title: Fulminant Clostridium difficile: an underappreciated and increasing cause of death and complications.
abstract: OBJECTIVE
  To review the epidemiology and characteristics of patients who died or underwent colectomy secondary to fulminant Clostridium difficile colitis.
  
  
  BACKGROUND
  In patients with C. difficile colitis, a progressive, systemic inflammatory state may develop that is unresponsive to medical therapy; it may progress to colectomy or death.
  
  
  METHODS
  The authors reviewed 2,334 hospitalized patients with C. difficile colitis from January 1989 to December 2000. Sixty-four patients died or underwent colectomy for pathologically proven C. difficile colitis.
  
  
  RESULTS
  In 2000, the incidence of C. difficile colitis in hospitalized patients increased from a baseline of 0.68% to 1.2%, and the incidence of patients with C. difficile colitis in whom life-threatening symptoms developed increased from 1.6% to 3.2%. Forty-four patients required a colectomy and 20 others died directly from C. difficile colitis. Twenty-two percent had a prior history of C. difficile colitis. A recent surgical procedure and immunosuppression were common predisposing conditions. Lung transplant patients were 46 times more likely to have C. difficile colitis and eight times more likely to have severe disease. Abdominal computed tomography scan correctly diagnosed all patients, whereas 12.5% of toxin assays and 10% of endoscopies were falsely negative. Patients undergoing colectomy for C. difficile colitis had an overall death rate of 57%. Significant predictors of death after colectomy were preoperative vasopressor requirements and age.
  
  
  CONCLUSIONS
  C. difficile colitis is a significant and increasing cause of death. Surgical treatment of C. difficile colitis has a high death rate once the fulminant expression of the disease is present.
authors.affiliation: Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA. dallalr@msx.upmc.edu
authors.forename: Ramsey M
authors.initials: RM
authors.lastname: Dallal
authors.forename: Brian G
authors.initials: BG
authors.lastname: Harbrecht
authors.forename: Arthur J
authors.initials: AJ
authors.lastname: Boujoukas
authors.forename: Carl A
authors.initials: CA
authors.lastname: Sirio
authors.forename: Linda M
authors.initials: LM
authors.lastname: Farkas
authors.forename: Kenneth K
authors.initials: KK
authors.lastname: Lee
authors.forename: Richard L
authors.initials: RL
authors.lastname: Simmons
mesh_terms: D018806:APACHE; D000368:Aged; D003082:Colectomy; D018450:Disease Progression; D004761:Enterocolitis, Pseudomembranous / Q000000981:diagnostic imaging / Q000401:mortality* / Q000601:surgery; D005260:Female; D006801:Humans; D008875:Middle Aged; D010414:Pennsylvania / Q000453:epidemiology; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed