Clostridium difficile infection surgery: Difference between revisions

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__NOTOC__
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{{Clostridium difficile}}
{{Siren|Clostridium difficile infection}}
{{CMG}}
{{Clostridium difficile infection}}
{{CMG}}; {{AE}} {{YD}}


== Overview ==  
== Overview ==  
Patients with signs/symptoms of fulminant colitits should be evaluated by surgery for possible urgent surgery for [[bowel perforation]], impending perforation, severe ileus with megacolon, or refractory [[septicemia]].
Indications for surgery include peritoneal signs, persistent bacteremia, progressive clinical disease with organ damage (e.g. renal or pulmonary disease), or evidence on CT scan demonstrating worsening infection.


==Surgery==
==Surgery==
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* Persistent [[bacteremia]]
* Persistent [[bacteremia]]
* Progressive disease
* Progressive disease
* CT showing pericolonic inflammation with increasing bowel wall edema.
* Abdominal CT scan demonstrating pericolonic inflammation with increasing bowel wall edema
 
=== Clinical Features and Lab Findings That Warrant Surgical Consultation and Management ===
According to the 2013 practice guidelines for diagnosis, treatment, and prevention of ''C. difficile'' infections<ref name="pmid23439232">{{cite journal| author=Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH et al.| title=Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 4 | pages= 478-98; quiz 499 | pmid=23439232 | doi=10.1038/ajg.2013.4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23439232  }} </ref>, consider surgical consultation and management among patients with the following clinical features and lab findings:
* Hypotension requiring vasopressor therapy
* Clinical signs of sepsis
* Target organ dysfunction (e.g. renal or pulmonary disease)
* Mental status changes
* Leukocytosis > 50,000 cells/microL
* Lactate > 5 mmol/L
* Failure to improve following 5 days of antimicrobial therapy


===Colectomy===
===Colectomy===
In those patients that develop systemic symptoms of CDC, colectomy may improve the outcome if performed before the need for [[vasopressor]]s. The usual intervention is a subtotal colectomy with [[ileostomy]].
* Among patients who develop systemic symptoms of ''C. difficile ''colitis, colectomy may improve outcomes if performed early prior to the need for [[vasopressor]] therapy.


=== Recurrence ===
* Subtotal colectomy with [[ileostomy]] is typically performed.
The evolution of protocols for patients with recurrent ''C. difficile'' diarrhea also present a challenge: there is no known proper length of time or universally accepted alternative drugs with which one should be treated. However, re-treatment with [[metronidazole]] or [[vancomycin]] at the previous dose for 10 to 14 days is generally successful. The addition of [[rifampin]] to vancomycin also has been effective. Prophylaxis with competing, nonpathogenic organisms such as ''[[Lactobacillus]]'' spp. or ''[[Saccharomyces boulardii]]'' has been found to be helpful in preventing relapse in small numbers of patients (see, for example, [[Florastor]], or [[Lactinex]]). It is thought that these organisms, also known as [[probiotics]], help to restore the natural flora in the gut and make patients more resistant to colonization by ''C. difficile''.


==References==
==References==
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[[Category:Disease]]
[[Category:Disease]]
[[Category:Gastroenterology]]
[[Category:Gastroenterology]]
[[Category:Infectious disease]]
 
[[Category:Bacterial diseases]]
[[Category:Bacterial diseases]]

Latest revision as of 17:26, 18 September 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Yazan Daaboul, M.D.

Overview

Indications for surgery include peritoneal signs, persistent bacteremia, progressive clinical disease with organ damage (e.g. renal or pulmonary disease), or evidence on CT scan demonstrating worsening infection.

Surgery

Indications for Surgery

Indications for surgery include:

  • Peritoneal signs
  • Persistent bacteremia
  • Progressive disease
  • Abdominal CT scan demonstrating pericolonic inflammation with increasing bowel wall edema

Clinical Features and Lab Findings That Warrant Surgical Consultation and Management

According to the 2013 practice guidelines for diagnosis, treatment, and prevention of C. difficile infections[1], consider surgical consultation and management among patients with the following clinical features and lab findings:

  • Hypotension requiring vasopressor therapy
  • Clinical signs of sepsis
  • Target organ dysfunction (e.g. renal or pulmonary disease)
  • Mental status changes
  • Leukocytosis > 50,000 cells/microL
  • Lactate > 5 mmol/L
  • Failure to improve following 5 days of antimicrobial therapy

Colectomy

  • Among patients who develop systemic symptoms of C. difficile colitis, colectomy may improve outcomes if performed early prior to the need for vasopressor therapy.
  • Subtotal colectomy with ileostomy is typically performed.

References

  1. Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH; et al. (2013). "Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections". Am J Gastroenterol. 108 (4): 478–98, quiz 499. doi:10.1038/ajg.2013.4. PMID 23439232.

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