Timing and type of surgical treatment of Clostridium difficile-associated disease

A practice management guideline from the Eastern Association for the Surgery of Trauma

Paula Ferrada, Catherine G. Velopulos, Shahnaz Sultan, Elliott R. Haut, Emily Johnson, Anita Praba-Egge, Toby Enniss, Heath Dorion, Niels D. Martin, Patrick Bosarge, Amy Rushing, Therese M. Duane

Research output: Contribution to journalArticle

24 Citations (Scopus)

Abstract

Background: Clostridium difficile infection is the leading cause of nosocomial diarrhea in the United States; however, few patients will develop fulminant C. difficile-associated disease (CDAD), necessitating an urgent operative intervention. Mortality for patients who require operative intervention is very high, up to 80% in some series. Since there is no consensus in the literature regarding the best operative treatment for this disease, we sought to answer the following:PICO [population, intervention, comparison, and outcome] Question 1: In adult patients with CDAD, does early surgery compared with late surgery, as defined by the need for vasopressors, decrease mortality?PICO Question 2: In adult patients with CDAD, does total abdominal colectomy (TAC) compared with other types of surgical intervention decrease mortality? Methods: A subcommittee of the Practice Management Guideline Committee of the Eastern Association for the Surgery of Trauma conducted a systematic review and meta-analysis for the selected questions. RevMan software was used to generate forest plots. Grading of Recommendations, Assessment, Development and Evaluations methodology was used to rate the quality of the evidence, using GRADEpro software to create evidence tables. Results: Reduction in mortality was significantly associated with early surgery, with a risk ratio (RR) of 0.5 (95% confidence interval [CI], 0.35-0.72). The quality of evidence was rated "moderate." Considering only the first procedure performed, mortality seemed to trend higher for TAC, with an RR of 1.11 (95% CI, 0.69-1.80). Considering only the actual procedure performed, the point estimate switched sides, showing a trend toward decreased mortality with TAC (RR, 0.86; 95% CI, 0.56-1.31). The quality of evidence was rated "very low." Conclusion: We strongly recommend that adult patients with CDAD undergo early surgery, before the development of shock and need for vasopressors. We conditionally recommend total or subtotal colectomy (vs. partial colectomy or other surgery) when the diagnosis of The Centers for Disease Control and Prevention is known.

Original languageEnglish (US)
Pages (from-to)1484-1494
Number of pages11
JournalJournal of Trauma and Acute Care Surgery
Volume76
Issue number6
DOIs
StatePublished - Jan 1 2014

Fingerprint

Clostridium difficile
Practice Management
Practice Guidelines
Colectomy
Mortality
Wounds and Injuries
Odds Ratio
Confidence Intervals
Therapeutics
Software
Clostridium Infections
Centers for Disease Control and Prevention (U.S.)
Meta-Analysis
Diarrhea
Shock
Population

Keywords

  • Clostridium-difficile outcomes
  • Clostridiumdifficile mortality
  • Fulminant CDAD and surgery
  • guidelines and GRADE methodology
  • surgery and Clostridium-difficile associated disease

Cite this

Timing and type of surgical treatment of Clostridium difficile-associated disease : A practice management guideline from the Eastern Association for the Surgery of Trauma. / Ferrada, Paula; Velopulos, Catherine G.; Sultan, Shahnaz; Haut, Elliott R.; Johnson, Emily; Praba-Egge, Anita; Enniss, Toby; Dorion, Heath; Martin, Niels D.; Bosarge, Patrick; Rushing, Amy; Duane, Therese M.

In: Journal of Trauma and Acute Care Surgery, Vol. 76, No. 6, 01.01.2014, p. 1484-1494.

