Emergency Colectomy for Fulminant C. Difficile Colitis

Abstract & Commentary

By David J. Pierson, MD, Professor, Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington
Dr. Pierson reports no financial relationships relevant to this field of study. This article originally appeared in the July 2007 issue of Critical Care Alert. It was peer reviewed by William Thompson, MD. Dr. Thompson is Staff Pulmonologist, VA Medical Center; Associate Professor of Medicine, University of Washington. Dr. Thompson reports no financial relationships relevant to this field of study.

Synopsis: In this retrospective study of C. difficile colitis due to a hypervirulent strain, 53% of 165 patients died. Emergency colectomy was associated with a decreased mortality, especially among very elderly patients, those who were immunosuppressed, those with extreme leukocytosis, those with moderate hyperlactatemia, and those requiring vasopressors.

Source: Lamontagne F, et al. Impact of emergency colectomy on survival of patients with fulminant Clostridium difficile colitis during an epidemic caused by a hypervirulent strain. Ann Surg. 2007;245:267-272.

Using laboratory results from a recent 30-month period for case finding, Lamontagne and colleagues reviewed the medical records of all patients with fulminant Clostridium difficile-associated disease (CDAD) who received care in the ICUs of 2 tertiary-care hospitals in Quebec. During the period of this study, Quebec was experiencing an outbreak of a particularly virulent strain of C. difficile (hypervirulent toxin type III NAP1/027), which produces levels of toxins A and B that are 16 to 23 times higher than historical strains. Fulminating CDAD was defined as one or more of a positive C. difficile cytotoxin assay, endoscopic evidence of pseudomembranous colitis, or histopathologic evidence of pseudomembranous colitis from biopsy, colectomy specimen, or autopsy. All patients who were admitted to the ICU because of the CDAD, or developed it while in the ICU, were included.

Lamontagne et al identified 165 cases of CDAD (in 161 patients) during the study period. Twenty-four percent were healthcare-associated. The patients' ages ranged from 39 to 93 years (median, 75 years). Thirty percent of them were immunosuppressed (leukemia, lymphoma, organ transplantation, neutropenia, and/or > 1 month treatment with corticosteroids). In addition to diarrhea, manifestations of CDAD included abnormal plain abdominal films in 64% of 149 patients, signs of colitis in 78% of 85 abdominal CT scans, and pseudomembranes in 87% of 38 patients who underwent endoscopy. Median peak leukocyte count was 30.9 x 109 cells/L (interquartile range, 20.8-44.1 x 109 cells/L). Serum lactate levels ranged between 0.7 and 23.0 mmol/L (median, 3.1 mmol/L; IQR 2.1-5.6 mmol/L).

Thirty-eight patients (23%) underwent colectomy, which was subtotal or total in 35. Listed indications for colectomy were persistent vasopressor-requiring shock (15 patients), megacolon (11 patients), lack of response to medical treatment (10 patients), and perforation (2 patients). Compared to the patients who did not undergo colectomy, those who did had fewer comorbidities (assessed by Charlson score), higher leukocyte counts (20 x 109 cells/L in 95% vs 73%), and more frequent shock requiring vasopressors (71% vs 52%).

Mortality ascribed to CDAD within 30 days of ICU admission was 87/165 (53%). Thirty-eight (43%) of those deaths occurred within 48 hours of ICU admission. Among the entire cohort, by multivariate analysis, death was more likely to occur in patients aged 75 years or older, who were immunosuppressed, those requiring vasopressors, those in whom peak leukocyte count exceeded 50 x 109 cells/L, and those with lactate levels of 5 mmol/L or higher (all, P < 0.05). Mortality among the patients who underwent colectomy was 34%, compared with 58% in patients treated medically (P = 0.02). Subgroup analysis suggested that patients most likely to benefit from emergency colectomy were those older than 65, those with leukocyte counts > 20 x 109 cells/L, and those with moderate elevations of serum lactate (2.2-4.9 mmol/L).

Commentary

C difficile, which was identified as the causative agent in pseudomembranous colitis in 1978, has emerged as a pathogen of increasing importance in critical care. The incidence of CDAD appears to be on the rise everywhere, and more and more areas are reporting the emergence of hypervirulent strains associated with increased morbidity and mortality. When patients develop very high leukocyte counts in the ICU — especially exceeding 25 or 30 x 109 cells/L — CDAD should be considered, even if they have not been on multiple or broad-spectrum antibiotics.

This retrospective study highlights the frequency and potential lethality of CDAD, and it suggests that emergency colectomy can be life-saving. However, because of its design, it cannot establish the latter with certainty, nor tell us for sure how to select patients for this procedure. For example, surgeons may have selected patients more likely to survive for colectomy and been reluctant to operate on those with immunosuppression or more comorbidities, influencing the observed mortality differences in those groups. Lamontagne et al acknowledge these and other limitations. In spite of these, however, this study calls needed attention to the seriousness of CDAD today, particularly in the presence of hypervirulent toxin production, and to emergency colectomy as a potentially life-saving procedure.