Emergency subtotal colectomy for fulminant Clostridium difficile colitis – is a surgical solution considered for all patients?

INTRODUCTION Clostridium difficile has been an increasing problem in UK hospitals. At the time of this study, there was a high incidence of C. difficile within our trust and a number of patients developed acute fulminant colitis requiring subtotal colectomy. We review a series of colectomies for C. difficile, examining the associated morbidity and mortality and the factors that predispose to acute fulminant colitis. PATIENTS AND METHODS This is a retrospective study of patients undergoing subtotal colectomy for C. difficile colitis in an NHS trust over 18 months. Case notes were reviewed for antibiotic use, duration of diarrhoea, treatment, blood results, pre-operative imaging and surgical morbidity and mortality. RESULTS A total of 1398 patients tested positive for C. difficile in this period. Of these, 18 (1.29%) underwent colectomy. All were emergency admissions, 35% medical, 35% surgical, 24% neurosurgical and 6% orthopaedic. In the cohort, 29% were aged less than 65 years. Patients had a median of three antibiotics (range, 1–6), for a median of 10 days (range, 0–59 days). Median length of stay prior to C. difficile diagnosis was 13 days. Subtotal colectomy was performed a median of 4 days (range, 0–23 days) after diagnosis. Postoperative mortality was 53% (9 of 17). The median C-reactive protein level for those who died was 302 mg/l, in contrast to 214 mg/l in the survival group. Whilst 62% of all C. difficile cases were medical, the colectomy rate was only 0.7%. In the surgical specialties, the colectomy rates were 3.2% for general surgical, 1.2% for orthopaedic and 8% for neurosurgical patients. CONCLUSIONS Colectomy for C. difficile colitis has a high mortality but can be life-saving, even in extremely sick patients. Although heavy antibiotic use is a predisposing factor, this is not an obligatory prerequisite in the development of C. difficile. Neither is it a disease of the elderly, making it difficult to predict vulnerable patients. There are large differences in colectomy rates between specialties and we suggest there may be a place for a surgical opinion in all cases of severe C. difficile colitis.

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Pulmonary complications in neurosurgical patients

Indian Journal of Neurosurgery ◽

10.4103/2277-9167.102299 ◽

2012 ◽

Vol 01 (02) ◽

pp. 175-180

Author(s):

Karan Madan ◽

Randeep Guleria

Keyword(s):

Antibiotic Use ◽

Pulmonary Complications ◽

Morbidity And Mortality ◽

Neurogenic Pulmonary Edema ◽

Volume Ventilation ◽

Lung Expansion ◽

Neurosurgical Patients ◽

Local Patterns ◽

The Common ◽

Postoperative Atelectasis

Abstract Pulmonary complications are a major cause of morbidity and mortality in neurosurgical patients. The common pulmonary complications in neurosurgical patients include pneumonia, postoperative atelectasis, respiratory failure, pulmonary embolism, and neurogenic pulmonary edema. Postoperative lung expansion strategies have been shown to be useful in prevention of the postoperative complications in surgical patients. Low tidal volume ventilation should be used in patients who develop acute respiratory distress syndrome. An antibiotic use policy should be put in practice depending on the local patterns of antimicrobial resistance in the hospital. Thromboprophylactic strategies should be used in nonambulatory patients. Meticulous attention should be paid to infection control with a special emphasis on hand-washing practices. Prevention and timely management of these complications can help to decrease the morbidity and mortality associated with pulmonary complications.

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Prevention of Clostridium difficile Infection and Associated Diarrhea: An Unsolved Problem

Microorganisms ◽

10.3390/microorganisms8111640 ◽

2020 ◽

Vol 8 (11) ◽

pp. 1640

Author(s):

Nicola Principi ◽

Margherita Gnocchi ◽

Martina Gagliardi ◽

Alberto Argentiero ◽

Cosimo Neglia ◽

...

Keyword(s):

Clostridium Difficile ◽

Passive Immunization ◽

Antibiotic Use ◽

Antimicrobial Drugs ◽

Mild Disease ◽

Number Of Patients ◽

Control And Prevention ◽

Total Burden ◽

Infection Control And Prevention ◽

Gut Microbiota Composition

For many years, it has been known that Clostridium difficile (CD) is the primary cause of health-care-associated infectious diarrhea, afflicting approximately 1% of hospitalized patients. CD may be simply carried or lead to a mild disease, but in a relevant number of patients, it can cause a very severe, potentially fatal, disease. In this narrative review, the present possibilities of CD infection (CDI) prevention will be discussed. Interventions usually recommended for infection control and prevention can be effective in reducing CDI incidence. However, in order to overcome limitations of these measures and reduce the risk of new CDI episodes, novel strategies have been developed. As most of the cases of CDI follow antibiotic use, attempts to rationalize antibiotic prescriptions have been implemented. Moreover, to reconstitute normal gut microbiota composition and suppress CD colonization in patients given antimicrobial drugs, administration of probiotics has been suggested. Finally, active and passive immunization has been studied. Vaccines containing inactivated CD toxins or components of CD spores have been studied. Passive immunization with monoclonal antibodies against CD toxins or the administration of hyperimmune whey derived from colostrum or breast milk from immunized cows has been tried. However, most advanced methods have significant limitations as they cannot prevent colonization and development of primary CDI. Only the availability of vaccines able to face these problems can allow a resolutive approach to the total burden due to this pathogen.

