Concerned about a patient

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Foxxy Cleopatra

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Hi to all-

Just wanted to get opinions on what to do for a s/p laparoscopic appy patient (found to have a gangrenous appendix) with an ileus 4 days post-op, abdominal distention, C. diff positive stool, and a WBC=36. Afebrile and vital signs stable with good UOP.

We're hydrating and treating with Fortaz and Clinda, as well as PO Flagyl for the C. diff. I'm worried about a possible abscess and don't want this poor patient to deteriorate. Is it too early to order a CT (should I wait until at least 5 days post-op?)

Any advice is appreciated!

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Tough spot. All of the symptomotology could be attributable to the c diff, which can evolve into a life threatening septic colitis without appropriate treatment. Unfortunately, an essential part of the treatment is withdrawal of the offending antibiotics.

CT is a good idea to rule out intra-abd abscess which could be addressed with perc drainage, although you're right, it's a wee bit early. You would need to repeat in a few days if persistent or worsening symptoms develop. Regardless of the CT findings, I'd stop all abx except flagyl, and assess response. Clinda, of course, is expecially implicated in c diff infections. I've seen one patient die from unresolved c diff, and two others who required subtotal colectomies to survive, so it's nothing to take lightly. You could do flex sig to assess the degree of colitis if CT is persistently nonrevealing and you are not seeing a positive response to treatment.
 
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Fortaz/Clinda(?) in a patient with possible c. diff colitis is just a terrible idea. The broad spectrum beta-lactams (Unasyn,Zosyn,Fortaz, etc..) are pretty good mono-therapy for intra-abdominal infections without adding the potential problems of Clindamycin. Flagyl has pretty much relagated Clindamycin to second line coverage of anerobes (It is still a nice drug for some strep/staph soft tissue infections). In this case, it's clear that you really do not know what's going on with this patient as you're hedging your treatment between an infected post-op collection & colitis.

I'm a little curious about this patient. Do they have a reason to be previously colonized with c. diff (ie. nursing home patient, recent hospitalization, antibiotic tx.)? I ask this because it is rare to develop colitis this soon after initial tx. with antibiotics & I'm wondering if this could represent someone colonized rather then mounting a clostridial infection. Womansurg's suggestion about doing a lower endoscopy would answer this -> if there's no raging inflamation on you scope, that's not your problem. Evidence of colitis would not exclude a developing pelvic abscess or stump leak from your appendectomy.

With your description of a not toxic appearing patient, I think I'd

-do the endoscopy
- stop clindamycin
- continue tx. with the fortaz + flagyl (IV & oral) until the c. diff ? is answered
- ride it out unless they get toxic for a few days & plan a CT POD 6 or 7 with perc. drainage if there's something organized. If there's fluid which is not organized your radiologist will prob. decline placing a drain. I would then plan on repeating the scan a few days later if your patient is still kind of lingering & there's still fluid in the pelvis MAKE your radiologist place a drain

Your other option is to proactively reexplore the patient (open or laparoscopic) & drain an infection or remove whatever fluid remains from the previous operation (I'm assuming this one got irrigated liberally @ the first operation & sometimes the residual fluid can be colonized enough to maintain a persistant inflamatory state). This way of mangement has become less common in the era of CT scanning with IR availability for percutaneous drainage.
 
Thanks for the replies- I appreciate it.

This patient was previously healthy 17 y.o. male until last Friday (a week before the 4th.) He started having nausea, vomiting, and diarrhea so he went to his local hospital (a rural area about an hour away.) It seemed their differential was gastroenteritis v. an STD (tests came back negative) and they gave him a shot of Rocephin and sent him home. He came back last Sunday with persistent symptoms (this time with abdominal pain) so they sent him over to our hospital.

General Peds admitted him and did a pretty good workup (CT, KUB, CBC, BMP, LFT's, stool cultures.) Other than the white counts that persistenly had been 28-31, the labs were fine. They consulted us so we went to read the CT with the radiologist, who picked up the appendicitis.

