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PubMed · 8646945

Clostridium difficile colitis in the critically ill.

S Grundfest-Broniatowski·M Quader·F Alexander·R M Walsh·I Lavery·J Milsom
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Abstract

UNLABELLED: Morbidity and treatment of Clostridium difficile colitis (CDC) continue to be controversial. Some claim minimum morbidity, which may be a function of differences in patient population and/or bacterial virulence. METHODS: To evaluate the effect of CDC in the critically ill, we retrospectively reviewed the records of 59 intensive care unit patients with CDC who were diagnosed by fecal toxin assays or clinical evidence of pseudomembranous colitis from January 1991 to October 1994. Symptoms, signs, antibiotic regimens, diagnostic tests, Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, morbidity, and mortality were analyzed, and results of surgical treatment were compared with the literature. RESULTS: Mean age was 66.4 (17-95) years, with a male to female ratio of 1.8:1. First treatment was metronidazole by mouth in 15 patients (25.4 percent), vancomycin by mouth in 30 patients (50.8 percent), sequential by mouth vancomycin/metronidazole in 3 patients (5.1 percent), and intravenous metronidazole in 5 patients (8.5 percent). Six patients had no medical therapy before surgery or discharge. Ten patients (17 percent) had recurrence and 12 (20.3 percent) required surgery for progressive toxicity or peritonitis. Of three patients who were initially treated by diverting stomas, one died and two required total colectomy (TAC). Two underwent partial resection (1 that was nearly a total colectomy), and seven others had a TAC. Surgical patients had worse mean APACHE II scores at diagnosis (24.4 vs. 19.9; P < 0.001). Thirty-day mortality in surgical patients was 41.7 vs. 14.7 percent in medical patients (P < 0.5). CONCLUSION: Twenty percent of critically ill patients with CDC required operation. TAC and diversion appeared to be more effective surgical treatments than diversion alone.

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APACHEAdolescentAdultAgedAged, 80 and overAnti-Bacterial AgentsColectomyCombined Modality TherapyCritical IllnessEnterocolitis, PseudomembranousFemaleHospital MortalityHumansMaleMetronidazoleMiddle AgedMorbidityRetrospective StudiesTreatment OutcomeVancomycinJournal ArticleReview

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S Grundfest-Broniatowski, M Quader, F Alexander, R M Walsh, I Lavery, J Milsom. 1996. Clostridium difficile colitis in the critically ill.. https://doi.org/10.1007/bf02056938

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A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group.

BACKGROUND: To determine whether a restrictive strategy of red-cell transfusion and a liberal strategy produced equivalent results in critically ill patients, we compared the rates of death from all causes at 30 days and the severity of organ dysfunction. METHODS: We enrolled 838 critically ill patients with euvolemia after initial treatment who had hemoglobin concentrations of less than 9.0 g per deciliter within 72 hours after admission to the intensive care unit and randomly assigned 418 patients to a restrictive strategy of transfusion, in which red cells were transfused if the hemoglobin concentration dropped below 7.0 g per deciliter and hemoglobin concentrations were maintained at 7.0 to 9.0 g per deciliter, and 420 patients to a liberal strategy, in which transfusions were given when the hemoglobin concentration fell below 10.0 g per deciliter and hemoglobin concentrations were maintained at 10.0 to 12.0 g per deciliter. RESULTS: Overall, 30-day mortality was similar in the two groups (18.7 percent vs. 23.3 percent, P= 0.11). However, the rates were significantly lower with the restrictive transfusion strategy among patients who were less acutely ill -- those with an Acute Physiology and Chronic Health Evaluation II score of < or =20 (8.7 percent in the restrictive-strategy group and 16.1 percent in the liberal-strategy group; P=0.03) -- and among patients who were less than 55 years of age (5.7 percent and 13.0 percent, respectively; P=0.02), but not among patients with clinically significant cardiac disease (20.5 percent and 22.9 percent, respectively; P=0.69). The mortality rate during hospitalization was significantly lower in the restrictive-strategy group (22.3 percent vs. 28.1 percent, P=0.05). CONCLUSIONS: A restrictive strategy of red-cell transfusion is at least as effective as and possibly superior to a liberal transfusion strategy in critically ill patients, with the possible exception of patients with acute myocardial infarction and unstable angina.

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