Should a patient with severe Clostridioides difficile disease be referred to Gastroenterology (GI)?

Should a Patient with Severe Clostridioides difficile Disease Be Referred to Gastroenterology?

Yes, patients with severe Clostridioides difficile infection who progress to systemic toxicity should undergo early surgical consultation and multidisciplinary care including gastroenterology, along with appropriate medical treatment. 1

Defining Severe and Fulminant CDI

Severe CDI is defined as infection with leukocyte count ≥15 × 10⁹ cells/L and/or creatinine ≥1.5 mg/dL 1. Fulminant CDI presents as severe disease with shock, ileus, or megacolon 1.

When GI Referral is Critical

Patients requiring immediate multidisciplinary consultation (including gastroenterology, surgery, critical care, and infectious disease) include those with 1:

• Severe CDI not responding to standard antibiotics within 2-5 days of initiating treatment
• Signs of systemic toxicity including septic shock or cardiorespiratory failure
• Evidence of toxic megacolon, fulminant colitis, perforation, or ischemia 1
• Severe abdominal pain with peritoneal signs 2

Role of Gastroenterology in Severe CDI

Gastroenterology consultation is essential for 1:

• Endoscopic evaluation and diagnosis confirmation: Colonoscopy or flexible sigmoidoscopy allows direct visualization of pseudomembranes and assessment of disease severity 1
• Fecal microbiota transplantation (FMT): First dose should be delivered via colonoscopy or flexible sigmoidoscopy in hospitalized patients with severe/fulminant CDI not responding to antibiotics 1
• Repeat FMT administration: Most patients with severe or fulminant CDI will need repeat FMT every 3-5 days based on treatment response 1

Predictors Requiring Urgent Consultation

High-risk features mandating immediate multidisciplinary evaluation include 1, 3:

• Age >70 years
• Severe leukocytosis (WBC ≥35,000/μL) or leukopenia (<4,000/μL)
• Bandemia (neutrophil bands ≥10%)
• Thrombocytopenia (platelet count <150 × 10³/mm³)
• Coagulopathy (INR >2.0)
• Renal insufficiency (BUN >40 mg/dL)
• Respiratory failure requiring mechanical ventilation
• Vasopressor requirement for septic shock
• Acute kidney injury

Treatment Coordination

GI involvement facilitates optimal medical management 1, 4:

• Ensures appropriate multi-route antibiotic delivery (oral vancomycin 125-500 mg four times daily, intravenous metronidazole 500 mg three times daily, and rectal vancomycin 0.25-1 g 2-4 times daily) 1
• Coordinates FMT timing with surgical team if operative intervention becomes necessary
• Monitors treatment response via stool output, white blood cell count, and C-reactive protein 1
• Arranges outpatient follow-up FMT to prevent recurrence after resolution 1

Surgical Considerations

Early surgical consultation is mandatory for patients with fulminant colitis progressing to systemic toxicity 1. The mortality rate of emergency surgery in CDI is 35%, with higher survival rates in dedicated surgical units 1. Surgical options include subtotal colectomy or diverting loop ileostomy with colonic antibiotic lavage 1.

Special Populations

Immunocompromised patients (transplant recipients, hematology-oncology patients, HIV-infected individuals) have CDI incidence ranging from 0.77% to 22.9% depending on transplant type and require particularly aggressive multidisciplinary management 1.

Common Pitfalls to Avoid

• Delaying consultation until patient deteriorates to requiring colectomy—early GI involvement enables FMT as alternative to surgery 1, 5
• Attempting FMT via nasoenteric tube in severe disease—this increases aspiration risk and should be avoided 1
• Using enema or capsule FMT as first-line in severe/fulminant disease—insufficient evidence supports these routes 1
• Failing to continue anti-CDI antibiotics during FMT treatment—most protocols continue antibiotics with FMT 1