The American Society of Colon and Rectal Surgeons Clinical Practice
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CLINICAL PRACTICE GUIDELINES 05/18/2021 on m7j+Lz0A3Xux7u8LH54Mj5YEKJ1nYV8VK4orUjhbpk89GhwzOnar+8anRBK3LfF1V2zEXE1u0nGxPGdFl1M3hEeUEtFEphcxy9cz7yeir/pEV8b5POc6vbIuuK2BN7bKd/4WfXOBO9Zdt9xCqbLQaKAuqUBNPYvKIxVC/YioDhw= by http://journals.lww.com/dcrjournal from Downloaded The American Society of Colon and Rectal Surgeons Downloaded Clinical Practice Guidelines for the Management of from http://journals.lww.com/dcrjournal Clostridioides difficile Infection Vitaliy Poylin, M.D.1 • Alexander T. Hawkins, M.D., M.P.H.2 • Anuradha R. Bhama, M.D.3 Marylise Boutros, M.D.4 • Amy L. Lightner, M.D.5 • Sahil Khanna, M.B.B.S., M.S.6 Ian M. Paquette, M.D.7 • Daniel L. Feingold, M.D.8 by m7j+Lz0A3Xux7u8LH54Mj5YEKJ1nYV8VK4orUjhbpk89GhwzOnar+8anRBK3LfF1V2zEXE1u0nGxPGdFl1M3hEeUEtFEphcxy9cz7yeir/pEV8b5POc6vbIuuK2BN7bKd/4WfXOBO9Zdt9xCqbLQaKAuqUBNPYvKIxVC/YioDhw= Prepared by the Clinical Practice Guidelines Committee of The American Society of Colon and Rectal Surgeons 1 Division of Gastrointestinal Surgery, Northwestern Medicine, Chicago, Illinois 2 Department of Surgery, Section of Colon & Rectal Surgery, Vanderbilt University Medical Center, Nashville, Tennessee 3 Department of Surgery, Division of Colon & Rectal Surgery, Rush University Medical Center, Chicago, Illinois 4 Jewish General Hospital, McGill University, Montreal, Quebec, Canada 5 Department of Colorectal Surgery, Digestive Disease Surgery Institute, Cleveland Clinic, Cleveland, Ohio 6 Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota 7 Department of Surgery, University of Cincinnati, Cincinnati, Ohio 8 Section of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey he American Society of Colon and Rectal These guidelines should not be deemed inclusive of all Surgeons (ASCRS) is dedicated to ensuring high- proper methods of care nor exclusive of methods of care quality patient care by advancing the science, reasonably directed toward obtaining the same results. Tprevention, and management of disorders and diseases The ultimate judgment regarding the propriety of any spe- of the colon, rectum, and anus. The Clinical Practice cific procedure must be made by the physician considering Guidelines Committee is composed of society members all the circumstances presented by the individual patient. who are chosen because they have demonstrated exper- tise in the specialty of colon and rectal surgery. This STATEMENT OF THE PROBLEM committee was created to lead international efforts in defining quality care for conditions related to the colon, Clostridioides difficile, formerly known as Clostridium dif- rectum, and anus and develop clinical practice guide- ficile, is an anaerobic, gram-positive, bacillus bacterium lines based on the best available evidence. Although not that can be a normal inhabitant of the human colon and proscriptive, these guidelines provide information on is most commonly transmitted via a fecal-oral route.1 which decisions can be made and do not dictate a spe- Alterations in the bacterial component of the microbiota, cific form of treatment. These guidelines are intended most often due to the use of antibiotics, can lead to eco- for the use of all practitioners, health care workers, and logical changes that select for both population growth of C patients who desire information about the management difficile as well as the induction of pathogenic behavior.2,3 of the conditions addressed by the topics covered in Although the number of patients with C difficile infection these guidelines. (CDI) in the United States appears relatively stable over the past decade (estimated 476,400 cases in 2011 associ- ated with 29,000 deaths and 462,100 cases in 2017 associ- Funding/Support: None reported. on ated with an estimated 20,500 deaths), the prevalence of 05/18/2021 3–5 Financial Disclosures: None reported. the disease remains high. Although the bacterium is present in the stool of approximately 3% of healthy adults, Correspondence: Daniel L. Feingold, M.D., Professor and Chair, up to 50% of those exposed to an inpatient facility may be Section of Colorectal Surgery, Rutgers University, 125 Patterson St, New asymptomatic carriers.5–8 Higher rates of CDI have been Brunswick, NJ 08901. E-mail: [email protected]. reported in patients after exposure to a prolonged dura- Dis Colon Rectum 2021; 64: 650–668 tion of antibiotics including perioperative antibiotics and DOI: 10.1097/DCR.0000000000002047 in patients with underlying comorbid conditions such as © The ASCRS 2021 IBD or immunosuppression.9–15 650 DISEASES OF THE COLON & RECTUM VOLUME 64: 6 (2021) Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited. DISEASES OF THE COLON & RECTUM VOLUME 64: 6 (2021) 