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Secondary acquired megacolon — Clinical Guidelines

Overview

Secondary acquired megacolon, often referred to as toxic megacolon, is a severe complication of Clostridium difficile infection (CDI) characterized by colonic distension, systemic toxicity, and potentially life-threatening complications such as perforation 19.

Diagnosis

Clinical presentation includes severe abdominal distension, fever, leukocytosis, and signs of systemic toxicity 19.

Stool tests for C. difficile toxin and nucleic acid amplification tests (NAAT) are essential 6.

Imaging (e.g., abdominal X-ray showing dilated colon) can confirm the diagnosis 19.

Endoscopic evaluation may reveal pseudomembranous colitis, though it is not always feasible in critically ill patients 19.

Management

First-line treatment: Intravenous metronidazole or vancomycin, with vancomycin often preferred for severe cases 6.

Adjunctive therapies: Consideration of intravenous fluids, electrolyte management, and supportive care including mechanical ventilation if respiratory failure occurs 19.

Fecal Microbiota Transplantation (FMT): For recurrent CDI, though primarily indicated for recurrent rather than toxic megacolon, it may be considered in refractory cases 4 12.

Surgical intervention: Reserved for cases with colonic perforation, toxic megacolon refractory to medical management, or suspected perforation 19.

Special Populations

Elderly: Higher risk of recurrence and complications; tailored antibiotic stewardship and close monitoring are crucial 24.

Comorbidities: Patients with underlying conditions like hematologic malignancies or recent splenectomy may have increased susceptibility and severity 25.

Key Recommendations

Initiate high-dose intravenous vancomycin for severe cases of CDI progressing to toxic megacolon (Evidence: Strong 6).

Aggressive supportive care including fluid resuscitation and management of systemic complications is essential (Evidence: Moderate 19).

Consider fecal microbiota transplantation for recurrent CDI, though its role in toxic megacolon is less defined and should be individualized (Evidence: Moderate 4 12).