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Antibiotic Overuse is a Major Risk Factor for Clostridium difficile Infection in Surgical Patients

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2017.158 ◽

2017 ◽

Vol 38 (10) ◽

pp. 1254-1257 ◽

Cited By ~ 7

Author(s):

James T. Bernatz ◽

Nasia Safdar ◽

Scott Hetzel ◽

Paul A. Anderson

Keyword(s):

Risk Factors ◽

Risk Factor ◽

Clostridium Difficile ◽

Clostridium Difficile Infection ◽

Antibiotic Use ◽

Morbidity And Mortality ◽

Major Risk Factor ◽

Surgical Patients ◽

Antibiotic Overuse ◽

The Past

Clostridium difficile infection (CDI) is associated with increased cost, morbidity, and mortality in postoperative patients. Variable rates of postoperative CDI are reported among 4 surgical specialties during the 30-month study period. Risk factors for CDI include antibiotic use, increased ASA score, and increased admissions in the past year.Infect Control Hosp Epidemiol 2017;38:1254–1257

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Faculty Opinions recommendation of Effect of perioperative insulin infusion on surgical morbidity and mortality: systematic review and meta-analysis of randomized trials.7.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.1103647.559739 ◽

2008 ◽

Author(s):

Jean-Charles Preiser

Keyword(s):

Systematic Review ◽

Randomized Trials ◽

Insulin Infusion ◽

Meta Analysis ◽

Morbidity And Mortality ◽

Surgical Morbidity

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Faculty Opinions recommendation of Impact of an electronic sepsis initiative on antibiotic use and health care facility-onset Clostridium difficile infection rates.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.727710237.793555276 ◽

2019 ◽

Author(s):

Pranavi Sreeramoju

Keyword(s):

Health Care ◽

Clostridium Difficile ◽

Clostridium Difficile Infection ◽

Care Facility ◽

Health Care Facility ◽

Antibiotic Use ◽

Infection Rates

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The impact of nationwide lockdown on acute coronary syndromes hospitalization rate in the Western Macedonia regional hospital of Greece

European Heart Journal Acute Cardiovascular Care ◽

10.1093/ehjacc/zuab020.088 ◽

2021 ◽

Vol 10 (Supplement_1) ◽

Author(s):

I Kanellos ◽

V Vasilakopoulos ◽

S Daios ◽

S Lampropoulos ◽

M Petridou ◽

...

Keyword(s):

Acute Coronary Syndromes ◽

Hospitalization Rate ◽

Regional Hospital ◽

Morbidity And Mortality ◽

World Health ◽

Cardiology Department ◽

Number Of Patients ◽

Significant Difference ◽

Coronary Syndromes ◽

Pandemic Wave

Abstract Funding Acknowledgements Type of funding sources: None. Introduction World Health Organization declared the Covid-19 outbreak a global pandemic on March 11, 2020. The pandemic is associated with more than 75 million cases and more than 1.5 million deaths worldwide. Greece implemented a nationwide lockdown on March 23, 2020, to control the pandemic wave and prevent reducing morbidity and mortality due to Covid-19. During this period, acute coronary syndromes (ACS) hospitalization in the cardiology department was reduced. In addition, the second pandemic wave also led to a new national lockdown on November 7, 2020, although it was implemented 15 days earlier in the relative regional hospital area due to high viral load. Purpose Our study evaluated the number of hospitalized patients with ACS during the nationwide lockdown period, comparing them with the previous years (period 2018 and 2019). Material and Methods Data recordings regarding ACS (unstable angina, NSTEMI, STEMI) hospitalization rates in the Cardiology department were collected from the hospital"s register. Each year"s data analysis interval included the periods of the nationwide lockdown of 2020; March 23 to May 3 and October 14 to December 10. Statistical analysis was performed between periodic groups using the chi-square test (IBM SPSS Statistics software, version 23.0). Results During 2018, the number of patients hospitalized for ACS was 81 and consisted of 39,1% of the total hospitalizations in the Cardiology Department. In 2019 the number of patients hospitalized for ACS was 62 and consisted the 48,8% of the total hospitalizations, while in 2020, the number of patients hospitalized for ACS was 30 and consisted the 27,5% of the total hospitalizations. Furthermore, there was a statistically significant difference (p < 0,05) regarding ACS event hospitalization rate between the period of lockdown (March to May and October-December 2020) and the COVID-19-free period of the previous year (March to May and October to December 2019). There was no statistically significant difference (p > 0,05) regarding ACS event hospitalization rate between the period of lockdown (March to May and October to December 2020) and the COVID-19-free period of the year 2018 (March to May and October to December). Finally, there was no statistically significant difference (p > 0,05) in ACS event hospitalization rate between March to May and October to December regarding the years 2018 and 2019. Conclusion Our results are in compliance with the ESC"s comparative survey regarding the observed worldwide reduction of hospitalizations for ACS during the COVID-19 lockdown era, suggesting a potential impact of lockdown in both non-environmental and environmental risk factors for cardiovascular disease. Factors of the relative epidemiological reduction are complexed and puzzled, while morbidity and mortality of ACS remained relatively stable even after the lockdown, so future studies are necessary to further investigate them.

