ORIGINAL CONTRIBUTION Risk Factors for Mortality Following Emergency Colectomy for Fulminant Clostridium difficile Infection Jacques Pepin, M.D., F.R.C.P.C. 1 & Thanh Truc Vo, M.D. 1 Marylise Boutros, M.D., M.Sc. 2 & Eric Marcotte, M.D. 1 Sandra Dial, M.D., F.R.C.P.C. 2 & Serge Dub2, M.D., F.R.C.S.C. 3,4 Carol-Ann Vasilevsky, M.D., F.R.C.S.C. 2 & Nathalie McFadden, M.D., F.R.C.S.C. 1 Carlos Patino, M.D. 3 & Annie-Claude Labb2, M.D., F.R.C.P.C. 3,4 1 University of Sherbrooke, Sherbrooke, Quebec, Canada 2 McGill University, Montr2al, Ontario, Canada 3HHpital Maisonneuve-Rosemont, Montr2al, Ontario, Canada 4 University of Montreal, Montr2al, Ontario, Canada PURPOSE: This study evaluated risk factors for mortality after emergency colectomy for fulminant Clostridium difficile infection. METHODS: Retrospective study of 130 cases of Clostridium difficile infection that required a colectomy between 1994 and 2007 in four hospitals of Quebec, Canada. Primary outcome was 30-day mortality. RESULTS: Twenty-five cases underwent colectomy in 1994 to 2002, 41 in 2003, 40 in 2004, and 24 in 2005 to 2007. Common indications were septic shock (41 percent) and nonresponse to medical treatment (39 percent). Overall, 30-day mortality was 37 percent. Mortality increased with age but was not influenced by comorbidities burden. Mortality correlated with preoperative lactate (e2.1 mmol/L: 26 percent; 2.2Y4.9 mmol/L: 52 percent; Q5.0 mmol/L: 75 percent, P G 0.001), leukocytosis (G20.0 Â 10 9 /L: 32 percent; 20.0Y49.9 Â 10 9 /L: 33 percent; Q50.0 Â 10 9 /L: 73 percent, P = 0.008), albumin (Q25 g/L: 19 percent; 15Y24 g/L: 38 percent; G15 g/L: 52 percent, P = 0.04) and renal failure. In multivariate analysis, risk factors for mortality were age (per year, adjusted odds ratio: 1.03, 95 percent confidence interval: 1.00Y1.06), preoperative lactate greater than or equal to 5.0 mmol/L (adjusted odds ratio: 10.32, 95 percent confidence interval: 2.59Y41.1), leukocytosis greater than or equal to 50.0 Â10 9 /L (adjusted odds ratio: 3.68, 95 percent confidence interval: 0.92Y14.8) and albumin less than 15 g/L (adjusted odds ratio, 6.57, 95 percent confidence interval: 1.31Y33.1). CONCLUSIONS: Incidence of Clostridium difficile infection-related emergency colectomies increased 20-fold during the epidemic. Postoperative mortality can be predicted by simple laboratory parameters. Three-fourths of patients with leukocytosis greater or equal to 50.0 Â10 9 /L or lactate greater or equal to 5.0 mmol/L died. When possible, emergency colectomy should be performed earlier. KEY WORDS: Clostridium difficile; Colectomy; Septic shock; Canada. S ince the year 2000, a virulent strain of Clostridium difficile has spread across the United States, Canada, and Western Europe. 1Y8 This toxinotype III strain of C. difficile (designated as BI/NAP1/027) produces levels of toxins A and B 16 to 23 times higher than historical strains 9 ; the elevated toxicity seems to be caused by a 1 bp deletion in the tcdC gene that normally down-regulates toxin production. 10,11 Concomitantly, the number and proportion of patients with C. difficile infection (CDI) developing megacolon, perforation, septic shock, or other DISEASES OF THE COLON &RECTUM VOLUME 52: 3 (2009) 400 Carlos PatiDo, M.D., was supported by an unrestricted research grant from Astellas Canada Inc. Read at the meeting of The American Society of Colon and Rectum Surgeons, Boston, Massachusetts, June 7 to 11, 2008. Address of correspondence: Jacques Pepin, M.D., F.R.C.P.C., CHUS, 3001, 12eme Avenue Nord, Sherbrooke, Quebec, Canada J1H 5N4. E-mail: jacques.pepin@usherbrooke.ca Dis Colon Rectum 2009; 52: 400Y405 DOI: 10.1007/DCR.0b013e31819a69aa BThe ASCRS 2009 Copyright @ The ASCRS 2009. Unauthorized reproduction of this article is prohibited.