Research output: Contribution to journalArticle

Ferrada, P, Velopulos, CG, Sultan, S, Haut, ER, Johnson, E, Praba-Egge, A, Enniss, T, Dorion, H, Martin, ND, Bosarge, P, Rushing, A & Duane, TM 2014, 'Timing and type of surgical treatment of Clostridium difficile-associated disease: A practice management guideline from the Eastern Association for the Surgery of Trauma', Journal of Trauma and Acute Care Surgery, vol. 76, no. 6, pp. 1484-1494. https://doi.org/10.1097/TA.0000000000000232
Ferrada, Paula ; Velopulos, Catherine G. ; Sultan, Shahnaz ; Haut, Elliott R. ; Johnson, Emily ; Praba-Egge, Anita ; Enniss, Toby ; Dorion, Heath ; Martin, Niels D. ; Bosarge, Patrick ; Rushing, Amy ; Duane, Therese M. / Timing and type of surgical treatment of Clostridium difficile-associated disease : A practice management guideline from the Eastern Association for the Surgery of Trauma. In: Journal of Trauma and Acute Care Surgery. 2014 ; Vol. 76, No. 6. pp. 1484-1494.
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abstract = "Background: Clostridium difficile infection is the leading cause of nosocomial diarrhea in the United States; however, few patients will develop fulminant C. difficile-associated disease (CDAD), necessitating an urgent operative intervention. Mortality for patients who require operative intervention is very high, up to 80{\%} in some series. Since there is no consensus in the literature regarding the best operative treatment for this disease, we sought to answer the following:PICO [population, intervention, comparison, and outcome] Question 1: In adult patients with CDAD, does early surgery compared with late surgery, as defined by the need for vasopressors, decrease mortality?PICO Question 2: In adult patients with CDAD, does total abdominal colectomy (TAC) compared with other types of surgical intervention decrease mortality? Methods: A subcommittee of the Practice Management Guideline Committee of the Eastern Association for the Surgery of Trauma conducted a systematic review and meta-analysis for the selected questions. RevMan software was used to generate forest plots. Grading of Recommendations, Assessment, Development and Evaluations methodology was used to rate the quality of the evidence, using GRADEpro software to create evidence tables. Results: Reduction in mortality was significantly associated with early surgery, with a risk ratio (RR) of 0.5 (95{\%} confidence interval [CI], 0.35-0.72). The quality of evidence was rated {"}moderate.{"} Considering only the first procedure performed, mortality seemed to trend higher for TAC, with an RR of 1.11 (95{\%} CI, 0.69-1.80). Considering only the actual procedure performed, the point estimate switched sides, showing a trend toward decreased mortality with TAC (RR, 0.86; 95{\%} CI, 0.56-1.31). The quality of evidence was rated {"}very low.{"} Conclusion: We strongly recommend that adult patients with CDAD undergo early surgery, before the development of shock and need for vasopressors. We conditionally recommend total or subtotal colectomy (vs. partial colectomy or other surgery) when the diagnosis of The Centers for Disease Control and Prevention is known.",
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AU - Haut, Elliott R.

AU - Johnson, Emily

AU - Praba-Egge, Anita

AU - Enniss, Toby

AU - Dorion, Heath

AU - Martin, Niels D.

AU - Bosarge, Patrick

AU - Rushing, Amy

AU - Duane, Therese M.

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N2 - Background: Clostridium difficile infection is the leading cause of nosocomial diarrhea in the United States; however, few patients will develop fulminant C. difficile-associated disease (CDAD), necessitating an urgent operative intervention. Mortality for patients who require operative intervention is very high, up to 80% in some series. Since there is no consensus in the literature regarding the best operative treatment for this disease, we sought to answer the following:PICO [population, intervention, comparison, and outcome] Question 1: In adult patients with CDAD, does early surgery compared with late surgery, as defined by the need for vasopressors, decrease mortality?PICO Question 2: In adult patients with CDAD, does total abdominal colectomy (TAC) compared with other types of surgical intervention decrease mortality? Methods: A subcommittee of the Practice Management Guideline Committee of the Eastern Association for the Surgery of Trauma conducted a systematic review and meta-analysis for the selected questions. RevMan software was used to generate forest plots. Grading of Recommendations, Assessment, Development and Evaluations methodology was used to rate the quality of the evidence, using GRADEpro software to create evidence tables. Results: Reduction in mortality was significantly associated with early surgery, with a risk ratio (RR) of 0.5 (95% confidence interval [CI], 0.35-0.72). The quality of evidence was rated "moderate." Considering only the first procedure performed, mortality seemed to trend higher for TAC, with an RR of 1.11 (95% CI, 0.69-1.80). Considering only the actual procedure performed, the point estimate switched sides, showing a trend toward decreased mortality with TAC (RR, 0.86; 95% CI, 0.56-1.31). The quality of evidence was rated "very low." Conclusion: We strongly recommend that adult patients with CDAD undergo early surgery, before the development of shock and need for vasopressors. We conditionally recommend total or subtotal colectomy (vs. partial colectomy or other surgery) when the diagnosis of The Centers for Disease Control and Prevention is known.

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