title: Fulminant Clostridium difficile colitis: patterns of care and predictors of mortality.
abstract: OBJECTIVE
  There exist predictors of mortality and the need for colectomy among patients with fulminant Clostridium difficile colitis.
  
  
  METHODS
  Retrospective study.
  
  
  METHODS
  Academic tertiary referral center.
  
  
  METHODS
  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.
  
  
  METHODS
  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, >or=35 000/microL or <4000/microL) or bandemia (neutrophil bands, >or=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.
authors.affiliation: Department of Surgery, Division of Trauma, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. esailhamer@partners.org
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Sailhamer
authors.forename: Katherine
authors.initials: K
authors.lastname: Carson
authors.forename: Yuchiao
authors.initials: Y
authors.lastname: Chang
authors.forename: Nikolaos
authors.initials: N
authors.lastname: Zacharias
authors.forename: Konstantinos
authors.initials: K
authors.lastname: Spaniolas
authors.forename: Malek
authors.initials: M
authors.lastname: Tabbara
authors.forename: Hasan B
authors.initials: HB
authors.lastname: Alam
authors.forename: Marc A
authors.initials: MA
authors.lastname: DeMoya
authors.forename: George C
authors.initials: GC
authors.lastname: Velmahos
mesh_terms: D000367:Age Factors; D000368:Aged; D016360:Clostridioides difficile; D003015:Clostridium Infections / Q000401:mortality* / Q000601:surgery*; D003082:Colectomy; D004761:Enterocolitis, Pseudomembranous / Q000382:microbiology* / Q000401:mortality* / Q000601:surgery*; D005260:Female; D006333:Heart Failure / Q000150:complications; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data; D007964:Leukocytosis / Q000150:complications; D007970:Leukopenia / Q000150:complications; D008297:Male; D008404:Massachusetts / Q000453:epidemiology; D015999:Multivariate Analysis; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate; D016896:Treatment Outcome