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CLINICAL REVIEW: S E Noblett, M Welfare, and K Seymour The role of surgery in Clostridium difficile colitis BMJ 2009; 338: b1563 [Full text]

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Highly Costly Infection

Daniel Jabbari   (7 May 2009)

Clostridium difficile infection is under-recognised in the community

Jayakeerthi Rangaiah, Mark Wilks and Michael Millar   (9 May 2009)

Clostridium Deficile

Maria Sadia   (11 May 2009)

Why is the operative mortality in C difficile colitis so high?

Richard G Fiddian-Green   (16 May 2009)

Re: Clostridium difficile infection is under-recognised in the community

Keith Seymour   (18 May 2009)

Beware Clostridium Difficile Enteritis

Benjamin Box   (27 May 2009)

Energy metabolism in C difficile enteritis and colitis

Richard G Fiddian-Green   (28 May 2009)

Highly Costly Infection 7 May 2009
Daniel Jabbari, General Practice FY2 Hazeldene House Surgery, Main Road, Great Haywood, Stafford. ST18 0SU Send response to journal: Re: Highly Costly Infection	There is no doubt that C-difficile is a disabling infection especially in elderly people. The patients who come to a hospital for a simple orthopaedic operation particularly with a background of Inflammatory bowel disease are more at risk. Sometimes with a prophylactic dose of Antibiotics they may get C-difficile infection and later toxic megacolon even have further operation or long time ITU admission which cause a huge cost for both patients and the NHS. Competing interests: None declared
Clostridium difficile infection is under-recognised in the community 9 May 2009
Jayakeerthi Rangaiah, Specialist Registrar in Microbiology Division of Infection, Barts and The London NHS Trust, London, E1 2ES, Mark Wilks and Michael Millar Send response to journal: Re: Clostridium difficile infection is under-recognised in the community	We support the call of Noblett et al for more research on community acquired Clostridium difficile infections (CDI).[1] We recently reviewed clinical and microbiology data from patients with positive Clostridium difficile toxin (CDT) test results in the microbiology laboratory of Barts and The London NHS Trust from May 2007 to April 2008. We found a wide variation in the requesting practice of GPs for CDT test and identical rates of toxin positivity for both community and hospital patients. There were a total of 24 patients presenting with diarrhoea either to GP (n=12) or to the A&E (n=12) who tested positive with the CDT test. All except one had a history of either hospitalisation in the previous 6 months or exposure to antibiotics in the last 4 weeks. Five of the 12 patients presenting to A&E with diarrhoea had visited a GP within last 7 days without CDI being suspected. Death was attributable to CDI in 3 patients. Community-onset CDI is increasingly recognised.[2] Prior exposure to antibiotics and hospitalization are major risk factors.[3] While the question of additional risk factors remains to be investigated further, it is very important to have a robust system for early diagnosis and adequate management of CDI in patients becoming symptomatic in the community. We suggest that GPs should test patients for CDT when they present with diarrhoea and a recent history of either hospitalisation or antibiotics exposure. The currently used tests are not very sensitive.[4]GPs should be prepared to empirically treat patients with risk factors if diarrhoea is severe. References: 1. Noblett SE, Welfare M and Seymour K. The role of surgery in Clostridium difficile colitis. BMJ 2009;338:b1563 2. Herbert L. DuPont, Kevin Garey, Juan-Pablo Caeiro and Zhi-dong Jiang. New advances in Clostridium difficile infection: changing epidemiology, diagnosis, treatment and control. Curr Opin in Inf Dis 2008;21:500-507 3. M.H. Wilcox, L. Mooney, R. Bendall, C.D. Settle and W.N. Fawley. A case-control study of community-associated Clostridium difficile infection. Journal of Antimicrobial Chemotherapy. 2008;62:388-396 4. Tim Planche, Adamma Aghaizu, Richard Holliman, Peter Riley, Jan Poloniecki, Aodhan Breathnach, Sanjeev Krishna. Diagnosis of clostridium difficile infection by toxin detection kits: a systematic review. Lancet infectious diseases 2008;8(12):777-84 Competing interests: None declared
Clostridium Deficile 11 May 2009
