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Clostridioides difficile Enteritis in Patients Following Total Colectomy—a Rare but Genuine Clinical Entity

OBJECTIVE: Clostridioides difficile infection (CDI) frequently causes colitis following antibiotic exposure and is a leading cause of gastrointestinal infectious mortality. Infection in the small bowel, C. difficile enteritis (CDE), was previously thought impossible, but case series have challenged...

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Autores principales: Ulrich, Robert J, Bott, Jonathan, Imlay, Hannah, Lopez, Kerri, Cinti, Sandro, Rao, Krishna
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Oxford University Press 2019
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6822686/
https://www.ncbi.nlm.nih.gov/pubmed/31687419
http://dx.doi.org/10.1093/ofid/ofz409
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author Ulrich, Robert J
Bott, Jonathan
Imlay, Hannah
Lopez, Kerri
Cinti, Sandro
Rao, Krishna
author_facet Ulrich, Robert J
Bott, Jonathan
Imlay, Hannah
Lopez, Kerri
Cinti, Sandro
Rao, Krishna
author_sort Ulrich, Robert J
collection PubMed
description OBJECTIVE: Clostridioides difficile infection (CDI) frequently causes colitis following antibiotic exposure and is a leading cause of gastrointestinal infectious mortality. Infection in the small bowel, C. difficile enteritis (CDE), was previously thought impossible, but case series have challenged this dogma. Clostridioides difficile enteritis prevalence, severity, and potential risk factors are unknown. METHODS: We retrospectively analyzed all total colectomy patients over a 20-year period at our institution. C. difficile enteritis was defined by clinical symptoms and positive C. difficile stool testing after colectomy. We compared CDE cases to controls using multivariable analysis to identify potential CDE risk factors. RESULTS: C. difficile enteritis occurred in 44 of 855 (5.1%) patients, a median of 130 days after colectomy. Compared to controls, CDE patients were similar in age, gender, and presence of immunosuppression. The majority (64%) had antibiotics <30 days prior to CDE. In multivariable analysis, CDE risk factors included perioperative acid suppression (hazard ratio [HR], 2.52; 95% confidence interval [CI], 1.26–5.04; P = .009), colectomy for inflammatory bowel disease (HR, 2.95; CI, 1.29–6.72; P = .010), colectomy for CDI (HR, 9.95; CI, 2.70–36.63; P ≤ .001), and β-lactam use in the setting of enteral feeds (HR, 17.83; CI, 2.75–115.68; P = .003). C. difficile enteritis presented with severe disease half of the time, with 81.8% requiring hospitalization. CONCLUSIONS: C. difficile enteritis is a rare clinical entity that should be considered in postcolectomy patients presenting with CDI symptoms, even years after surgery. Like traditional CDI, likely CDE risk factors include acid suppression and inflammatory bowel disease. Prior antibiotic use in the setting of enteral feeds may amplify CDE risk. C. difficile enteritis often presents as severe disease and frequently requires hospitalization.
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spelling pubmed-68226862019-11-04 Clostridioides difficile Enteritis in Patients Following Total Colectomy—a Rare but Genuine Clinical Entity Ulrich, Robert J Bott, Jonathan Imlay, Hannah Lopez, Kerri Cinti, Sandro Rao, Krishna Open Forum Infect Dis Major Article OBJECTIVE: Clostridioides difficile infection (CDI) frequently causes colitis following antibiotic exposure and is a leading cause of gastrointestinal infectious mortality. Infection in the small bowel, C. difficile enteritis (CDE), was previously thought impossible, but case series have challenged this dogma. Clostridioides difficile enteritis prevalence, severity, and potential risk factors are unknown. METHODS: We retrospectively analyzed all total colectomy patients over a 20-year period at our institution. C. difficile enteritis was defined by clinical symptoms and positive C. difficile stool testing after colectomy. We compared CDE cases to controls using multivariable analysis to identify potential CDE risk factors. RESULTS: C. difficile enteritis occurred in 44 of 855 (5.1%) patients, a median of 130 days after colectomy. Compared to controls, CDE patients were similar in age, gender, and presence of immunosuppression. The majority (64%) had antibiotics <30 days prior to CDE. In multivariable analysis, CDE risk factors included perioperative acid suppression (hazard ratio [HR], 2.52; 95% confidence interval [CI], 1.26–5.04; P = .009), colectomy for inflammatory bowel disease (HR, 2.95; CI, 1.29–6.72; P = .010), colectomy for CDI (HR, 9.95; CI, 2.70–36.63; P ≤ .001), and β-lactam use in the setting of enteral feeds (HR, 17.83; CI, 2.75–115.68; P = .003). C. difficile enteritis presented with severe disease half of the time, with 81.8% requiring hospitalization. CONCLUSIONS: C. difficile enteritis is a rare clinical entity that should be considered in postcolectomy patients presenting with CDI symptoms, even years after surgery. Like traditional CDI, likely CDE risk factors include acid suppression and inflammatory bowel disease. Prior antibiotic use in the setting of enteral feeds may amplify CDE risk. C. difficile enteritis often presents as severe disease and frequently requires hospitalization. Oxford University Press 2019-10-31 /pmc/articles/PMC6822686/ /pubmed/31687419 http://dx.doi.org/10.1093/ofid/ofz409 Text en © The Author(s) 2019. Published by Oxford University Press on behalf of Infectious Diseases Society of America. http://creativecommons.org/licenses/by-nc-nd/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work is properly cited. For commercial re-use, please contact journals.permissions@oup.com
spellingShingle Major Article
Ulrich, Robert J
Bott, Jonathan
Imlay, Hannah
Lopez, Kerri
Cinti, Sandro
Rao, Krishna
Clostridioides difficile Enteritis in Patients Following Total Colectomy—a Rare but Genuine Clinical Entity
title Clostridioides difficile Enteritis in Patients Following Total Colectomy—a Rare but Genuine Clinical Entity
title_full Clostridioides difficile Enteritis in Patients Following Total Colectomy—a Rare but Genuine Clinical Entity
title_fullStr Clostridioides difficile Enteritis in Patients Following Total Colectomy—a Rare but Genuine Clinical Entity
title_full_unstemmed Clostridioides difficile Enteritis in Patients Following Total Colectomy—a Rare but Genuine Clinical Entity
title_short Clostridioides difficile Enteritis in Patients Following Total Colectomy—a Rare but Genuine Clinical Entity
title_sort clostridioides difficile enteritis in patients following total colectomy—a rare but genuine clinical entity
topic Major Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6822686/
https://www.ncbi.nlm.nih.gov/pubmed/31687419
http://dx.doi.org/10.1093/ofid/ofz409
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