Pseudomembranous Colitis Surgery Guidelines

Updated: Feb 23, 2021
  • Author: Said Fadi Yassin, MD; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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Guidelines

WSES Guidelines on C difficile Infection in Surgical Patients

In February 2019, the World Society of Emergency Surgery (WSES) published the following guidelines on diagnosis and treatment of Clostridioides (Clostridium) difficile infection (CDI) in surgical patients. [15]

Diagnosis

Diagnosis of CDI should be based on clinical signs and symptoms in combination with laboratory tests. Stool testing should only be performed on diarrheal stools from at-risk patients with clinically significant diarrhea (≥3 loose stools in 24 hours) with no obvious alternative explanation.

For patients with ileus who may be unable to produce stool specimens, polymerase chain reaction (PCR) testing of perirectal swabs is an acceptable alternative to stool specimen analysis.

Nucleic acid amplification testing (NAAT) for C difficile toxin genes appears to be sensitive and specific and may be used as a standard diagnostic test for CDI. NAAT may be performed as a single-step algorithm or included in a two-step algorithm starting with toxin enzyme immunoassay (EIA).

Glutamate dehydrogenase (GDH) testing is sensitive but does not differentiate between toxigenic and nontoxigenic strains. It may be used in association with toxin A/B EIA testing. Algorithms including screening with EIA for GDH followed by toxin assay may be suggested.

EIA for toxin A/B is fast, inexpensive, and highly specific but is relatively insensitive and is not recommended alone.

C difficile culture is relatively slow but sensitive and is rarely performed as a routine diagnostic test. It is recommended for subsequent epidemiologic typing and characterization of strains.

Repeat testing after a first negative sample during the same diarrheal episode may be useful only in selected cases with (a) ongoing clinical suspicion during an epidemic situation or (b) high clinical suspicion during endemic situations.

Computed tomography (CT) is suggested for patients with clinical manifestations of severe-to-complicated C difficile colitis; however, it is not sensitive enough for screening.

Ultrasonography (US) may be useful in critically ill patients suspected of having pseudomembranous colitis who cannot be transported to the CT suite.

Flexible sigmoidoscopy may be helpful in diagnosing C difficile colitis when there is a high level of clinical suspicion for CDI.

Antibiotic therapy

Unnecessary antibiotics should be discontinued if CDI is suspected. Unnecessary proton pump inhibitors (PPIs) should be discontinued in patients at high risk for CDI.

Empirical antibiotic therapy should be avoided unless CDI is strongly suspected. In such cases, empirical therapy for CDI should be considered while test results are awaited.

Oral metronidazole should be limited to treatment of an initial episode of mild-to-moderate CDI. Oral vancomycin is recommended for treatment of mild-to-moderate disease unresponsive to metronidazole. Repeated or prolonged courses of metronidazole should be avoided. Oral vancomycin and fidaxomicin are both recommended for treatment of severe CDI.

When oral antibiotics cannot reach the colon, vancomycin may be administered as a retention enema via a large rectal tube or catheter.

Fidaxomicin may be used to treat CDI, especially in patients at higher risk for recurrence (eg, elderly patients or those receiving concomitant antibiotics).

Surgical management

Patients with severe CDI who progress to systemic toxicity should undergo early surgical consultation and should be evaluated for potential surgical intervention.

For patients with fulminant colitis, total colectomy should be considered. However, diverting loop ileostomy with colonic lavage is a useful alternative.

Fulminant colitis should be treated with high-dose vancomycin (500 mg q6hr), orally or via enema or both, in combination with intravenous (IV) metronidazole (500 mg q8hr).

Supportive care

Early detection of shock and aggressive management of organ dysfunction are essential for improved outcomes in fulminant colitis. Supportive measures (eg, IV fluid resuscitation, albumin supplementation, and electrolyte replacement) should be provided to all patients with severe CDI.

