6 ‘A gut instinct’: tackling Clostridioides difficile infection in surgical patients

Introduction Clostridioides difficile infection (CDI) is a leading healthcare-associated infection, ranging from mild diarrhoea to severe colitis with toxic megacolon, pseudomembranous colitis, and death. Surgical patients are particularly vulnerable due to frequent antimicrobial use for treatment and prophylactic indications, often lengthy admissions, and comorbidities. Early recognition of CDI is vital, as diarrhoea in surgical patients may be mistaken for bowel pathology or other surgical conditions, delaying diagnosis. Fulminant CDI may necessitate emergent surgical intervention when medical management fails. Aim The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) define severe CDI (sCDI) and severe-complicated CDI (scCDI) by criteria including fever, leucocytosis, imaging findings and toxic megacolon. This study reviewed CDI cases over a one-year period, focusing on severity, trends and patient outcomes. Methods This a retrospective observational study examined all episodes of CDI diagnosed in a tertiary referral hospital between 6/1/23 and 6/1/24. Patients aged >16 years meeting CDI case definitions were identified from a secure database, and demographic, laboratory and outcome data were captured from patient records. ESCMID definitions of sCDI/scCDI were applied to each episode. Results There were 140 CDI episodes in 131 patients, with surgical patients accounting for 34 episodes (24%). The average age was 63 years [range: 16–90] and 62% were male (n = 21). Of surgical patients, 33 (97%) of CDI were healthcare-associated, with one community-associated case. Among surgical patients, CDI episodes were most commonly diagnosed in neurosurgical patients (n = 12, 35%), colorectal surgery (n = 8, 23.5%), and vascular surgery patients (n = 5, 15%). Recent antimicrobial use was common (n = 32, 94.1%), with beta-lactams prescribed for 27 patients (79%) within the three months prior to CDI diagnosis, most commonly piperacillin-tazobactam. Marked leucocytosis was observed in 41% of surgical cases, with fever in 23.5%, and 29% of patients experienced a delay in CDI diagnosis longer than two days from symptom onset. Examining CDI severity, 59% met criteria for sCDI or scCDI. No patient underwent surgery for CDI during the study period. One patient required ICU admission for toxic megacolon and died from CDI-related complications. Examining the non-surgical patient cohort, 106 CDI episodes were recorded, 32% in males (n = 34) and the average age was 69 years [19–95]. Recent antimicrobial use was seen in 97 patients (91.5%). While a similar proportion of episodes as in surgical patients were classed as sCDI or scCDI (58%); a higher burden of scCDI was seen among this group (17%), including four patients with toxic megacolon, one of whom required critical care admission, later dying from CDI. Conclusions This study highlights the burden of CDI in surgical patients, emphasising the risk of delayed diagnosis, the high prevalence of antimicrobial use and the severity of disease in this population. With 59% of surgical patients presenting with severe or severe-complicated CDI, early recognition is critical to optimising outcomes. These findings underscore the need for vigilance across all surgical settings to prevent, diagnose, and manage CDI effectively. One limitation is that CDI diagnosed in surgical patients after hospital discharge may not have been captured, especially if the patient attended another healthcare setting for management of CDI.