651 TABLE 1. Terminology associated with Clostridioides difficile Term Definition Antibiotic-associated diarrhea Diarrhea in an individual who is currently taking or has recently taken antibiotics (not necessarily from C difficile, although C difficile is a cause of this type of diarrhea) Symptoms include watery diarrhea and abdominal cramping Asymptomatic colonization/carrier Patients colonized with C difficile without signs or symptoms of CDI C difficile infection (CDI) Presence of diarrhea characterized by >3 watery stools per day in the setting of positive C difficile testing Other symptoms can include fever, abdominal pain, cramping, nausea, and loss of appetite Higher-risk patients include elderly or immunocompromised patients, nursing home residents, and patients with severe underlying comorbidities who have been exposed to antibiotics Pseudomembranous colitis Presence of plaque formations on colon mucosa Considered pathognomonic for CDI in the appropriate clinical setting Mild/nonsevere infection CDI with leukocyte count <15 × 103/µL and creatinine <1.5 mg/dL Severe infection CDI with leukocyte count >15 × 103/µL or renal failure with creatinine >1.5 mg/dL Severe-complicated/fulminant disease CDI with hypotension, sepsis, shock, ileus, or megacolon or requiring intensive care unit care Toxic colitis CDI with extreme inflammation and dilation of the colon resulting from severe colitis Can present with abdominal distension and pain, fever, dehydration, sepsis Recurrent CDI Recurrence of symptoms with a positive stool test within 8 weeks after the completion of a course of CDI therapy with resolution of symptoms Refractory CDI More than 3 loose/watery stools per day with positive stool toxin assay despite appropriate therapy CDI = Clostridioides difficile infection. Clinical manifestations of C difficile can range from METHODOLOGY an asymptomatic carrier state to mild CDI to severe, fulminant, life-threatening infection. Although descrip- These guidelines were developed on the platform of the pre- viously published Practice Parameters for the Management tions of presentation and severity of disease vary in 42 the literature, commonly used definitions are included of Clostridium difficile Infection published in 2015. An in Table 1.16–19 C difficile infection most commonly organized, systematic search of MEDLINE, PubMed, involves the colon, where it can manifest with pseudo- EMBASE, Web of Science, and the Cochrane Database membranes covering the colonic mucosa (“pseudomem- of Collected Reviews was performed between September branous colitis”). In rare circumstances, CDI may also 1, 2014 and September 20, 2020. Key word combina- involve the small bowel.20,21 In the early 2000s, predomi- tions included “Clostridium difficile,” “Clostridioides dif- nantly in North America, but also in Europe, there was ficile,” “Clostridia,” “colitis,” “pseudomembranous colitis,” an increased incidence of more severe CDI due to the “antibiotic-associated,” “diarrhea,” “cdiff,” “vancomycin,” emergence of certain bacterial strains (ie, ribotypes) like “flagyl,” “metronidazole,” “rifaximin,” “antibiotics,” “col- the BI/NAP1/027/toxinotype III strain, which is associ- ectomy,” “ileostomy,” “lavage,” “toxin,” “toxin binding,” ated with a life-threatening infection.22–25 Although rates “fecal transplant,” “probiotics,” “transmission,” “recur- of infection with this “hypervirulent” strain recently rence,” “recalcitrant,” “treatment,” “length of therapy,” decreased in North America, rates remain significant “perforation,” “fulminant,” “prophylaxis,” “prevention,” globally.26,27 and “megacolon.” Although the search was not limited A variety of practice measures and collaborative by language, only abstracts and reports with human sub- efforts have been implemented to reduce the rate of CDI jects were included. Emphasis was placed on prospective and have had moderate success.18,19,28–32 The combination trials, meta-analyses, systematic reviews, and practice of antibiotic stewardship programs and improved diag- guidelines. Peer-reviewed observational studies and ret- nosis and treatment have decreased the incidence and rospective studies were included when higher-quality mortality rates of CDI; however, CDI continues to be a evidence was insufficient. Directed searches using embed- source of morbidity and mortality due in part to a rise in ded references from primary articles were performed in recurrent and resistant infections.33–37 The relatively high selected circumstances. In brief, 8651 titles were identi- incidence of CDI and the significant economic burden of fied after excluding duplicates, and these abstracts were certain infection control measures, such as “deep cleaning” screened. Overall, 8014 articles were excluded and a total of hospital