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W3137392258 abstract "The American Society of Colon and Rectal Surgeons (ASCRS) is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Clinical Practice Guidelines Committee is composed of society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. Although not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician considering all the circumstances presented by the individual patient. STATEMENT OF THE PROBLEM Clostridioides difficile, formerly known as Clostridium difficile, is an anaerobic, gram-positive, bacillus bacterium that can be a normal inhabitant of the human colon and is most commonly transmitted via a fecal-oral route.1 Alterations in the bacterial component of the microbiota, most often due to the use of antibiotics, can lead to ecological changes that select for both population growth of C difficile as well as the induction of pathogenic behavior.2,3 Although the number of patients with C difficile infection (CDI) in the United States appears relatively stable over the past decade (estimated 476,400 cases in 2011 associated with 29,000 deaths and 462,100 cases in 2017 associated with an estimated 20,500 deaths), the prevalence of the disease remains high.3–5 Although the bacterium is present in the stool of approximately 3% of healthy adults, up to 50% of those exposed to an inpatient facility may be asymptomatic carriers.5–8 Higher rates of CDI have been reported in patients after exposure to a prolonged duration of antibiotics including perioperative antibiotics and in patients with underlying comorbid conditions such as IBD or immunosuppression.9–15 Clinical manifestations of C difficile can range from an asymptomatic carrier state to mild CDI to severe, fulminant, life-threatening infection. Although descriptions of presentation and severity of disease vary in the literature, commonly used definitions are included in Table 1.16–19C difficile infection most commonly involves the colon, where it can manifest with pseudomembranes covering the colonic mucosa (“pseudomembranous colitis”). In rare circumstances, CDI may also involve the small bowel.20,21 In the early 2000s, predominantly in North America, but also in Europe, there was an increased incidence of more severe CDI due to the emergence of certain bacterial strains (ie, ribotypes) like the BI/NAP1/027/toxinotype III strain, which is associated with a life-threatening infection.22–25 Although rates of infection with this “hypervirulent” strain recently decreased in North America, rates remain significant globally.26,27 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 testingOther symptoms can include fever, abdominal pain, cramping, nausea, and loss of appetiteHigher-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 mucosaConsidered 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 colitisCan 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. A variety of practice measures and collaborative efforts have been implemented to reduce the rate of CDI and have had moderate success.18,19,28–32 The combination of antibiotic stewardship programs and improved diagnosis and treatment have decreased the incidence and mortality rates of CDI; however, CDI continues to be a source of morbidity and mortality due in part to a rise in recurrent and resistant infections.33–37 The relatively high incidence of CDI and the significant economic burden of certain infection control measures, such as “deep cleaning” of hospital rooms, requires a careful balance between prevention and cost.21,38–41 Although several guidelines have been published on this subject, CDI presents a unique challenge in colon and rectal surgery.17,18,20,42,43 This clinical practice guideline focuses on the evaluation, management, and prevention of CDI. METHODOLOGY These guidelines were developed on the platform of the previously published Practice Parameters for the Management of Clostridium difficile Infection published in 2015.42 An organized, systematic search of MEDLINE, PubMed, EMBASE, Web of Science, and the Cochrane Database of Collected Reviews was performed between September 1, 2014 and September 20, 2020. Key word combinations included “Clostridium difficile,” “Clostridioides difficile,” “Clostridia,” “colitis,” “pseudomembranous colitis,” “antibiotic-associated,” “diarrhea,” “cdiff,” “vancomycin,” “flagyl,” “metronidazole,” “rifaximin,” “antibiotics,” “colectomy,” “ileostomy,” “lavage,” “toxin,” “toxin binding,” “fecal transplant,” “probiotics,” “transmission,” “recurrence,” “recalcitrant,” “treatment,” “length of therapy,” “perforation,” “fulminant,” “prophylaxis,” “prevention,” and “megacolon.” Although the search was not limited by language, only abstracts and reports with human subjects were included. Emphasis was placed on prospective trials, meta-analyses, systematic reviews, and practice guidelines. Peer-reviewed observational studies and retrospective studies were included when higher-quality evidence was insufficient. Directed searches using embedded references from primary articles were performed in selected circumstances. In brief, 8651 titles were identified after excluding duplicates, and these abstracts were screened. Overall, 8014 articles were excluded and a total of 637 full-text articles were evaluated of which 389 were excluded due to the availability of higher-level evidence, and a total of 248 were articles included in the final document (Fig. 1). The source material was evaluated for methodologic quality, the evidence base was