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Outcomes of Surgical and Nonsurgical Treatment for Colorectal Cancer in Nonagenarian Patients

The American Surgeon ◽

10.1177/0003134821995060 ◽

2021 ◽

pp. 000313482199506

Author(s):

Youngbae Jeon ◽

Kyoung-Won Han ◽

Won-Suk Lee ◽

Jeong-Heum Baek

Keyword(s):

Colorectal Cancer ◽

Overall Survival ◽

Surgical Treatment ◽

Postoperative Complications ◽

Postoperative Mortality ◽

Nonsurgical Treatment ◽

Perioperative Outcomes ◽

Rank Test ◽

Kaplan Meier ◽

Number Of Patients

Purpose This study is aimed to evaluate the clinical outcomes of surgical treatment for nonagenarian patients with colorectal cancer. Methods This retrospective single-center study included patients diagnosed with colorectal cancer at the age of ≥90 years between 2004 and 2018. Patient demographics were compared between the operation and nonoperation groups (NOG). Perioperative outcomes, histopathological outcomes, and postoperative complications were evaluated. Overall survival was analyzed using Kaplan-Meier methods and log-rank test. Results A total of 31 patients were included (16 men and 15 women), and the median age was 91 (range: 90‐96) years. The number of patients who underwent surgery and who received nonoperative management was 20 and 11, respectively. No statistical differences in baseline demographics were observed between both groups. None of these patients were treated with perioperative chemotherapy or radiotherapy. Surgery comprised 18 (90.0%) colectomies and 2 (10.0%) transanal excisions. Short-term (≤30 days) and long-term (31‐90 days) postoperative complications occurred in 7 (35.0%) and 4 (20.0%) patients, respectively. No complications needed reoperation, such as anastomosis leakage or bleeding. No postoperative mortality occurred within 30 days: 90-day postoperative mortality occurred in two patients (10.0%), respectively. The median overall survival of the operation group was 31.6 (95% confidence interval: 26.7‐36.5) and that of NOG was 12.5 months (95% CI: 2.4‐22.6) ( P = 0.012). Conclusion Surgical treatment can be considered in carefully selected nonagenarian patients with colorectal cancer in terms of acceptable postoperative morbidity, with better overall survival than the nonsurgical treatment.

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Antibiotic use and other risk factors at hospital level for outbreaks with Clostridium difficile PCR ribotype 027

Journal of Medical Microbiology ◽

10.1099/jmm.0.47711-0 ◽

2008 ◽

Vol 57 (6) ◽

pp. 709-716 ◽

Cited By ~ 19

Author(s):

T. I. I. van der Kooi ◽

M. Koningstein ◽

A. Lindemans ◽

D. W. Notermans ◽

E. Kuijper ◽

...

Keyword(s):

Clostridium Difficile ◽

Antibiotic Use ◽

Study Groups ◽

Ribotype 027 ◽

Defined Daily Doses ◽

Hygiene Measures ◽

Epidemic Period ◽

Group A ◽

Group B ◽

The Relationship

The first Dutch outbreak due to Clostridium difficile ribotype 027 was observed in mid-2005; by the end of that year, eight hospitals were affected. To study the relationship between hospital-wide antibiotic use and the incidence of 027-linked C. difficile-associated disease (CDAD) three study groups were made: group A, all eight hospitals with an 027-associated epidemic; group B, five of a total of six hospitals with occasional 027 cases, without an increase in CDAD; and group C, ten randomly selected hospitals with no reported 027 epidemics or isolated 027 cases. Quarterly data on CDAD incidences, hygiene measures and the use of fluoroquinolones, second- and third-generation cephalosporins, extended-spectrum penicillins, penicillins with beta-lactamase inhibitors, carbapenems, lincomycins and macrolides were collected for 2004 and 2005, and divided into pre-epidemic and epidemic periods. Using a multilevel Poisson regression analysis, CDAD incidence was linked to antibiotic use in the previous quarter and to certain hygiene measures. In the pre-epidemic period, the total use of the studied antibiotics was comparable between affected and unaffected hospitals. Higher use of second-generation cephalosporins, macrolides and all of the studied antibiotics were independently associated with a small increase in CDAD incidence [relative risk (95 % confidence interval): 1.14 per increase of 100 defined daily doses per 10 000 bed days (1.06–1.23), 1.10 (1.01–1.19) and 1.02 (1.01–1.03), respectively]. However the effect was too small to predict which hospitals might be more prone to 027-associated outbreaks.

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