with Dr. Bruno Pinto, Dr. João Guimarães
Clostridioides difficile, formerly known as clostridium, is an anaerobic gram positive bacterium that colonizes the intestinal tract via the fecal oral route. It’s one of the most common nosocomial infections. The main risk factors are recent antibiotic use and hospitalization. Clostridioides difficile infection is suspected when a patient has an acute episode of diarrhea without any other obvious explanation, especially in the presence of risk factors. Diagnosis is then established with a positive laboratory stool test.
The first treatment step consists in stopping previous antibiotic coverage. Currently, medical treatment is based on targeted antibiotic therapy. In mild or severe infection the guidelines recommend starting with oral vancomycin 125mg 4 times per day or fidaxomicin 200mg twice daily for 10 days. Fulminant infection is defined by the presence of shock, ileus or megacolon. Current guidelines recommend treatment with oral vancomycin 500mg 4 times per day plus intravenous metronidazole 500mg every 8 hours.
Surgical treatment is indicated for fulminant colitis. Choosing the correct timing for surgery is the cornerstone to improve patients’ survival. There are some clinical criteria to guide surgical decision, including the evidence of peritonitis, colonic perforation, respiratory, circulatory or other end organ failure and abdominal compartment syndrome. These are generally considered absolute indications for surgical management. Other relative indications include hyperlactacidemia >5mmol/L or white blood cell count greater than 50.000 cells/mL.
The standard approach is total abdominal colectomy, which remains the procedure of choice in the presence of colonic perforation/necrosis or abdominal compartment syndrome. However, in recent years, the diverting loop ileostomy with colonic lavage has been used as an alternative procedure, considering some studies that associate it with a lower mortality. The procedure should be complemented with colonic flushes of vancomycin for 7 to 10 days.
There are no randomized trials regarding outcomes about these two surgical strategies. The original trial published by Neal et al. in 2011 was a single center retrospective study that showed over an 18 month period a mortality advantage favoring the diverting loop ileostomy. In 2017, Ferrada et al. compared the two approaches in a multicenter retrospective study and again showed a lower mortality favoring the loop ileostomy. However in 2019 Juo et al., in a retrospective cohort study with data from an United States of America database, demonstrated no significant differences between the two approaches concerning mortality, even though there was a rising adoption of this newer surgical strategy.
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