Maria Sadia, FP-2 UK Send response to journal: Re: Clostridium Deficile	With the introduction of broad-spectrum antibiotcs in the latter half of the twentieth century, antibiotic associated diarrhea became more common. Pseudomembranous colitis was first described as a complication of C. difficile infection in 1978. The administration of antibiotics is the most significant and most frequently reported predisposing factor for Clostridium difficile-associated disease. Clostridium difficile colonization and disease develop more commonly after prolonged antibiotic treatment, but they have also been reported with some antimicrobial agents after short term (usually three doses) perioperative prophylaxis. The most common culprits are clindamycin, cephalosporin, quinolones and ampicillin. C. difficile infection (CDI) can range in severity from asymptomatic to severe and life-threatening, especially among the elderly. People are most often nosocomially infected in hospitals, nursing homes, or institutions, although C. difficile infection in the community, outpatient setting is increasing. Patients should be treated as soon as possible when the diagnosis of Clostridium difficile colitis (CDC) is made to avoid frank sepsis or bowel perforation. As prevention is better than cure, unnecessary antibiotics should be avoided, if the causative pathogen is known, use a directed-spectrum antibiotic, combinations of antibiotics should not be used, prescription charts should include stop dates, and antibiotics for surgical prophylaxis should only be given preoperatively. Competing interests: John Nkrumah
Why is the operative mortality in C difficile colitis so high? 16 May 2009
Richard G Fiddian-Green, FRCS, FACS None Send response to journal: Re: Why is the operative mortality in C difficile colitis so high?	Truelove at Oxford revolutionized the management of ulcerative colitis first by demonatrating the efficacy of cortisone and second by advocating aggressive treatment in severe attacks (2). There were "no deaths directly due to ulcerative colitis or to surgical treatment in.. [87] patients" treated for severe ulcerative colitis(3). This is a common experience in major centers today. The worst I had to handle had such severe colitis that there was no recognizable bowel wall there being transmural necrosis and a perforation that had been sealed by the diaphragm. Despite leakage of some stool as I took it down the postoperative course was uneventful, the only extra precaution taken being to leave the wound open and allow it to heal be second intention. This is common practice for contaminated wounds. Fulminant amoebic colitis, on the other hand, had a reported mortality of between 55% and 87.5% until the introduction of colonic lavage and defunctioning ileostomy which reduced mortality to 5% (4). "Patients underwent restorative surgery ..following the initial surgery. The extent of colonic stricturing invariably warranted colonic resection. This included total colectomy (N = 12), right hemicolectomy (N = 5), left hemicolectomy (N = 2), and right and transverse colectomy (N = 1). The overall survival rate of the 23 patients presenting with FAC was [reduced to] 82.6% (N = 19). The distinction between severe ulcerative colitis and fulminant amoebic colitis is that the latter has a clearly defined cause and specific treatment. C difficile colitis is more closely allied to amoebic colitis than to ulcerative colitis in that a specific pathogen, and its toxins, has been implicated and can be effectively treated with the appropriate antibiotics. Managed effectively, therefore, one would have expected the mortality to be much lower than that reported in this review (5). There are two possible reasons for the unexpectedly high operative mortality in C difficile colitis; delayed diagnosis and effective intervention as the authors imply and a systemic cause that increases the liklihood of developing severe colitis and is not addressed by resectional surgery. Either way it should be possible to manage patients well enough to reduce the mortality to near zero percent, as in the case of severe ulcerative colitis, even in those that come to surgery. The major impediment would appear to be the environment in which the disease first appears. In all these care would seem to be being provided by those who have little or no knowledge of fulminant colitis or the most effective means of managing it. Indeed in some the medications being administered might even be an initiating and/or compounding event. Making substantial reductions in the mortality from fulminant C difficile colitis will take much more than access to gastroenterologists and/or surgeons capable of delivering the care they need. 1. Truelove SC, Witts LJ. Cortisone in ulverative colitis . BMJ 1995; 104-1048. 2. Truelove SC, Jewell DP.Intensive intravenous regimen for severe attacks of ulcerative colitis.1: Lancet. 1974 Jun 1;1(7866):1067-70. 3. Truelove SC, Willoughby CP, Lee EG, Kettlewell MG. Further experience in the treatment of severe attacks of ulcerative colitis. Lancet. 1978 Nov 18;2(8099):1086-8. 4. SINGH Bhugwan; MOODLEY Jaynathan; RAMDIAL Pratistadevi K. Fulminant amoebic colitis: A favorable outcome. International surgery. 2001, vol. 86, no2, pp. 77-81. 5. S E Noblett, M Welfare, and K Seymour The role of surgery in Clostridium difficile colitis BMJ 2009; 338: b1563. Competing interests: None declared
Re: Clostridium difficile infection is under-recognised in the community 18 May 2009
