Severe Clostridium difficile colitis

PURPOSE: Reports of fatality related toClostridium difficilecolitis and a sharp increase in prevalence of this infection prompted a study of patients who develop a more aggressive form of this disease. METHODS: Over 38 months, 710 patients at our institution developedC. difficilecolitis. Twenty-one (3 percent) of these patients either required intensive care unit admission or died as a result of their infection. A retrospective, case-controlled study was undertaken to compare these patients, who were considered to have severeC. difficilecolitis, with the remaining patients with milder disease. RESULTS: Factors that predisposed to the development of severeC. difficilecolitis included intercurrent malignancy, chronic obstructive pulmonary disease, immunosuppressive and antiperistaltic medications, renal failure, and administration of clindamycin (P<0.05 for all). Patients with severeC. difficilecolitis were more likely to have abdominal pain, tenderness and distention, peritonitis, hemoconcentration (>5 points), hypoalbuminemia (<3 mg/dl), and elevated or suppressed white blood cell count (>25,000; <1,500;P<0.05 for all). These factors were used to create a scoring system that could distinguish between patients with severeC. difficilecolitis and those with mild disease. Thirteen patients in the late stages of terminal illness with metastatic malignancy or age >90 were considered poor or inappropriate surgical candidates. Only the remaining eight patients could have potentially recovered from operation with hope for long-term survival. Of these, seven were treated without colonic resection, and six of the seven survived, whereas one patient underwent colectomy and did not survive. CONCLUSIONS: Patients with severeC. difficilecolitis can be readily identified. Often they have coexisting illness that precludes operation. In this series, only 1 of 21 patients with severeC. difficilemight have benefited from an aggressive surgical approach.