Adams Sasha D, Mercer David W
Department of Surgery, University of Texas Medical School at Houston, Houston, Texas 77030, USA.
Curr Opin Crit Care. 2007 Aug;13(4):450-5. doi: 10.1097/MCC.0b013e3282638879.
Clostridium difficile is the most common cause of nosocomial infectious diarrhea in adults. The purpose of this review is to increase awareness that infection from C. difficile is not always indolent, but with fulminant colitis, it can be lethal. The epidemiology, pathogenesis and treatment of C. difficile infection are discussed, with special emphasis on management of fulminant colitis.
Clostridium difficile causes fulminant colitis in 3-8% of patients. Early predictors of disease include immunosuppression, hypotension, hypoalbuminemia, and a pronounced leukocytosis. In patients with fulminant colitis, early colectomy before vasopressor therapy is required and may improve survival.
The incidence and virulence of C. difficile infection are increasing. Antibiotic use and length of hospital stay correlate strongly with infection. Oral or intravenous metronidazole is the recommended first-line therapy, with discontinuation of systemic antibiotics if possible. Forty percent of patients may have a prolonged course and 20% will relapse despite adequate therapy. Fulminant colitis develops in 3-8% of patients; diagnosis can be difficult with diarrhea absent in 20% of the subgroup. Once diagnosed, subtotal colectomy with ileostomy is usually required. In patients with a marked leukocytosis or bandemia, surgery is advisable because the leukocytosis frequently precedes hypotension and the requirement for vasopressor therapy, which carries a poor prognosis.
艰难梭菌是成人医院感染性腹泻最常见的病因。本综述旨在提高人们的认识，即艰难梭菌感染并非总是隐匿性的，在暴发性结肠炎时，它可能是致命的。本文讨论了艰难梭菌感染的流行病学、发病机制和治疗方法，特别强调了暴发性结肠炎的管理。
艰难梭菌在3% - 8%的患者中引起暴发性结肠炎。疾病的早期预测因素包括免疫抑制、低血压、低白蛋白血症和明显的白细胞增多。对于暴发性结肠炎患者，需要在使用血管升压药治疗前尽早进行结肠切除术，这可能会提高生存率。
艰难梭菌感染的发病率和毒力正在增加。抗生素的使用和住院时间与感染密切相关。口服或静脉注射甲硝唑是推荐的一线治疗方法，如有可能应停用全身抗生素。40%的患者病程可能延长，20%的患者即使接受充分治疗仍会复发。3% - 8%的患者会发生暴发性结肠炎；20%的亚组患者无腹泻，诊断可能困难。一旦确诊，通常需要行结肠次全切除术并造口术。对于白细胞明显增多或出现杆状核细胞增多的患者，建议进行手术，因为白细胞增多通常先于低血压和需要使用血管升压药治疗，而后者预后较差。
