Severe Clostridium difficile colitis.
OBJECTIVE
Reports of fatality related to Clostridium difficile colitis and a sharp increase in prevalence of this infection prompted a study of patients who develop a more aggressive form of this disease.


METHODS
Over 38 months, 710 patients at our institution developed C. difficile colitis. Twenty-one (3 percent) of these patients either required intensive care unit admission or died as a result of their infection. A retrospective, case-controlled study was undertaken to compare these patients, who were considered to have severe C. difficile colitis, with the remaining patients with milder disease.


RESULTS
Factors that predisposed to the development of severe C. difficile colitis included intercurrent malignancy, chronic obstructive pulmonary disease, immunosuppressive and antiperistaltic medications, renal failure, and administration of clindamycin (P < 0.05 for all). Patients with severe C. difficile colitis were more likely to have abdominal pain, tenderness and distention, peritonitis, hemoconcentration (> 5 points), hypoalbuminemia (< 3 mg/dl), and elevated or suppressed white blood cell count (> 25,000; < 1,500; P < 0.05 for all). These factors were used to create a scoring system that could distinguish between patients with severe C. difficile colitis and those with mild disease. Thirteen patients in the late stages of terminal illness with metastatic malignancy or age > 90 were considered poor or inappropriate surgical candidates. Only the remaining eight patients could have potentially recovered from operation with hope for long-term survival. Of these, seven were treated without colonic resection, and six of the seven survived, whereas one patient underwent colectomy and did not survive.


CONCLUSIONS
Patients with severe C. difficile colitis can be readily identified. Often they have coexisting illness that precludes operation. In this series, only 1 of 21 patients with severe C. difficile might have benefited from an aggressive surgical approach.
Rubin
M S
MS
Department of Surgery, Beth Israel Hospital, Harvard Medical School, Boston, Massachusetts, USA.
Bodenstein
L E
LE
Kent
K C
KC
D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D016022:Case-Control Studies; D003082:Colectomy; D003113:Colonoscopy; D003131:Combined Modality Therapy; D004359:Drug Therapy, Combination; D004761:Enterocolitis, Pseudomembranous / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012720:Severity of Illness Index; D015996:Survival Rate; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome