Factors that predict clinical outcome after colectomy for fulminant Clostridium difficile colitis


Background: Historically, the incidence of C. difficile-associated colitis has increased significantly over the last decade. Of these patients, approximately 10% - 20% will ultimately require colectomy due to fulminant disease and progression to toxic colitis. Despite operative intervention, the mortality for this population remains high (35% - 80%). This study evaluates for preoperative risk factors for mortality. Methods: Retrospective medical record review of 47 patients who underwent emergent colectomy for fulminant C. ddifficile colitis over a five-year period at three teaching hospitals in New York City. Results: Forty-seven patients with Clostridium difficile colitis underwent colectomy from January 2003 to December 2008. The mean age was 66 years with 31 (67%) male and 16 (34%) female. The 30-day mortality was 34% (16/47 patients). Thirty-eight (81%) underwent subtotal colectomy, six (13%) Hartmann resection, two (4%) right hemicolectomy, and one (2%) underwent left colectomy. Univariate analysis showed that age (71.6 vs. 67.5 years; p = 0.402), white blood cell count (35,500 vs. 27,700/mm3; p = 0.271), and use of vaso-pressors in the pre-operative period *p = 0.440) were not statistically predictive of postoperative mortality. Conversely, preoperative serum lactate level (4.3 vs. 2.1 mmol/L p + 0.009) was statistically greater in the postoperative mortality group. Conclusion: In the setting of fulminant C. difficile colitis, serum lactate levels can help predict postoperative outcome following emergent colectomy and should be closely followed to facilitate the decision to proceed with surgery.

