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Evolving Strategies to Manage Clostridium difficile Colitis

  • Evidence-Based Current Surgical Practice
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Clostridium difficile infection remains a common nosocomial illness with a significant impact on health care delivery. As molecular phenotyping of this organism has changed our understanding of its transmission and virulence, so too have diagnostic methods and treatment strategies evolved in recent years. The burden of this infection falls predominantly on elderly patients with comorbidities who have recently received antibiotics. Oral or enteral vancomycin is now preferred for first-line antimicrobial treatment across the disease spectrum, including mild-moderate initial cases. Fidaxomicin (a novel macrolide antibiotic), bezlotoxumab (a monoclonal antibody against toxin TcdB), and fecal microbiota transplantation expand the therapeutic armamentarium, particularly for recurrent infection. Operative treatment should be reserved for patients with fulminant infection, and early identification of patients who would benefit from an operation remains a challenge. Less invasive surgical options—such as laparoscopic diverting ileostomy with colonic irrigation—may improve survival and other outcomes relative to total abdominal colectomy and represent an attractive alternative particularly for frail patients.

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Abbreviations

CDI:

Clostridium difficile infection

PPI:

Proton pump inhibitor

rCDI:

Recurrent Clostridium difficile infection

NAAT:

Nucleic acid amplification test

FMT:

Fecal microbiota transplant

NSQIP:

National Surgical Quality Improvement Program

GIL:

Gastrointestinal lavage

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Funding

Dr. Bowman was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through grant #UL1 TR001860, and by the Agency for Healthcare Research and Quality through grant #T32HS022236.

Author information

Authors and Affiliations

  1. Department of Surgery, University of California, Davis, Medical Center, 2335 Stockton Blvd., Sacramento, CA, 95817, USA

    Jessica A. Bowman & Garth H. Utter

  2. Department of Surgery Outcomes Research Group (Utter), University of California, Davis, Medical Center, Sacramento, CA, USA

    Garth H. Utter

Authors
  1. Jessica A. Bowman
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Corresponding author

Correspondence to Garth H. Utter.

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Disclaimer

The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or AHRQ.

Disclosure Information

Dr. Utter reports non-financial support from the American Association for the Surgery of Trauma during the conduct of the study. Dr. Bowman does not report any.

Additional information

Learning objectives

1. Understand the transmission of Clostridium difficile in hospital settings

2. Describe the recommended antibiotic treatment of Clostridium difficile infection

3. Discuss the roles of novel therapies such as probiotics, immunotherapy, and fecal microbiota transplant in prevention and treatment of Clostridium difficile infection

4. Describe the surgical options for treatment of Clostridium difficile infection, including the underlying rationale

Questions

1. Which of the following strains of Clostridium difficile is considered the most virulent?

a. NAP1

b. NAP4

c. NAP7

d. NAP11

2. Which of the following is NOT associated with Clostridium difficile infection (CDI)?

a. Age > 65 years

b. Recent antibiotic use

c. Non-steroidal anti-inflammatory drug use

d. Proton pump inhibitor use

3. Which of the following statements is true regarding CDI diagnosis?

a. Nucleic acid amplification testing (NAAT) identifies the amount of TcdA toxin

b. NAAT cannot readily discriminate between those with active infection and those who are colonized

c. Following resolution of symptoms, repeat NAAT should be performed to ensure cure

d. CT scan is helpful in the identification of pseudomembranes

4. Which of the following is the most appropriate treatment for mild-moderate initial CDI?

a. Oral vancomycin

b. Intravenous fidaxomicin

c. Intravenous vancomycin

d. Rectal metronidazole

5. Which of the following is an appropriate treatment for recurrent CDI?

a. 10-day course of intravenous vancomycin if the initial episode was treated with metronidazole

b. 10-day course of oral vancomycin if the initial episode was treated with vancomycin

c. Oral vancomycin taper if the initial episode was treated with vancomycin

d. Oral fidaxomicin if the initial episode was treated with metronidazole

6. Which of the following is a true statement regarding fecal microbiota transplant (FMT)?

a. FMT is associated with a cure of approximately 80%

b. FMT administered via oral capsules had a significantly lower likelihood of cure than FMT via colonoscopy

c. FMT can be administered via suppositories

d. FMT with frozen stool had a significantly lower cure rate than with fresh stool

7. Which of the following is NOT involved as part of diverting ileostomy and colonic irrigation?

a. Diagnostic laparoscopy

b. Intraoperative lavage with polyethylene glycol

c. Postoperative antegrade irrigation with polyethylene glycol

d. Postoperative retrograde (per rectum) vancomycin enemas

8. Which of the following is a true statement regarding surgical outcomes for CDI?

a. Total abdominal colectomy is associated with 20% 30-day mortality

b. The standard NSQIP calculator overestimates CDI-related surgical mortality

c. Diverting ileostomy can be successfully completed in only 50% of cases

d. Ileostomy reversal appears to be more common after diverting ileostomy than after total abdominal colectomy

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Disclosure Information

Dr. Utter reports non-financial support from the American Association for the Surgery of Trauma during the conduct of the study. Dr. Bowman does not report any.

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Bowman, J.A., Utter, G.H. Evolving Strategies to Manage Clostridium difficile Colitis. J Gastrointest Surg 24, 484–491 (2020). https://doi.org/10.1007/s11605-019-04478-5

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