examined, and a treatment guideline was formulated by the subcommittee for this guideline. The final grade of recommendation and level of evidence for each statement were determined using the Grades of Recommendation, Assessment, Development, and Evaluation system (Table 2).44 When there was disagreement regarding the evidence or grade or treatment guidelines, consensus was obtained from the committee chair, vice chair, and 2 assigned reviewers. Members of the ASCRS Clinical Practice Guidelines Committee worked in joint production of these guidelines from inception to publication. Recommendations formulated by the subcommittee were reviewed by the entire Clinical Practice Guidelines Committee as well as by an invited gastroenterologist and an infectious disease specialist. The submission was peer-reviewed by Diseases of the Colon & Rectum, and the final recommendations were approved by the ASCRS Executive Council. In general, each ASCRS Clinical Practice Guideline is updated every 5 years. No funding was received for preparing this guideline, and the authors have declared no competing interests related to this material. This guideline conforms to the Appraisal of Guidelines for Research and Evaluation (AGREE) checklist. TABLE 2. - The GRADE system: grading recommendations. Description Benefit versus risk and burdens Methodologic quality of supporting evidence Implications 1A Strong recommendation,High-quality evidence Benefits clearly outweigh risk and burdens or vice versa RCTs without important limitations or overwhelming evidence from observational studies Strong recommendation, can apply to most patients in most circumstances without reservation 1B Strong recommendation,Moderate-quality evidence Benefits clearly outweigh risk and burdens or vice versa RCTs with important limitations (inconsistent results, methodologic flaws, indirect or imprecise) or exceptionally strong evidence from observational studies Strong recommendation, can apply to most patients in most circumstances without reservation 1C Strong recommendation,Low- or very-low quality evidence Benefits clearly outweigh risk and burdens or vice versa Observational studies or case series Strong recommendation but may change when higher-quality evidence becomes available 2A Weak recommendation,High-quality evidence Benefits closely balanced with risks and burdens RCTs without important limitations or overwhelming evidence from observational studies Weak recommendation, best action may differ depending on circumstances or patients’ or societal values 2B Weak recommendations,Moderate-quality evidence Benefits closely balanced with risks and burdens RCTs with important limitations (inconsistent results, methodologic flaws, indirect or imprecise) or exceptionally strong evidence from observational studies Weak recommendation, best action may differ depending on circumstances or patients’ or societal values 2C Weak recommendation,Low- or very-low quality evidence Uncertainty in the estimates of benefits, risks, and burden; benefits, risk and burden may be closely balanced Observational studies or case series Very weak recommendations; other alternatives may be equally reasonable GRADE = Grades of Recommendation, Assessment, Development, and Evaluation; RCT = randomized controlled trial.Adapted from Guyatt G, Gutermen D, Baumann MH, et al. Grading strength of recommendations and quality of evidence in clinical guidelines: report from an American College of Chest Physicians Task Force. Chest. 2006;129:174–181. Used with permission. FIGURE 1.: PRISMA literature search flow sheet.Evaluation 1. When CDI is suspected, a disease-specific history should be performed emphasizing risk factors, symptoms, underlying comorbidities, and signs of severe or fulminant disease. Grade of recommendation: Strong recommendation based on low-quality evidence, 1C. Symptoms related to CDI result from the release of bacterial toxins that cause inflammation of the colonic mucosa and fluid secretion resulting in diarrhea and typically manifest soon after starting antibiotic therapy for another disease process, but can be delayed for up to 3 months after discontinuation of antimicrobial therapy.1,45 The strongest risk factor for developing CDI is recent antibiotic use (within 3 months), and increased duration of exposure and number of antibiotics used are associated with higher risk for developing CDI.9,43,46–48 Although most antibiotics can change the colonic bacterial milieu leading to dysbiosis, drugs such as clindamycin, ampicillin, penicillin with beta-lactamase inhibitors, fluoroquinolones, and third-generation cephalosporins are more commonly associated with developing CDI.46,49 Other risk factors for CDI include having contact with a health care facility whether as an inpatient or an outpatient. Historically, CDI was considered a nosocomial infection solely due to hospitalization or living in an extended care facility; however, an increasing proportion of CDI has been recognized as community acquired, which may be divided into community associated and community-onset health care facility associated.50–52 Risk factors for community-acquired CDI are not well defined, but appear to be similar to nosocomial CDI and include environmental and antibiotic exposures as reviewed above.50 Other notable risk factors include advanced age, female sex, immunosuppression, IBD (especially ulcerative colitis), and medical comorbidities (eg, congestive heart failure, diabetes, renal failure, and liver disease).11,43,46,50–64 Emergency hospitalization