References

1 Oh S, Sung YS, Jang M, Kim YJ, Park HW, Nho D et al.. Impact of the coronavirus disease 2019 pandemic on the incidence of other infectious diseases in the hematology hospital in Korea. The Korean journal of internal medicine 2024. link 2 Kelly CR, Allegretti JR. Review Article: Gastroenterology and Clostridium difficile Infection: Past, Present, and Future. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 2023. link 3 El-Matary W, Nugent Z, Yu BN, Lix LM, Targownik LE, Bernstein CN et al.. Trends and Predictors of Clostridium difficile Infection among Children: A Canadian Population-Based Study. The Journal of pediatrics 2019. link 4 Davidovics ZH, Michail S, Nicholson MR, Kociolek LK, Pai N, Hansen R et al.. Fecal Microbiota Transplantation for Recurrent Clostridium difficile Infection and Other Conditions in Children: A Joint Position Paper From the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. Journal of pediatric gastroenterology and nutrition 2019. link 5 Dicks LMT, Mikkelsen LS, Brandsborg E, Marcotte H. Clostridium difficile, the Difficult "Kloster" Fuelled by Antibiotics. Current microbiology 2019. link 6 McDonald LC, Gerding DN, Johnson S, Bakken JS, Carroll KC, Coffin SE et al.. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 2018. link 7 Madden GR, Poulter MD, Sifri CD. Diagnostic stewardship and the 2017 update of the IDSA-SHEA Clinical Practice Guidelines for Clostridium difficile Infection. Diagnosis (Berlin, Germany) 2018. link 8 Carnahan RM, Kuntz JL, Wang SV, Fuller C, Gagne JJ, Leonard CE et al.. Evaluation of the US Food and Drug Administration sentinel analysis tools in confirming previously observed drug-outcome associations: The case of clindamycin and Clostridium difficile infection. Pharmacoepidemiology and drug safety 2018. link 9 Pegues DA, Han J, Gilmar C, McDonnell B, Gaynes S. Impact of Ultraviolet Germicidal Irradiation for No-Touch Terminal Room Disinfection on Clostridium difficile Infection Incidence Among Hematology-Oncology Patients. Infection control and hospital epidemiology 2017. link 10 Ma Y, Yang J, Cui B, Xu H, Xiao C, Zhang F. How Chinese clinicians face ethical and social challenges in fecal microbiota transplantation: a questionnaire study. BMC medical ethics 2017. link 11 Dudzicz S, Adamczak M, Więcek A. Clostridium Difficile Infection in the Nephrology Ward. Kidney & blood pressure research 2017. link 12 Sokol H, Galperine T, Kapel N, Bourlioux P, Seksik P, Barbut F et al.. Faecal microbiota transplantation in recurrent Clostridium difficile infection: Recommendations from the French Group of Faecal microbiota Transplantation. Digestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver 2016. link 13 Kujawa-Szewieczek A, Adamczak M, Kwiecień K, Dudzicz S, Prażak Z, Więcek A. Analysis of Clostridium difficile infections in patients hospitalized at the nephrological ward in Poland. Postepy higieny i medycyny doswiadczalnej (Online) 2016. link 14 Paramsothy S, Walsh AJ, Borody T, Samuel D, van den Bogaerde J, Leong RW et al.. Gastroenterologist perceptions of faecal microbiota transplantation. World journal of gastroenterology 2015. link 15 Carter GP, Chakravorty A, Pham Nguyen TA, Mileto S, Schreiber F, Li L et al.. Defining the Roles of TcdA and TcdB in Localized Gastrointestinal Disease, Systemic Organ Damage, and the Host Response during Clostridium difficile Infections. mBio 2015. link 16 Lübbert C, John E, von Müller L. Clostridium difficile infection: guideline-based diagnosis and treatment. Deutsches Arzteblatt international 2014. link 17 Salva S, Duran N, Rodriguez V, Nieto L, Serra J, Rello J. Clostridium difficile in the ICU: study of the incidence, recurrence, clinical characteristics and complications in a university hospital. Medicina intensiva 2014. link 18 Kawsar HI, Gopal KV, Shahnewaz J, Daw HA. Constipation in Clostridium difficile infection. BMJ case reports 2012. link 19 Tan CB, Rajan D, Shah M, Ahmed S, Freedman L, Rizvon K et al.. Toxic megacolon from fulminant Clostridium difficile infection induced by topical silver sulphadiazine. BMJ case reports 2012. link 20 Inadomi JM, Gunnarsson CL, Rizzo JA, Fang H. Projected increased growth rate of anesthesia professional-delivered sedation for colonoscopy and EGD in the United States: 2009 to 2015. Gastrointestinal endoscopy 2010. link 21 Poilane I, Humeniuk-Ainouz C, Durand I, Janoir C, Cruaud P, Delmée M et al.. Molecular characterization of Clostridium difficile clinical isolates in a geriatric hospital. Journal of medical microbiology 2007. link 22 Cherifi S, Delmee M, Van Broeck J, Beyer I, Byl B, Mascart G. Management of an outbreak of Clostridium difficile-associated disease among geriatric patients. Infection control and hospital epidemiology 2006. link 23 Fawley WN, Parnell P, Verity P, Freeman J, Wilcox MH. Molecular epidemiology of endemic Clostridium difficile infection and the significance of subtypes of the United Kingdom epidemic strain (PCR ribotype 1). Journal of clinical microbiology 2005. link 24 Tal S, Gurevich A, Guller V, Gurevich I, Berger D, Levi S. Risk factors for recurrence of Clostridium difficile-associated diarrhea in the elderly. Scandinavian journal of infectious diseases 2002. link 25 Edwards DP, Saleemi MA, Grundy C, Chisholm EM. Clostridium difficile toxic megacolon following splenectomy. Journal of the Royal Army Medical Corps 1997. link 26 Magee JT, Brazier JS, Hosein IK, Ribeiro CD, Hill DW, Griffiths A et al.. An investigation of a nosocomial outbreak of Clostridium difficile by pyrolysis mass spectrometry. Journal of medical microbiology 1993. link 27 Cefai C, Elliott TS, Woodhouse KW. Gastrointestinal carriage rate of Clostridium difficile in elderly, chronic care hospital patients. The Journal of hospital infection 1988. link90086-2) 28 Katoh T, Honda T, Miwatani T. Purification and some properties of cytotoxin produced by Clostridium difficile. Microbiology and immunology 1988. link 29 Agrawal R, John EG, Marchini A, Assadi FK, Sullivan-Bolyai J. Fever due to Clostridium difficile during hemodialytic treatment. The International journal of pediatric nephrology 1986. link 30 Parry MF, Rha CK. Pseudomembranous colitis caused by topical clindamycin phosphate. Archives of dermatology 1986. link 31 Milstone EB, McDonald AJ, Scholhamer CF. Pseudomembranous colitis after topical application of clindamycin. Archives of dermatology 1981. link

Secondary acquired megacolon