Fulminant Clostridium difficile: an underappreciated and increasing cause of death and complications

Abstract

Objective: To review the epidemiology and characteristics of patients who died or underwent colectomy secondary to fulminant Clostridium difficile colitis.

Summary background data: In patients with C. difficile colitis, a progressive, systemic inflammatory state may develop that is unresponsive to medical therapy; it may progress to colectomy or death.

Methods: The authors reviewed 2,334 hospitalized patients with C. difficile colitis from January 1989 to December 2000. Sixty-four patients died or underwent colectomy for pathologically proven C. difficile colitis.

Results: In 2000, the incidence of C. difficile colitis in hospitalized patients increased from a baseline of 0.68% to 1.2%, and the incidence of patients with C. difficile colitis in whom life-threatening symptoms developed increased from 1.6% to 3.2%. Forty-four patients required a colectomy and 20 others died directly from C. difficile colitis. Twenty-two percent had a prior history of C. difficile colitis. A recent surgical procedure and immunosuppression were common predisposing conditions. Lung transplant patients were 46 times more likely to have C. difficile colitis and eight times more likely to have severe disease. Abdominal computed tomography scan correctly diagnosed all patients, whereas 12.5% of toxin assays and 10% of endoscopies were falsely negative. Patients undergoing colectomy for C. difficile colitis had an overall death rate of 57%. Significant predictors of death after colectomy were preoperative vasopressor requirements and age.

Conclusions: C. difficile colitis is a significant and increasing cause of death. Surgical treatment of C. difficile colitis has a high death rate once the fulminant expression of the disease is present.

Figure 1. The monthly incidence of Clostridium difficile colitis has increased from the years 1999 to 2000.

Figure 2. Number of patients with morphologic proof of Clostridium difficile colitis requiring colectomy or dying.

Figure 3. Time interval from initial symptoms to colectomy or death in patients with fulminant Clostridium difficile (median 9 days).

Figure 4. APACHE III scores (thin lines are one standard deviation) as a function of days before colectomy in 20 patients with fulminant Clostridium difficile.

Figure 5. Abdominal computed tomography scans from three patients with findings diagnostic of fulminant Clostridium difficile colitis. Patients with systemic symptoms from C. difficile colitis in whom thickening and dilatation of the colon and ascites develop require a colectomy.