Keith Seymour, Consultant Surgeon North Tyne side General Hospital, Rake Lane, North Sheilds, Tyne and Wear, NE29 8DN Send response to journal: Re: Re: Clostridium difficile infection is under-recognised in the community	We agree that C Diff presenting in the community as diarrhoea (CDAD) is an under recognised phenomenon and one that requires more research attention. Strict adherence to antibiotic prescribing protocols should be supported in all healthcare settings as an important mechanism of limiting this mechanism of the disease. Increased awareness of the phenomenon of community presentation of CDAD should benefit patients by earlier initiation of appropriate therapy. Competing interests: None declared
Beware Clostridium Difficile Enteritis 27 May 2009
Benjamin Box, Fellow in Laparoscopic Colorectal Surgery Royal Victoria Infirmary Newcastle Upon Tyne Send response to journal: Re: Beware Clostridium Difficile Enteritis	I read this article on a difficult topic with great interest. One subject that was not dealt with was small intestinal involvement by clostridium difficile infection. There are case reports of this complication and it has also been identified as a cause of high ileostomy output (1). The possibilty of an enteritis rather than a pure colitis should be considered prior to embarking on colectomy. During my surgical training I was involved in 5 laparotomies for patients with acute clostridial difficile colitis. 4 of these patients had a preoperative diagnosis of acute psuedomembranous colitis of which 3 underwent colectomy and 2 survived. 2 patients were severely septic following ilesotomy closure of which one did not have a preoperative diagnosis of clostridium difficile infection. At laparotomy there was considerable bowel oedema but it was essentially a negative procedure. The other patient had clostridium difficile enterocolitis but coletomy was abandoned due to the fragile nature of the inflamed small bowel. This demonstrated florid pseudomembranes. Both patients survived. Small bowel involvement should be therefore considered. Computed tomography of the abdomen may be helpful in determining if there is enteritis rather than colitis. The precise criteria for colectomy remain unclear. 1.Fulminant Small Bowel Enteritis. A Rare Complication of Clostridium Difficile Associated disease. Fleming K et al Inflammatory Bowel Disease 2009 Jun 15(6) 801-802. Competing interests: None declared
Energy metabolism in C difficile enteritis and colitis 28 May 2009
Richard G Fiddian-Green, FRCS, FACS None Send response to journal: Re: Energy metabolism in C difficile enteritis and colitis	In his rapid response Benjamin Box, Fellow in Laparoscopic Colorectal Surgery, describes his experience with 5 cases one of which had "C difficile enteritis". Two points: First C difficile colitis and enteritis may be the regional manifestations of a systemic disorder, an acute or acute on chronic energy supply/demand mismatch identifiable from a low intramucosal pH (1-3). This may create the metabolic milieu in which C difficile can thrive, aided by the suppression of other organisms by antibiotics. If so early identification and reversal should prevent C difficle proliferation and its regional manifestations for it normal cellular metabolism may prevent damage by its toxins as considered in my electronic correspondence on Pasteur's germ vs Virchow's cell theories. Ischemic enteritis is seen on occasion following repair of a ruptured abdominal aortic aneurysm but ischaemic colitis is far more common. In this case it is the systemic rather than the regional disease that does the damage (4,5). Second the thought of dealing with a hot colon laparoscopically terrifies me given the fragility of the bowel and, optimally, the need to remove adherent omentum without devascularizing it. Indeed as experience with laparoscopic colon surgery grows I predict that the number of early and late postoperative adhesive obstructions and strangulated herniae encountered will far exceed that following competent open surgery for the limitation in exposure and anatomical flexibility would seem to make them unavoidable. 1. Clostridium difficile colitis: A marker for ischemic colitis? Richard Fiddian-Green. CMAJ • November 23, 2004; 171 (11). 2. Chronic intestinal ischaemia and Hirschsprung’s disease Richard G Fiddian-Green. Archives of Disease in Childhood 2007;92:185. 3. Sigmoid Intramural pH for Prediction of Ischemic Colitis During Aortic Surgery:...Schiedler et al. Arch Surg.1987; 122: 881-886. 4. Early detection of major complications after abdominal aortic surgery: Predictive value of sigmoid colon and gastric intramucosal ph monitoring Dr. M. Björck, B. Hedberg. British Journal of Surgery Volume 81 Issue 1, Pages 25 - 30. 5. Fiddian-Green RG. Gut mucosal ischemia during cardiac surgery. Semin Thorac Cardiovasc Surg. 1990 Oct;2(4):389-99 Competing interests: Patents issued in my name.