title: Antibiotic Regimen after a Total Abdominal Colectomy with Ileostomy for Fulminant Clostridium difficile Colitis: A Multi-Institutional Study.
abstract: BACKGROUND
  Fulminant Clostridium difficile colitis (fCDC) is a highly lethal disease with mortality rates ranging between 12% and 80%. Although often these patients require a total abdominal colectomy (TAC) with ileostomy, there is no established management protocol for post-operative antibiotics. In this study we aim to make some recommendations for post-operative antibiotic usage, while describing the practice across different institutions.
  
  
  METHODS
  Multi-institutional retrospective case series including fCDC patients who underwent a TAC between January 1, 2007, and June 30, 2012. We first analyzed the complete cohort and consecutively performed a survivor analysis, comparing different antibiotic regimens. Additionally we stratified by time interval (antibiotics for ≤7 d, or ≥8 d). Primary outcome was in-hospital mortality. Additional secondary outcomes included hospital length of stay (HLOS), ICU LOS, number of ventilator-free days, and occurrence of intra-abdominal complications (proctitis, abscess, sepsis, etc.).
  
  
  RESULTS
  A total of 100 fCDC patients that underwent a TAC were included across five institutions. Four different antibiotic regimens were compared; A (metronidazole IV+vancomycin PO), B (metronidazole IV), C (metronidazole IV+vanco PO and PR), and D (metronidazole IV+vancomycin PR). The combination of IV metronidazole with or without PO vancomycin showed superior outcomes in terms of a shorter ICU length of stay and more ventilator-free days. However, when comparing metronidazole alone vs. metronidazole and any combination of vancomycin, no significant differences were found. Neither the addition of vancomycin enema, nor the time interval changed outcomes.
  
  
  CONCLUSIONS
  Patients, after a TAC for fCDC, may be placed on either IV metronidazole or PO vancomycin depending upon local antibiograms, and proctitis may be treated with the addition of a vancomycin enema (PR). There was no data to support routine treatment of more than 7 d.
authors.affiliation: 1 Department of Surgery, Division of Trauma, Emergency Surgery & Critical Care, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts.|2 Department of Trauma Surgery, Leiden University Medical Center and Leiden University , Leiden, the Netherlands .
authors.forename: Gwendolyn M
authors.initials: GM
authors.lastname: van der Wilden
authors.affiliation: 1 Department of Surgery, Division of Trauma, Emergency Surgery & Critical Care, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts.
authors.forename: Melanie P
authors.initials: MP
authors.lastname: Subramanian
authors.affiliation: 3 Department of Medicine, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts.
authors.forename: Yuchiao
authors.initials: Y
authors.lastname: Chang
authors.affiliation: 4 Department of Surgery, UF Health Science Center and University of Florida College of Medicine , Gainesville, Florida.
authors.forename: Lawrence
authors.initials: L
authors.lastname: Lottenberg
authors.affiliation: 5 Department of Surgery, University of Virginia Health System and University of Virginia School of Medicine , Charlottesville, Virginia.
authors.forename: Robert
authors.initials: R
authors.lastname: Sawyer
authors.affiliation: 5 Department of Surgery, University of Virginia Health System and University of Virginia School of Medicine , Charlottesville, Virginia.
authors.forename: Stephen W
authors.initials: SW
authors.lastname: Davies
authors.affiliation: 6 Department of Surgery, VCU Medical Center and Virginia Commonwealth University School of Medicine , Richmond, Virginia.
authors.forename: Paula
authors.initials: P
authors.lastname: Ferrada
authors.affiliation: 6 Department of Surgery, VCU Medical Center and Virginia Commonwealth University School of Medicine , Richmond, Virginia.
authors.forename: Jinfeng
authors.initials: J
authors.lastname: Han
authors.affiliation: 7 Department of Surgery, Thomas Jefferson University Hospital and Thomas Jefferson University , Philadelphia, Pennsylvania.
authors.forename: Alec
authors.initials: A
authors.lastname: Beekley
authors.affiliation: 1 Department of Surgery, Division of Trauma, Emergency Surgery & Critical Care, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts.
authors.forename: George C
authors.initials: GC
authors.lastname: Velmahos
authors.affiliation: 1 Department of Surgery, Division of Trauma, Emergency Surgery & Critical Care, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts.
authors.forename: Marc A
authors.initials: MA
authors.lastname: de Moya
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D016360:Clostridioides difficile; D003082:Colectomy / Q000009:adverse effects*; D004761:Enterocolitis, Pseudomembranous / Q000188:drug therapy / Q000453:epidemiology; D005260:Female; D006801:Humans; D007081:Ileostomy / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000188:drug therapy / Q000453:epidemiology; D012189:Retrospective Studies
chemical_list: D000900:Anti-Bacterial Agents