CLOSTRIDIUM-DIFFICILE COLITIS IN THE CRITICALLY ILL

Morbidity and treatment of Clostridium difficile colitis (CDC) continu e to be controversial. Some claim minimum morbidity, which may be a fu nction of differences in patient population and/or bacterial virulence . METHODS: To evaluate the effect of CDC in the critically ill, we ret rospectively reviewed the records of 59 intensive care unit patients w ith CDC who were diagnosed by fecal toxin assays or clinical evidence of pseudomembranous colitis from January 1991 to October 1994. Symptom s, signs, antibiotic regimens, diagnostic tests, Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, morbidity, and mortal ity were analyzed, and results of surgical treatment were compared wit h the literature. RESULTS: Mean age was 66.4 (17-95) years, with a mal e to female ratio of 1.8:1. First treatment was metronidazole by mouth in 15 patients (25.4 percent), vancomycin by mouth in 30 patients (50 .8 percent), sequential by mouth vancomycin/metronidazole in 3 patient s (5.1 percent), and intravenous metronidazole in 5 patients (8.5 perc ent). Six patients had no medical therapy before surgery or discharge. Ten patients (17 percent) had recurrence and 12 (20.3 percent) requir ed surgery for progressive toxicity or peritonitis. Of three patients who were initially treated by diverting stomas, one died and two requi red total colectomy (TAG). Two underwent partial resection (1 that was nearly a total colectomy), and seven others had a TAG. Surgical patie nts had worse mean APACHE II scores at diagnosis (24.4 vs. 19.9; P < 0 .001). Thirty-day mortality in surgical patients was 41.7 vs. 14.7 per cent in medical patients (P < 0.5). CONLUSION, Twenty, percent of crit ically ill patients with CDC required operation. TAC and diversion app eared to be more effective surgical treatments than diversion alone.