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Leitman, I. , Narang, R. , Martinez, J. , Abbadessa, B. , Avgerinos, D. , Dayan, E. and Cassaro, S. (2012) Factors that predict clinical outcome after colectomy for fulminant Clostridium difficile colitis. Open Journal of Gastroenterology, 2, 51-55. doi: 10.4236/ojgas.2012.22011.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] Johnson, S., Samore, M.H., Farrow, K.A., et al. (1999) Epidemics of diarrhea caused by a clindamycin-resistant strain of Clostridium difficile in four hospitals. The New England Journal of Medicine, 341, 1645-1651. doi:10.1056/NEJM199911253412203
[2] Fekety, R. (1997) Guidelines for the diagnosis and management of Clostridium difficile—associated diarrhea and colitis. The American Journal of Gastroenterology, 92, 739-750.
[3] Grundfest-Broniatowski, S., Quader, M., Alexander, F., Walsh, R.M., Lavery, I. and Milsom, J. (1996) Clostridium difficile colitis in the critically ill. Diseases of the Colon & Rectum, 39, 619-623. doi:10.1007/BF02056938
[4] Synnott, K., Mealy, K., Merry, C., Kyne, L., Keane, C. and Quill, R. (1998) Timing of surgery for fulminating pseudo-membranous colitis. British Journal of Surgery, 85, 229-231. doi:10.1046/j.1365-2168.1998.00519.x
[5] Lamontagne, F., Labbé, A.C., Haeck, O., et al. (2007) Impact of emergency colectomy on survival of patients with fulminant Clostridium difficile colitis during an epidemic caused by a hypervirulent strain. Annals of Surgery, 245, 267-272. doi:10.1097/01.sla.0000236628.79550.e5
[6] Byrn, J.C., et al. (2008) Predictors of mortality after colectomy for fulminant Clostridium difficile colitis. Archives of Surgery, 143, 150-154. doi:10.1001/archsurg.2007.46
[7] Sailhamer, E.A., et al. (2009) Fulminant Clostridium difficile colitis: Patterns of care and predictors of mortality. Archives of Surgery, 144, 433-439. doi:10.1001/archsurg.2009.51
[8] Perera, A.D., et al. (2010) Colectomy for fulminant Clostridium difficile colitis: Predictors of mortality. The American Journal of Surgery, 76, 418-421.
[9] Just, I., Selzer, J., Von Eichel-Streiber, C. and Aktories, K. (1995) The enterotoxin from Clostridium difficile (ToxA) monoglucosylates the Rho proteins. Journal of clinical investigation, 95, 1026-1031. doi:10.1172/JCI117747
[10] Kurian, A., et al. (2011) In-hospital and 6-month mortality rates after open elective vs open emergent colectomy in patients older than 80 years. Diseases of the Colon & Rectum, 54, 467-471. doi:10.1007/DCR.0b013e3182060904
[11] Morris, A.M., Jobe, B.A., Stoney, M., Sheppard, B.C., Deveney, C.W. and Deveney, K.E. (2002) Clostridium difficile colitis: An increasingly aggressive iatrogenic disease? Archives of Surgery, 137, 1096-1100. doi:10.1001/archsurg.137.10.1096
[12] Dallal, R.M., Harbrecht, B.G., Boujoukas, A.J., et al. (2002) Fulminant Clostridium difficile: An underappreciated and increasing cause of death and complications. Annals of Surgery, 235, 363-372. doi:10.1097/00000658-200203000-00008
[13] Muto, C.A., Pokrywka, M., Shutt, K., et al. (2005) A large outbreak of Clostridium difficile—associated disease with an unexpected proportion of deaths and colectomies at a teaching hospital following increased fluoroquinolone use. Infection Control and Hospital Epidemiology, 26, 273-280. doi:10.1086/502539
[14] Klipfel, A., Schein, M., Fahoum, B. and Wise, L. (2000) Acute abdomen and Clostridium difficile colitis: Still a lethal combination. Digestive Surgery, 17, 160- 163. doi:10.1159/000018821
[15] Samore, M.H., Venkataraman, L., DeGirolami, P.C., Arbeit, R.D. and Karchmer, A.W. (1996) Clinical and molecular epidemiology of sporadic and clustered cases of nosocomial Clostridium difficile diarrhea. American Journal of Medicine, 100, 32-40. doi:10.1016/S0002-9343(96)90008-X
[16] Ryan, K.J. and Ray, C.G. (2004) Sherris medical microbiology. 4th Edition, McGraw Hill, New York.
[17] Al-Abed, Y.A., Gray, E.A. and Rothnie, N.D. (2010) Outcomes of emergency colectomy for fulminant Clostridium difficile colitis. Surgeon, 8, 330-333. doi:10.1016/j.surge.2010.06.003
[18] Butala, P. and Divino, C.M. (2010) Surgical aspects of fulminant Clostridium difficile colitis. The American Journal of Surgery, 200, 131-135. doi:10.1016/j.amjsurg.2009.07.040
[19] Pepin, J., Vo, T.T., Boutros, M., et al. (2009) Risk factors for mortality following emergency colectomy for fulminant Clostridium difficile infection. Diseases of the Colon & Rectum, 52, 400-405. doi:10.1007/DCR.0b013e31819a69aa
[20] Pepin, J., Valiquette, L., Alary, M.E., et al. (2004) Clostridium difficile—associated diarrhea in a region of Quebec from 1991 to 2003: A changing pattern of disease seve- rity. Canadian Medical Association Journal, 171, 466- 472. doi:10.1503/cmaj.1041104
[21] Osman, K.A., Ahmed, M.H., Hamad, M.A. and Mathur, D. (2011) Emergency colectomy for fulminant Clostridium difficile colitis: Striking the right balance. Scandi- navian Journal of Gastroenterology, 46, 1222- 1227. doi:10.3109/00365521.2011.605469
[22] Olivas, A.D., Umanskiy, K., Zuckerbraun, B. and Alverdy, J.C. (2010) Avoiding colectomy during surgical management of fulminant Clostridium difficile colitis. Surgical Infections (Larchmt), 11, 299-305. doi:10.1089/sur.2010.026
[23] Thomas, K.L., Holmes, K.R., Jackson, B.R., et al. (2007) A cost comparison of metronidazole and vancomycin treatment of Clostridium difficile—associated diarrhea. The American Journal of Gastroenterology, 102, 268.
[24] Kumar, V., Yoselevitz, S. and Dutta, S.K. (2007) Clostridium difficile colitis: A shift from a traditional hospital acquired infection to a community and nursing home- based disease. The American Journal of Gastroenterology, 102, 266.
[25] Stewart, D.B. and Hollenbeak, C.S. (2011) Clostridium difficile colitis: Factors associated with outcome and assessment of mortality at a national level. Journal of Gastrointestinal Surgery, 15, 1548-1555. doi:10.1007/s11605-011-1615-6

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