Early surgical
intervention for fulminant pseudomembranous colitis.Am
Surg. 2008 Jan;74(1):20-6.
The objective of
this study of a retrospective case series was to determine factors
associated with survival after surgical intervention in
pseudomembranous colitis (PMC). The study was conducted at a tertiary
care medical center and comprised 36 patients who underwent colectomy
for fulminant PMC from 1995 to 2006. Patients including 21 females
ranged from 40 to 89 years of age (mean, 70 years). Comorbidities
included diabetes (39%), cardiovascular disease (77%), chronic
obstructive pulmonary disease (47%), and intake of immunosuppressive
medications (45%). Seventy-two per cent received antibiotics in the
previous 2 months. Only patients with a confirmation of PMC on
pathology specimens were included in the study. All patients underwent
colectomy. Patients were stratified into two groups: survivors and
nonsurvivors. Various clinical factors/ parameters used in the
management of patients with PMC were studied in these two groups.
Survival was correlated with mean white blood cell count (23,000
survivors versus 40,000 nonsurvivors, P < 0.01); multisystem organ
failure (16 per cent survivors versus 47 per cent nonsurvivors, P <
0.05); and preoperative pressors (16 per cent survivors versus 47 per
cent nonsurvivors, P < 0.05). Overall mortality for the study period
was 47 per cent. Mortality rate analysis revealed a lower rate for the
more recent years (32 per cent for 2000 to 2006 versus 65 per cent for
1995 to 1999, P < 0.05). In the more recent years, the time elapsing
before colectomy was also lower (1.4 days versus 2.5 days,
nonsignificant), and patients had less preoperative hemodynamic
instability (70 per cent versus 31 per cent, P < 0.03). In one
institution, survival after surgery for PMC was found to be associated
with a mean white blood cell count (< 37,000), nondependence on
preoperative vasopressors, and surgical intervention before the onset
of hemodynamic instability.
Historical perspectives on studies of Clostridium difficile and C.
difficile infection.Clin
Infect Dis. 2008 Jan 15;46 Suppl 1:S4-11.
The initial
period of studies on Clostridium difficile (published during
1978-1980) appeared to provide a nearly complete portfolio of
criteria for diagnosing and treating C. difficile infection (CDI).
The putative pathogenic role of C. difficile was established using
Koch's postulates, risk factors were well-defined, use of a cell
cytotoxicity assay as the diagnostic test provided accurate results,
and treatment with oral vancomycin was highly effective and rapidly
incorporated into practice. During the next 10 years, enzyme
immunoassays (EIAs) were introduced as diagnostic tests and became
the standard for most laboratories. This was not because EIAs were
as good as the cell cytotoxicity assay; rather, EIAs were
inexpensive and yielded results quickly. Similarly, metronidazole
became the favored treatment because it was less expensive and
quelled fears of colonization with vancomycin-resistant organisms,
not because it was better than vancomycin therapy. Cephalosporins
replaced clindamycin as the major inducers of CDI because they were
so extensively used, rather than because they incurred the same
risk. Some serious issues remained unresolved during this period:
the major challenges were to determine ways to treat seriously ill
patients for whom it was not possible to get vancomycin into the
colon and to find methods that stop persistent relapses. These
concerns persist today.