Peter K. Kim
Albert Einstein College of Medicine, USA
Dr. Peter K. Kim, MD, FACS completed his undergraduate studies magna cum laude in Biochemistry at Harvard College, M.D. with honors in research at Weill Medical College of Cornell University, and his surgical training at the University of Pittsburgh and Mount Sinai Medical Center. He is presently Assistant Professor of Surgery at Albert Einstein College of Medicine and Jacobi Medical Center in the Bronx, NY. He specializes his work in the complex management of lifethreatening surgical infections.
Severe C.difficile colitis refractory to medical therapy may require surgical intervention including subtotal colectomy. We initiated an adjuvant intracolonic vancomycin (ICV) enema protocol for inpatients with severe C.difficile colitis and compared the response in patients admitted from the community and nursing homes. A single hospital, retrospective chart review was performed on 47 consecutive patients with C.difficile colitis treated with ICV (1 gram in 500 cc normal saline q 6 h) from January 2007 through October 2009. Associations of patient characteristics with outcomes (response to ICV therapy, need for surgery, and mortality) were examined with bivariate tests and multivariable logistic models adjusting for age, hypoalbuminemia, acidosis, and nursing home status.Overall, 37 of 47 patients (79%) survived after ICV therapy.Incomplete responders who had surgery were more likely to survive than those patients who did not undergo subtotal colectomy (p<0.01). Seven of 9 patients who underwent surgery survived. Nursing home residence, acidosis, and hypoalbuminemia were significantly associated with non-resolution in bivariate analysis (all p<0.01). Multivariable logistic models confirmed that acidosis correlated with incomplete response to ICV (P=0.02), and older age correlated with death (P=0.04); hypoalbuminemia correlated significantly with both incomplete response to ICV and death (P=0.04). Hypoalbuminemia is a major predictor of poor response to ICV and death from severe C.Difficile colitis. Early surgery should be considered for geriatric patients who present with hypoalbuminemia and acidosis. In this discussion, we will review the current medical and surgical therapies for severe C.Difficile colitis.