and surgery, especially GI surgery, malnutrition, tube feeding, acid suppression with proton pump inhibitors, and bowel preparation are also considered potential risk factors for developing CDI.46,65,66 The clinical presentation of CDI ranges from mild diarrhea to fulminant colitis associated with a systemic inflammatory response that develops in less than 10% of patients and may be associated with abdominal pain or distension, severe diarrhea, ileus, dehydration, organ failure, or sepsis.63,67C difficile diarrhea is characterized by otherwise unexplained watery stools 3 or more times a day without intervening constipation or formed bowel movements. In general, patients who do not exhibit these kinds of bowel symptoms should not be tested for CDI. This recommendation notwithstanding, patients with a concern for fulminant disease who present with an ileus or megacolon and patients with an unexplained significant leukocytosis may benefit from a C difficile evaluation.18,19 Although C difficile most commonly causes colitis, a few reports describe its pathogenicity in the small bowel, as well.20,21,68 In almost all of these cases, clinically significant disease was identified in patients with an ileostomy and was associated with patients with a history of IBD, a prolonged antibiotic course, or recent surgery or a prior episode of CDI.69 Whether or not bowel preparation increases the risk for CDI remains controversial. Recent analyses of randomized, controlled trials and national data sets suggest a protective effect from oral antibiotic bowel preparation.70–72 A recent retrospective review of 24,000 patients from the National Surgical Quality Improvement Program showed that combined bowel preparation (ie, including mechanical and antibiotic components) significantly decreased rates of CDI, in comparison with patients who received mechanical bowel preparation alone (OR, 0.58; p < 0.001).73 Similar results were reported by Kim et al74 in a propensity-matched analysis of 957 paired patients who differed only according to the bowel preparation received (combined preparation versus no preparation). In this Michigan Surgical Quality Collaborative–Colectomy Best Practices Project study, patients receiving combined bowel preparation had significantly lower rates of CDI than patients who did not receive a bowel preparation (0.5% versus 1.8%, p = 0.01).74 However, a trial of 310 patients with colon cancer who were randomly assigned to mechanical bowel preparation with or without oral antibiotics found no difference in the rates of CDI between the groups.75 In addition, a recent meta-analysis of 4 randomized, controlled trials demonstrated an increased risk of CDI related to the use of oral antibiotics during bowel preparation (OR, 4.46; 95% CI, 0.96–20.66), but the absolute incidence of CDI was extremely low (only 11 events among 2753 patients), limiting the clinical relevance of these findings.71 This study concluded that the incidence of CDI after colorectal surgery is low regardless of the bowel preparation used and, given the demonstrated benefits of bowel preparation related to a reduction in infectious risk profiles, the concern regarding CDI is not sufficient enough to warrant omitting bowel preparation in these patients.72 2. Patients should be evaluated to determine the severity of CDI and for the presence of peritonitis or multisystem organ failure. Grade of recommendation: Strong recommendation based on low-quality evidence, 1C. In general, it is difficult to classify CDI severity on the basis of history and physical examination alone. Clinical assessment and laboratory testing (complete blood count and renal and liver function) are typically performed to evaluate the patient and to help identify potential organ failure and associated sepsis.12,76,77 A significant leukocytosis typically raises the suspicion for CDI but is not considered pathognomonic.76,77 The stratification of the severity of CDI as mild/nonsevere, severe, or severe-complicated/fulminant is loosely defined and is based on data and expert opinion (Table 1).19 Diarrhea, leukocytosis (but less than 15 × 103/µL), and abdominal pain with positive testing for C difficile in the absence of hypotension or organ failure such as kidney injury is typically defined as mild disease, whereas severe CDI typically includes an elevated creatinine or leukocytosis over 15 × 103/µL. In severe-complicated or fulminant CDI, patients may develop peritonitis, worsening abdominal pain and distension, sepsis, otherwise unexplained clinical deterioration, ileus or megacolon, and/or organ failure.18,78 The typically nonspecific physical examination findings of CDI, similar to non-CDI causes of colitis, underscore the importance of prompt evaluation with stool studies to expedite the diagnosis of CDI because mortality rates from severe CDI can reach 14% or higher.34,79 Multisystem organ failure is one of the strongest independent predictors of postoperative mortality following emergency colectomy for C difficile colitis.80,81 Early synthesis of key historical information, recognition of a suggestive clinical presentation, frequent clinical reevaluation, and confirmatory stool studies can diagnose CDI, facilitate appropriate therapy, and, potentially, avoid severe sepsis and its associated worse outcomes. 