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Patterns of Care and Predictors of Mortality

Elizabeth A. Sailhamer, MD, MMSc; Katherine Carson, MD; Yuchiao Chang, PhD; Nikolaos Zacharias, MD; Konstantinos Spaniolas, MD; Malek Tabbara, MD; Hasan B. Alam, MD; Marc A. DeMoya, MD; George C. Velmahos, MD

Arch Surg. 2009;144(5):433-439.

Hypothesis  There exist predictors of mortality and the need for colectomy among patients with fulminant Clostridium difficile colitis.

Design  Retrospective study.

Setting  Academic tertiary referral center.

Patients  We reviewed the records of 4796 inpatients diagnosed as having C difficile colitis from January 1, 1996, to December 31, 2007, and identified 199 (4.1%) with fulminant C difficile colitis, as defined by the need for colectomy or admission to the intensive care unit for C difficile colitis.

Main Outcome Measures  Risk of inpatient mortality was determined by multivariate analysis according to clinical predictors, colectomy, and medical team.

Results  The inhospital mortality rate for fulminant C difficile colitis was 34.7%. Independent predictors of mortality included the following: (1) age of 70 years or older, (2) severe leukocytosis or leukopenia (white blood cell count, 35 000/µL or <4000/µL) or bandemia (neutrophil bands, 10%), and (3) cardiorespiratory failure (intubation or vasopressors). When all 3 factors were present, the mortality rate was 57.1%; when all 3 were absent, the mortality rate was 0%. Patients who underwent colectomy had a trend toward decreased mortality rates (odds ratio, 0.49; 95% confidence interval, 0.21-1.1; P = .08). Among patients admitted primarily for fulminant C difficile colitis, care in the surgical department compared with the nonsurgical department resulted in a higher rate of operation (85.1% vs 11.2%; P < .001) and lower mortality rates (12.8% vs 39.3%; P = .001). Patients admitted directly to the surgical department had a shorter mean (SD) interval from admission to operation (0 vs 1.7 [2.8] days; P = .001).

Conclusions  Despite awareness and treatment, fulminant C difficile colitis remains a highly lethal disease. Reliable predictors of mortality exist and should be used to prompt aggressive surgical intervention. Survival rates are higher in patients who were cared for by surgical vs nonsurgical departments, possibly because of more frequent and earlier operations.

Author Affiliations: Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care (Drs Sailhamer, Zacharias, Spaniolas, Tabbara, Alam, DeMoya, Velmahos, and Carson), and General Medicine Division, Division of Biostatistics (Dr Chang), Massachusetts General Hospital, Harvard Medical School, Boston.

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Fulminant Clostridium difficile Colitis—Invited Critique
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Arch Surg. 2009;144(5):439-440.
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