Severe Clostridioides difficile Infection in the Intensive Care Unit-Medical and Surgical Management.

Clostridioides difficile remains a major cause of morbidity and mortality in the intensive care unit, and therefore, C difficile guidelines are frequently being updated. Currently, fidaxomicin is the suggested treatment of initial and recurrent infection. Oral vancomycin is an acceptable alternative, followed by rifaximin and fecal microbiota transplantation. Bezlotoxumab is suggested in recurrent cases within 6 months. If patients fail to improve within 3 to 5 days of therapy, especially in patients who have had nasogastric tubes or emergent surgery, fulminant colitis is possible and surgical consultation should be considered for total colectomy.

Multiple laparotomies are a predictor of fascial dehiscence in the setting of severe trauma.

The purpose of this study was to determine the incidence of wound dehiscence after repeat trauma laparotomy. We performed a retrospective analysis of adult trauma patients who underwent laparotomy at an urban level 1 trauma center during the past 5 years. Patients were divided into single (SL) and multiple laparotomy (ML) groups. Demographic, clinical, and outcome data were collected. Data were analyzed using chi2, t testing, and ANOVA. Overall dehiscence rate was 0.7 per cent. Multiple laparotomy patients had damage control, staged management of their injuries, or abdominal compartment syndrome as the reason for reexploration. SL and ML patients had similar age and sex. ML patients had a higher rate of intra-abdominal abscess than SL patients (13.7% vs 1.2% P < 0.0001), but intra-abdominal abscess did not predict wound dehiscence in the ML group (P = 0.24). This was true in spite of the fact that ML patients had a significantly higher Injury Severity Score (ISS) than SL patients (21.68 vs 14.35, P < 0.0001). Interestingly, wound infection did not predict dehiscence. Patients undergoing repeat laparotomy after trauma are at increased risk for wound dehiscence. This risk appears to be associated with intraabdominal abscess and ISS, but not wound infection. Surgeons should leave the skin open in the setting of repeat trauma laparotomy, which will allow serial assessment of the integrity of the fascial closure.