Surgery in CDI

Q: All of the following calls for surgical consultation in Clostridium difficle infection (CDI) except? 

A) Ileus
B) Peritonitis 
C Altered mental status 
D) When WBC count of ≥50,000 cells/mL 
E) Admission to ICU


Answer: D

The objective of the above question is to highlight an extremely important lesson in the surgical management of CDI i.e., "timing is the key and early surgical intervention is preferred in fulminant CDI". There are many indicators which may seem benign but call for a surgical consult in fulminant CDI. It includes hypotension, fever ≥38.5°C, significant abdominal distention or tenderness, altered mental status, WBC count of ≥20,000 cells/mL, lactate levels >2.2 mmol/L, admission to ICU, any sign of organ failures like ARDS or renal failure and no response to antibiotics within 3-5 days.

It may be too late by the time WBC count goes ≥ 50,000 cells/mL.

#infectious-disease
#surgical-critical care 


References:

1. van der Wilden GM, Velmahos GC, Chang Y, et al. Effects of a New Hospital-Wide Surgical Consultation Protocol in Patients with Clostridium difficile Colitis. Surg Infect (Larchmt) 2017; 18:563. 

2. Sailhamer EA, Carson K, Chang Y, et al. Fulminant Clostridium difficile colitis: patterns of care and predictors of mortality. Arch Surg 2009; 144:433. 

3.  Hall JF, Berger D. Outcome of colectomy for Clostridium difficile colitis: a plea for early surgical management. Am J Surg 2008; 196:384. 

4. Ferrada P, Velopulos CG, Sultan S, et al. Timing and type of surgical treatment of Clostridium difficile-associated disease: a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2014; 76:1484.