Original Article

Early Colectomy Saves Lives in Toxic Megacolon Due to Clostridium difficile Infection

Authors: Nasim Ahmed, MD, FACS, Yen-Hong Kuo, PhD

Abstract

Objective: The purpose of the study was to evaluate whether early colectomy in patients who have toxic megacolon due to Clostridium difficile colitis reduces mortality.

Methods: The study was performed using the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2016. All patients 18 to 89 years of age who underwent colectomy for toxic megacolon resulting from C. difficile colitis were included in the study. Other variables included in the study were patient demography, comorbidities, and outcomes. Patients who underwent colectomy before the presentation of septic shock (early group) were compared with patients who underwent colectomy after the onset of septic shock (late group). The main outcome of the study is 30-day all-cause mortality. Because there were some significant differences found in patient baseline characteristics in the univariate analysis, the propensity score of each patient was calculated and pair-matched analysis was performed. All P values are reported as 2-sided, and P < 0.05 was considered statistically significant.

Results: One hundred sixty-three patients met the inclusion criteria of the study. Approximately 85% of the patients underwent total abdominal colectomy. The average age of the patients was 65 years old, 51% of the patients were female, and 66% of the patients were white. The overall 30-day mortality was approximately 39%. The mortality rate of patients who underwent colectomy early compared to late was 13 (21%) vs 28 (45%), P = 0.009. The absolute risk difference was 0.24 with 95% CI: 0.07–0.42.

Conclusions: There was a reduction of 24% in 30-day mortality when colectomies were performed before the development of septic shock.
Posted in: Gastroenterology53

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Wysowski DK. Increase in deaths related to enterocolitis due to Clostridium difficile in the United States, 1999-2002. Public Health Rep 2006;121: 361-362.
2. Longo WE, Mazuski JE, Virgo KS, et al. Outcome after colectomy for Clostridium difficile colitis. Dis Colon Rectum 2004;47:1620-1626.
3. Dallal RM, Harbrecht BG, Boujoukas AJ, et al. Fulminant Clostridium difficile: an underappreciated and increasing cause of death and complications. Ann Surg 2002;235:363-372.
4. Loo VG, Poirier L, Miller MA, et al. A predominantly clonal multi-institutional outbreak of Clostridium difficile -associated diarrhea with high morbidity and mortality. N Engl J Med 2005;353:2442-2449.
5. Lamontagne F, Labbe AC, Haeck O, et al. Impact of emergency colectomy of survival of patients with fulminant Clostridium difficile colitis during an epidemic caused by a hypervirulent strain. Ann Surg 2007;245:267-272.
6. McDonald LC. Clostridium difficile : responding to a new threat from an old enemy. Infect Control Hosp Epidemiol 2005;26:672-675.
7. Ali SO, Welch JP, Dring RJ. Early surgical intervention for fulminant pseudomembranous colitis. Am Surg 2008;74:20-26.
8. Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol 2010;31:431-455.
9. Sethi AK, Al-Nassir WN, Nerandzic MM, et al. Persistence of skin contamination and environmental shedding of Clostridium difficile during and after treatment of C. difficile infection. Infect Control Hosp Epidemiol 2010;31:21-27.
10. Lungulescu OA, Cao W, Gatskevich E, et al. CSI: a severity index for Clostridium difficile infection at the time of admission. J Hosp Infect 2011;79:151-154.
11. Loo VG, Davis I, Embil J, et al. Association of Medical Microbiology and Infectious Disease Canada treatment practice guidelines for Clostridium difficile infection. J Assoc Med Microbiol Infect Dis Canada 2018;3. 2 :71-92.
12. Bauer MP, Hensgens MP, Miller MA, et al. Renal failure and leukocytosis are predictors of a complicated course of Clostridium difficile infection if measured on day of diagnosis. Clin Infect Dis 2012;55(suppl 2):S149-S153.
13. Miller MA, Louie T, Mullane K, et al. Derivation and validation of a simple clinical bedside score (ATLAS) for Clostridium difficile infection which predicts response to therapy. BMC Infect Dis 2013;13:148.
14. Louie TJ, Miller MA, Mullane KM, et al. Fidaxomicin versus vancomycin for Clostridium difficile infection. N Engl J Med 2011;364:422-431.
15. Shah DN, Bhatt NS, Welch JK, et al. Defining acute renal dysfunction as a criterion for the severity of Clostridium difficile infection in patients with community-onset vs hospital-onset infection. J Hosp Infect 2013;83:294-299.
16. Ahmed N, Kuo YH. Evaluating the outcomes of blunt thoracic trauma in elderly patients following a fall from a ground level: higher level care institution vs. lower level care institution. Eur J Trauma Emerg Surg 2019. DOI: 10.1007/s00068-019-01230-1.
17. Ho DE, Imai K, King G, et al. MatchIt: nonparametric preprocessing for parametric causal inference. J Stat Softw 2011;42. DOI: 10.18637/jss.v042.i08.
18. Sailhamer EA, Carson K, Chang Y, et al. Fulminant Clostridium difficile colitis: patterns of care and predictors of mortality. Arch Surg 2009;144:433-440.
19. Pepin J, Vo TT, Boutros M, et al. Risk factors for mortality following emergency colectomy for fulminant Clostridium difficile infection. Dis Colon Rectum 2009;52:400-405.
20. Seder CW, Villalba MR, Jr Robbins J, et al. Early colectomy may be associated with improved survival in fulminant Clostridium difficile colitis: an 8-year experience. Am J Surg 2009;197:302-307.
21. Dudukgian H, Sie E, Gonzalez-Ruiz C, et al. C. difficile colitis-predictors of fatal outcome. J Gastrointest Surg 2010;14:315-322.
22. Byrn JC, Maun DC, Gingold DS, et al. Predictors of mortality after colectomy for fulminant Clostridium difficile colitis. Arch Surg 2008;143:150-155.
23. Hall JF, Berger D. Outcome of colectomy for Clostridium difficile colitis: a plea for early surgical management. Am J Surg 2008;196:384-388. 24. Koss K, Clark MA, Sanders DS, et al. The outcome of surgery in fulminant Clostridium difficile colitis. Colorectal Dis 2006;8:149-154.