SEVERE CLOSTRIDIUM-DIFFICILE COLITIS

PURPOSE: Reports of fatality related to Clostridium difficile colitis and a sharp increase in prevalence of this infection prompted a study of patients who develop a more aggressive form of this disease. METHOD S: Over 38 months, 710 patients at our institution developed C. diffic ile colitis. 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 severe C. difficile colitis, wi th the remaining patients with milder disease. RESULTS: Factors that p redisposed to the development of severe C. difficile colitis included intercurrent malignancy, chronic obstructive pulmonary disease, immuno suppressive and antiperistaltic medications, renal failure, and admini stration of clindamycin (P < 0.05 for all). Patients with severe C. di fficile colitis were more likely to have abdominal pain, tenderness an d distention, peritonitis, hemoconcentration (>5 points), hypoalbumine mia (<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 s coring system that could distinguish between patients with severe C. d ifficile colitis 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 r emaining eight patients could have potentially recovered from operatio n with hope for long-term survival. Of these, seven were treated witho ut colonic resection, and six of the seven survived, whereas one patie nt underwent colectomy and did not survive. CONCLUSIONS: Patients with severe C. difficile colitis can be readily identified. Often they hav e coexisting illness that precludes operation. In this series, only 1 of 21 patients with severe C, difficile might have benefited from an a ggressive surgical approach.