SEVERE Clostridioides difficile infection (CDI) can progress rapidly to organ failure and sepsis, and while most patients respond to antibiotic therapy, a minority face life-threatening disease that may require surgical intervention. This review outlines evolving approaches to classification, medical optimization, and operative management for severe CDI.
CDI severity classifications are central to identifying when patients may require more than antibiotics alone. In cases of severe infection, clinical markers often include sepsis, shock, and evidence of multi-organ involvement despite guideline-directed therapy. Standard management focuses on careful resuscitation, discontinuation of nonessential antibiotics, and the prompt initiation of targeted CDI therapies. Ensuring that medical therapy has truly been maximized is essential before escalating to surgery.
For patients unresponsive to optimized medical therapy, surgical intervention may be life-saving. Total colectomy has long been the standard approach for fulminant CDI, but diversion with loop ileostomy and colonic lavage has emerged as a less invasive alternative. Each strategy carries distinct risks and benefits, making surgical consultation a critical step in decision-making. Timely referral to surgery can significantly affect outcomes, particularly given the high mortality associated with delayed intervention in fulminant cases.
The review emphasizes that only a small proportion of CDI patients will require surgery, but for those who do, early recognition and swift action can make the difference between recovery and death. For clinicians, the key lies in balancing aggressive medical therapy with readiness to escalate to surgical intervention when evidence indicates that medical management has failed.
Reference:
Salrin J, Stewart DB. Management of Severe Clostridioides difficile Infection. Infect Dis Clin North Am. 2025. doi: 10.1016/j.idc.2025.07.006