3. The diagnosis of CDI should include laboratory stool testing, and 2-step testing should be utilized to increase accuracy. Grade of recommendation: Strong recommendation based on high-quality evidence, 1A. Laboratory stool testing is the most accurate way to diagnose CDI. More than 30% of antibiotic-associated diarrhea is secondary to CDI, highlighting the importance of obtaining stool assays to evaluate for CDI.82 The goal of laboratory assessment is to diagnose CDI in a timely and accurate manner to facilitate treatment and containment and to institute isolation and contact precautions.83 Several different laboratory assays are currently available to diagnose CDI. Regardless of the specific study used, laboratory protocols recommend that only watery or loose stool samples (not swabs or formed stool) be sent, because patients with formed stool are unlikely to have CDI and laboratories can improve their false-positive rate, positive predictive value, and assay specificity by rejecting specimens that do not take the shape of the specimen container (ie, are not loose or soft).18 Because no single test has a high enough sensitivity and specificity to reliably distinguish between an asymptomatic carrier and symptomatic CDI, 2-step testing is typically preferred using 2 enzyme immunoassays highly sensitive for glutamate dehydrogenase (GDH) and highly specific for C difficile toxins (ie, antigen recognition).18,77,84–89 These assays are inexpensive and rapid, in general, and achieve a specificity and sensitivity of greater than 90%.35,85,90 An alternative to GDH-based testing, nucleic acid amplification testing (NAAT), targets chromosomal toxin genes and, in the past, these tests were expensive and time consuming; however, many facilities have adopted these as their primary testing modality.91–94 In practice, a positive initial screening using highly sensitive GDH or NAAT testing is usually followed by a highly specific test for C difficile toxin. An alternative diagnostic algorithm simultaneously performs both tests to expedite diagnosis but is associated with higher costs.85,91 In places where 2-step testing or toxin-based testing is not available, NAAT alone may be used, but the results should be interpreted in the context of risk factors and symptoms suggestive of CDI.19 Stool culture, although highly sensitive, does not differentiate between active infection and the presence of several nontoxigenic, nonpathologic strains of Clostridioides that may grow in culture. Because stool cultures are also time consuming, they are impractical for clinical use in general.77,95 Although stool testing is most appropriate when evaluating patients with a suspicion of having CDI, high rates of asymptomatic chronic colonization (up to 50% of patients in hospitals and long-term care facilities) have prompted calls for screening policies; however, these initiatives have not been well-supported by the evidence.5,6 Meanwhile, selective testing may be considered for higher-risk patients with a diarrheal illness but without a high suspicion for CDI who have had recent exposure to antibiotics or have IBD, renal failure, vascular disease, or a transplant, or who reside in a long-term care facility.96–98 4. Routine endoscopic evaluation to diagnose or determine the extent of CDI is not recommended. Grade of recommendation: Strong recommendation based on low-quality evidence, 1C. Adjunctive endoscopic evaluation may be performed when managing patients with CDI, but the absence of comparative and predictive studies limits the utility of endoscopy under these circumstances. Endoscopy also lacks a validated predictive value in guiding medical or surgical therapy or providing prognostic information.99,100 Given the rapid, sensitive, and specific stool assays used to diagnose CDI, the role of endoscopy in this setting is usually limited to potentially providing information when concomitant conditions confound the diagnosis or when unique circumstances require a more urgent diagnosis.101 Diagnostic lower endoscopy with biopsies may distinguish CDI from other types of colitides, such as cytomegalovirus, graft-versus-host disease, IBD, and ischemic colitis.99 Although pancolitis in the setting of CDI (ie, extending proximal to the splenic flexure) may suggest a more severe infection, the anatomic extent of luminal disease alone is unlikely to guide patient management or influence the decision for and timing of colectomy. In addition, pseudomembranes, often considered pathognomonic for CDI, are actually found in only approximately 45% to 55% of laboratory-proven cases of CDI and offer little additional diagnostic or prognostic value.99,100,102 In terms of the prevalence of pseudomembranes in the setting of CDI, the studies describing pseudomembranes are mainly retrospective and include only a fraction of patients with CDI who have undergone endoscopy, suggesting that the actual incidence of pseudomembranes would be lower than reported in these studies. The likelihood of finding pseudomembranes in patients with CDI who are immunosuppressed or have IBD is even lower.100,102 Therefore, routine endoscopic evaluation in the setting of CDI is not recommended because of the risk of complications like perforation and the limited clinical utility. 