Severe Clostridioides difficile Infection with Hypotension, Shock, Ileus, or Megacolon: When Colonoscopic FMT Fails to Clear Pseudomembrane
This protocol addresses fulminant Clostridioides difficile infection — severe CDI complicated by hypotension, shock, ileus, or megacolon — in the specific situation where a prior course of colonoscopic fecal microbiota transplantation (FMT) did not achieve its target.
Fulminant CDI is defined as severe Clostridioides difficile infection plus the presence of hypotension or shock, ileus, or megacolon. This combination marks the highest-acuity end of the CDI spectrum and places the patient beyond the reach of standard stepwise antibiotic approaches alone.
The preceding management step — fecal microbiota transplantation (FMT) delivered by colonoscopy, repeated at defined intervals alongside concurrent antimicrobial therapy — had a primary goal of achieving resolution of pseudomembrane in the colon. Failure to reach this endpoint in the context of ongoing hypotension, ileus, or megacolon is the clinical trigger that brings this protocol into play.
For patients who have reached this point, surgical intervention is the principal consideration. Which operative approach is most appropriate depends on the patient's clinical status, estimated tolerance to surgery, and the operating surgeon's judgement — the full protocol details the specific procedures evaluated in this setting.
References
DOI: 10.14309/ajg.0000000000001278
We recommend defining fulminant infection as patients meeting criteria for severe C. difficile infection plus presence of hypotension or shock or ileus or megacolon.
We suggest that for patients who require surgical intervention, that either a total colectomy with an end ileostomy and a stapled rectal stump or a diverting loop ileostomy with colonic lavage and intraluminal vancomycin, be used depending on clinical circumstances, the patient's estimated tolerance to surgery, and the surgeon's best judgement.
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