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Clostridium Difficile Infection from a Surgical Perspective.

Publication ,  Journal Article
Kaiser, AM; Hogen, R; Bordeianou, L; Alavi, K; Wise, PE; Sudan, R; CME Committee of the SSAT,
Published in: J Gastrointest Surg
July 2015

BACKGROUND: The incidence and the severity of Clostridium difficile infection (CDI) have increased significantly over the last decade, especially in high-risk populations such as patients with inflammatory bowel disease (IBD). Surgeons must be able to both identify and minimize the risk of CDI in their own surgical patients and determine which CDI patients will benefit from surgery. PURPOSE: We sought to define the risk factors, compare the treatment options, define the surgical indications, and identify factors that affect surgical outcomes for CDI based on the currently available literature. RESULTS: Antibiotic use, exposure to the C. difficile bacteria, IBD, and higher levels of co-morbidity are all risk factors for CDI. The majority of CDI can be treated with antibiotics. Severe or fulminant colitis, however, has a high potential for poor outcome, but experience and some data suggest a lower mortality rate with colectomy rather than with continued medical treatment. Open total abdominal colectomy with end ileostomy is typically the preferred surgical strategy. It is often difficult to determine which patients will fail medical management as some may not manifest clinical signs of severe infection. Surrogate parameters of failure of medical therapy include respiratory and/or renal insufficiency, age greater than 60 years, peripheral vascular disease, congestive heart failure, and coagulopathy, all of which have been associated with worse surgical outcomes. Evidence suggests that in appropriately selected patients, colectomy performed before the development of shock requiring vasopressors, respiratory failure, renal failure, multi-organ dysfunction, and mental status changes may reduce mortality of the most severe forms of colitis. For less severe or recurrent presentations, creation of a loop ileostomy with intra-operative colonic lavage, fecal microbiota transfer, and C. difficile vaccinations are being discussed but have only been studied in small case-controlled series. CONCLUSIONS: Prevention, containment, and non-surgical treatment are the cornerstone of management for CDI. However, the most severe forms with toxic colitis benefit from involvement of a surgical team. Swift open total abdominal colectomy with end ileostomy in patients with severe or fulminant C. difficile colitis has the best chance to reduce mortality if it is not delayed until shock, end organ damage, vasopressor requirement, mental status changes develop. Less aggressive approaches may be appropriate for milder and refractory forms but require further study before their applicability can be determined.

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Published In

J Gastrointest Surg

DOI

EISSN

1873-4626

Publication Date

July 2015

Volume

19

Issue

7

Start / End Page

1363 / 1377

Location

Netherlands

Related Subject Headings

  • Surgery
  • Risk Factors
  • Inflammatory Bowel Diseases
  • Infection Control
  • Immunoglobulins, Intravenous
  • Ileostomy
  • Humans
  • Fecal Microbiota Transplantation
  • Enterocolitis, Pseudomembranous
  • Colitis
 

Citation

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Kaiser, A. M., Hogen, R., Bordeianou, L., Alavi, K., Wise, P. E., Sudan, R., & CME Committee of the SSAT, . (2015). Clostridium Difficile Infection from a Surgical Perspective. J Gastrointest Surg, 19(7), 1363–1377. https://doi.org/10.1007/s11605-015-2785-4
Kaiser, Andreas M., Rachel Hogen, Liliana Bordeianou, Karim Alavi, Paul E. Wise, Ranjan Sudan, and Ranjan CME Committee of the SSAT. “Clostridium Difficile Infection from a Surgical Perspective.J Gastrointest Surg 19, no. 7 (July 2015): 1363–77. https://doi.org/10.1007/s11605-015-2785-4.
Kaiser AM, Hogen R, Bordeianou L, Alavi K, Wise PE, Sudan R, et al. Clostridium Difficile Infection from a Surgical Perspective. J Gastrointest Surg. 2015 Jul;19(7):1363–77.
Kaiser, Andreas M., et al. “Clostridium Difficile Infection from a Surgical Perspective.J Gastrointest Surg, vol. 19, no. 7, July 2015, pp. 1363–77. Pubmed, doi:10.1007/s11605-015-2785-4.
Kaiser AM, Hogen R, Bordeianou L, Alavi K, Wise PE, Sudan R, CME Committee of the SSAT. Clostridium Difficile Infection from a Surgical Perspective. J Gastrointest Surg. 2015 Jul;19(7):1363–1377.
Journal cover image

Published In

J Gastrointest Surg

DOI

EISSN

1873-4626

Publication Date

July 2015

Volume

19

Issue

7

Start / End Page

1363 / 1377

Location

Netherlands

Related Subject Headings

  • Surgery
  • Risk Factors
  • Inflammatory Bowel Diseases
  • Infection Control
  • Immunoglobulins, Intravenous
  • Ileostomy
  • Humans
  • Fecal Microbiota Transplantation
  • Enterocolitis, Pseudomembranous
  • Colitis