5. Radiologic evaluation has limited utility in the setting of CDI. Grade of recommendation: Weak recommendation based on low-quality evidence, 2C. In general, radiographic investigation has limited utility when managing patients with CDI. Although CT scans of the abdomen and pelvis, often obtained as part of the evaluation of an acute abdominal process, are highly specific for perforation, the predictive value of other CT findings in the setting of CDI is less clear. Cross-sectional imaging in patients with CDI can demonstrate colonic wall thickening and an abnormal haustral pattern or an “accordion sign” (hyperemic enhancing mucosa stretched over markedly thickened submucosal folds with contrast trapped between edematous haustral folds); however, these findings are nonspecific.103–106 Computed tomography scans from patients with CDI may also demonstrate ascites, pericolic fat stranding, or prominent intravenous contrast enhancement of the layers of the colonic wall and even portal venous gas or pneumatosis.107 The ability for CT scanning to predict the need for surgical intervention is poor (sensitivity 52%–85% and specificity 48%–92%).108 Older studies suggest that CT findings correlate poorly with the clinical severity of disease.104 In fact, about 40% of patients with CDI have a normal CT scan without radiographic evidence of colitis.104,109 A retrospective review of 176 hospitalized patients with CDI found that abnormal wall thickening, pancolitis, and bowel dilation demonstrated on CT imaging were associated with the need for colectomy, whereas wall thickening was an independent predictor of 30-day mortality; however, these findings had a low predictive value of 50%.110 Medical Management 6. Infection control measures should be implemented for hospitalized patients with CDI. Grade of recommendation: Strong recommendation based on moderate-quality evidence, 1B. Within the colon in the setting of dysbiosis and altered bile acid metabolism, C difficile exists in its vegetative (ie, functioning) form that is susceptible to antimicrobial agents. Outside the colon, however, C difficile survives in a spore form that is highly resistant to heat, acid, chemicals, and antibiotics.96,111 In a hospital setting, C difficile can readily spread from fomites like clothing or equipment28,112–114 and contamination can also occur by simple contact with intact skin of infected patients.28,96,112–115 Disease containment and prevention of transmission rely on patient isolation, the use of personal protective equipment, and hand washing with soap and water to physically remove spores from the surface of contaminated hands after patient encounters.114,115 Alcohol hand rubs, commonly used in health care settings, do not kill spores and therefore should not be used as a single agent for decontamination purposes under these circumstances.116,117 Rather, combining contact precautions and hand washing with soap and water is recommended to prevent transmission of CDI in hospital and long-term care facilities. Daily and terminal (ie, after patients are discharged) decontamination of patients’ rooms can also prevent transmission of CDI.28,118–120 Other methods of potential C difficile containment or decontamination including ultraviolet light-emitting devices, chlorhexidine washings, and changes in hospital architectural designs are not well-supported by evidence.121–126 The duration for maintaining contact precautions and whether to isolate patients suspected of possibly having CDI before obtaining diagnostic confirmation remain controversial topics, and policies vary between institutions. In general, lifting isolation precautions for patients undergoing CDI treatment 48 hours after cessation of diarrhea may be considered.127 7. Implementing an evidence-based antibiotic stewardship program can decrease rates of CDI. Grade of recommendation: Strong recommendation based on moderate-quality evidence, 1B. Antibiotic use is the main risk factor for developing CDI, and the overuse and inappropriate use of antibiotics, in particular, have been well documented to increase the risk of CDI.31,111,128–131 Multiple intervention bundles have been implemented in the United States and internationally with the primary goal of promoting appropriate antibiotic use and limiting duration of treatment in an effort to improve antibiotic-related outcomes.132–135 Although antibiotic stewardship programs vary between hospitals, most include defined prescribing parameters determined by infectious disease specialists and have resulted in significant decreases in overall antibiotic use.29,30,111,136,137 A Cochrane review by Davey et al31 of 221 studies found that compliance with antibiotic-prescribing practices in hospitalized patients reduced the duration of CDI treatment by 1.95 days (95% CI, 1.67–2.22) and reduced CDI rates up to 48.6% (interquartile range, –80.7% to –19.2%). Stewardship bundles typically include recommendations to stop associated antibiotics once CDI has been diagnosed, as clinically indicated, and extend the use of anti-C difficile treatment beyond the duration of other antibiotics for 5 to 14 days.30,97,113 In terms of other potential ways to reduce CDI rates, vaccines have been considered, although they remain investigational. Recently, a phase 3 multicenter trial evaluated the efficacy of a Clostridiodes toxoid vaccine, but the study was terminated prematurely because a data analysis demonstrated that the vaccine lacked clinical efficacy.138 8. Oral vancomycin or fidaxomicin is considered first-line treatment for an initial CDI, whereas metronidazole alone is no longer considered appropriate first-line treatment. Grade of recommendation: Strong recommendation based on high-quality evidence, 1A. Although various antibiot" @default.
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W3137392258 title "The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Clostridioides difficile Infection" @default.
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