachusetts General Hospital, Harvard Medical School, Boston.

Arch Surg. 2009;144(5):433-439. doi:10.1001/archsurg.2009.51
Abstract

Hypothesis  There exist predictors of mortality and the need for colectomy among patients with fulminant Clostridium difficile colitis.

Design  Retrospective study.

Setting  Academic tertiary referral center.

Patients  We reviewed the records of 4796 inpatients diagnosed as having C difficile colitis from January 1, 1996, to December 31, 2007, and identified 199 (4.1%) with fulminant C difficile colitis, as defined by the need for colectomy or admission to the intensive care unit for C difficile colitis.

Main Outcome Measures  Risk of inpatient mortality was determined by multivariate analysis according to clinical predictors, colectomy, and medical team.

Results  The inhospital mortality rate for fulminant C difficile colitis was 34.7%. Independent predictors of mortality included the following: (1) age of 70 years or older, (2) severe leukocytosis or leukopenia (white blood cell count, ≥35 000/μL or <4000/μL) or bandemia (neutrophil bands, ≥10%), and (3) cardiorespiratory failure (intubation or vasopressors). When all 3 factors were present, the mortality rate was 57.1%; when all 3 were absent, the mortality rate was 0%. Patients who underwent colectomy had a trend toward decreased mortality rates (odds ratio, 0.49; 95% confidence interval, 0.21-1.1; P = .08). Among patients admitted primarily for fulminant C difficile colitis, care in the surgical department compared with the nonsurgical department resulted in a higher rate of operation (85.1% vs 11.2%; P < .001) and lower mortality rates (12.8% vs 39.3%; P = .001). Patients admitted directly to the surgical department had a shorter mean (SD) interval from admission to operation (0 vs 1.7 [2.8] days; P = .001).

Conclusions  Despite awareness and treatment, fulminant C difficile colitis remains a highly lethal disease. Reliable predictors of mortality exist and should be used to prompt aggressive surgical intervention. Survival rates are higher in patients who were cared for by surgical vs nonsurgical departments, possibly because of more frequent and earlier operations.

×