We did a laparoscopic appy on Wednesday and he actually looked pretty good post-op. WBC dropped to 20 and he appeared stable. I checked the labs the peds team did (the tested for rotavirus and C. diff, both which I felt were unlikely, but wanted to see anyways) and that's when I saw that he was C. diff toxin positive.

At our hospital, we start all of our peds appendicitis patients on Fortaz and Clinda (so he was started on these after the C. diff test was performed) and I wrote for p.o. flagyl upon the C.diff result. Apparently, the peds attending had heard of some cases of C.diff that develop after one dose of rocephin so that was the motivation to test for it.

Today, he is stable; still with abdominal distention and ileus but stable vital signs, afebrile, and no more emesis. I was on call and pretty concerned about him Friday night- he was diaphoretic, cold extremeties, and appeared uncomfortable. He doesn't look any worse but not much better as of now.

We did stop the Clinda today and I'm hoping will do a CT tomorrow. His WBC is down a little (now at 30 from 36 on Friday).

Thanks again for the advice- the family and patient have been extremely nice and I would love to see this kid improve soon.

Oh yeah, do you guys feel there is an advantage to irrigating someone open versus laparoscopic in the setting of a hostile abdomen? I'm pretty new to the use of lapaorscopics I have seen at this place and was curious.

thanks!
 
Did you check your path on that appendix? Five days of active dz. Fri->Weds is a long time for an acute appendicitis not to have ruptured freely preoperatively. Was it really ugly looking during the operation or was it one of those +/- appendectomies? Also why was it 3 days after readmission on Sunday when his operation was done (I'm assuming the CT was done on admission when he bounced back that wekend)?

The time frame b/w his abx. treatment & his c. diff toxin test is still a lot more quick then then I would expect (he bounced back 48hrs after his initial presentation & tx.), but never say never.....

You can get c. diff colitis from just about any antibiotic (except Vancomycin which doesn't penetrate intraluminally), even single-dose preoperative Kefzol/Ancef has been implicated. Clindamycin was one of the first identified with the phenomena, but I believe I've read that it really is no bigger an offender then some of the other broad-spectrum abx. we use.


From your description, I think I'm leaning towards an infected collection rather then colitis (I don't think both things are going on simultaneously). Washouts laparoscopically are feasible here, but you're getting into the period where adhesions might make laparoscopic access a bit risky. Most older surgeons I know would not even consider it, while the younger guys who are laparocopy gurus would probably attempt it. Your best bet is to just hold out for the CT/Perc drain
 
droliver,

Thanks for asking. He started to improve on POD #5 when he had a bowel movement. We then started a diet and he ended up tolerating it well. However, his WBC jumped to 36 again around 1 week post-op. Otherwise, he looked pretty good clinically- abdominal distention and pain improved and he became afebrile. We CT'd him anyways at that point and it revealed a large subhepatic abscess and a smaller one around the suprapubic area. Interventional placed a drain in both and his WBC dropped to 14. He continued to appear well clinically.

Our peds surgery service uses Fortaz and Clinda for all appendicitis cases until they become afebrile and their WBC drops. We did d/c the clinda since he was also + for C.diff (which we were treating with p.o. flagyl.) After an 8 day course of Flagyl, we re-cx'd the stool and it was C. diff negative this time around.

We repeated CT on Sunday (drains were in for 3 days) and the suprapubic abscess was nearly resolved; the subhepatic one was greatly reduced but still visible. IR pulled the drain to the smaller abscess today. Cultures of the 2 abscesses were + for "rare E.coli and pseudomonas" (which were both sensitive to ceftaz.)

We sent him home on PO flagyl and amoxicillin (per attending's request.) He looked very good- now asymptomatic. The only thing I now question was whether we should have tried to double-cover the E.coli and P. aer. I don't know if any PO abx are great choices for intra-abdominal abscesses, though I was thinking that Cipro may be a fair choice.

He's going to go back to IR in a week to get the other drain d/c'd and follow up with us after that.

I hope he continues to do as well as he appeared today!
 
:) Good to hear & I'm glad to hear it played out the way I was predicting. As a newly minted skin surgeon I can feel all my knowledge of the abdomen slipping away.....
 
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