Intended for healthcare professionals

Clinical Review

The role of surgery in Clostridium difficile colitis

BMJ 2009; 338 doi: (Published 06 May 2009) Cite this as: BMJ 2009;338:b1563
  1. S E Noblett, specialist registrar in general surgery1,
  2. M Welfare, consultant gastroenterologist2,
  3. K Seymour, consultant surgeon1
  1. 1Department of Surgery, North Tyneside General Hospital, North Shields, Tyne and Wear NE29 8NH
  2. 2Department of Gastroenterology, North Tyneside General Hospital
  1. Correspondence to: K Seymour keith.seymour{at}
  • Accepted 16 February 2009

Summary points

  • The incidence of Clostridium difficile infection is increasing

  • A hypervirulent strain has recently emerged (ribotype 027)

  • Consider ribotyping in institutions where the incidence of complicated or fulminant colitis is increasing

  • Treatment should be proactive

  • Patients need a minimum twice daily review and deterioration should prompt action

  • Mortality is high but can be improved by timely intervention

Clostridium difficile infection was cited in one of every 250 death certificates completed in the United Kingdom in 2005,1 and it has become the leading cause of death from healthcare associated infections in much of the industrialised world.2 More than 50 000 cases of C difficile infection were reported in England in 2007—a 50-fold increase since 1990.1 Pseudomembranous colitis was first described in 1935, but it took another 40 years for C difficile to be identified as the causative organism.3 4 C difficile associated disease accounts for 15-25% of antibiotic associated diarrhoea,5 and its incidence is rising. The overall prevalence in patients admitted to hospital is around 1%; it can be as high as 20% in those who stay for more than one week and 50% in those who stay for at least four weeks.6 7

This review aims to draw attention to the symptoms of C difficile infection and to summarise evidence on the indications and optimum timing of surgical intervention for C difficile associated colitis. The quality of evidence for the treatment of C difficile associated disease is poor, and the recommendations in this review are based mainly on non-randomised observational studies (level III evidence).

Sources and selection criteria

We did a PubMed search for English language articles on Clostridium difficile colitis, fulminant colitis, and surgery. Further papers were identified from the reference lists of relevant major articles.

How does C difficile disease present?

C difficile causes a wide spectrum of disease, ranging from asymptomatic colonisation of …

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