Recurrent CDI

The first recurrence of CDI may be treated with vancomycin (particularly if metronidazole was used for the initial episode) or fidaxomicin. Antibiotic options for further recurrences include oral vancomycin in a tapered and pulsed regimen.

Probiotics

Limited direct evidence supports the use of probiotics in managing a first episode of CDI as an adjunct to antibiotics for immunocompetent patients.

Prophylactic probiotics may be considered for inpatients receiving antibiotics during a high-risk period before the disease develops. Probiotics should be not used in immunocompromised patients.

Probiotics for prevention of recurrent CDI may be an effective adjunct to standard antibiotic treatment (vancomycin) in patients with at least one prior episode of CDI.

Fecal microbiota transplantation

Fecal microbiota transplantation (FMT) may be an effective option for patients with multiple recurrences of CDI in whom appropriate antibiotic treatments have failed.

Monoclonal antibodies

Coadjuvant monoclonal antibody (bezlotoxumab) therapy may prevent CDI recurrences, particularly in patients who have CDI due to the 027 epidemic strain, are immunocompromised, or have severe CDI.

Intravenous immunoglobulin

IV immunoglobulin (IVIG) should be used only as adjunctive therapy in patients with multiple recurrences or fulminant CDI.

Enteral nutrition

Tube feeding patients should be clinically assessed due to their risk for developing CDI.

Antimotility agents

The use of antiperistaltic agents to treat CDI is discouraged. If such agents are used to control persistent symptoms, they must always be accompanied by medical therapy.

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IDSA/SHEA Guidelines on C difficile Infection in Adults and Children

In 2018, the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) published updated clinical practice guidelines on treatment of CDI in adults and children. [14]

Adult patients

Initial episode

Either vancomycin or fidaxomicin is recommended over metronidazole, at a dosage of vancomycin 125 mg PO q6hr or fidaxomicin 200 mg q12hr for 10 days.

If access to vancomycin or fidaxomicin is limited, metronidazole is suggested for an initial episode of nonsevere CDI only, at a dosage of 500 mg PO q8hr for 10 days. Repeated or prolonged courses should be avoided.

Fulminant infection

Vancomycin PO is the regimen of choice (strong recommendation, moderate quality of evidence); administration per rectum is acceptable if ileus is present. The dosage is 500 mg PO q6hr and 500 mg in ~100 mL normal saline per rectum q6hr as a retention enema. IV metronidazole should be administered together with oral or rectal vancomycin, particularly if ileus is present; the IV dosage is 500 mg q8hr.

If surgical management is necessary for severely ill patients, perform subtotal colectomy with preservation of the rectum; diverting loop ileostomy with colonic lavage followed by antegrade vancomycin flushes is an alternative.

Recurrent infection

A first recurrence of CDI may be treated with (a) vancomycin PO as a tapered and pulsed regimen rather than a second standard 10-day course of vancomycin or (b) a 10-day course of fidaxomicin rather than a standard 10-day course of vancomycin or (c) a standard 10-day course of vancomycin rather than a second course of metronidazole if metronidazole was used for the primary episode.

For patients with more than one recurrence, antibiotic treatment may consist of (a) oral vancomycin in a tapered and pulsed regimen, (b) a standard course of oral vancomycin followed by rifaximin, or (c) fidaxomicin.

For patients with multiple recurrences in whom appropriate antibiotic treatments have failed, FMT is recommended.

Current data are insufficient to recommend extending the length of anti–C difficile treatment beyond the recommended course empirically for patients who require continued antibiotic therapy directed against the underlying infection or restarting an anti–C difficile agent for those who require retreatment with antibiotics shortly after completion of CDI treatment.

Pediatric patients

For children with an initial episode or a first recurrence of nonsevere CDI, either metronidazole or vancomycin is recommended.

For children with an initial episode of severe CDI, oral vancomycin is recommended over metronidazole.

For children with more than one episode of recurrent CDI, oral vancomycin is recommended over metronidazole.

For children with multiple recurrences of CDI after standard antibiotic treatments, FMT may be considered.

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