Shaikh DH, Patel H, Munshi R, Sun H, Mehershahi S, Baiomi A, Alemam A, Pirzada U, Nawaz I, Naher K, Hanumanthu S, Nayudu S. Patients with Clostridium difficile infection and prior appendectomy may be prone to worse outcomes. World J Gastrointest Surg 2021; 13(11): 1436-1447 [PMID: 34950432 DOI: 10.4240/wjgs.v13.i11.1436]
Corresponding Author of This Article
Danial Haris Shaikh, MD, Doctor, Division of Gastroenterology, Department of Medicine, BronxCare Health System, 1650 Grand Concourse, Bronx, NY 10457, United States. dshaikh@bronxcare.org
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Retrospective Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Gastrointest Surg. Nov 27, 2021; 13(11): 1436-1447 Published online Nov 27, 2021. doi: 10.4240/wjgs.v13.i11.1436
Patients with Clostridium difficile infection and prior appendectomy may be prone to worse outcomes
Danial Haris Shaikh, Harish Patel, Rezwan Munshi, Haozhe Sun, Shehriyar Mehershahi, Ahmed Baiomi, Ahmed Alemam, Usman Pirzada, Iqra Nawaz, Kamrun Naher, Siddarth Hanumanthu, Suresh Nayudu
Danial Haris Shaikh, Harish Patel, Haozhe Sun, Shehriyar Mehershahi, Ahmed Baiomi, Ahmed Alemam, Siddarth Hanumanthu, Suresh Nayudu, Division of Gastroenterology, Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
Rezwan Munshi, Department of Medicine, Nassau University Medical Center, New York, NY 11554, United States
Usman Pirzada, Iqra Nawaz, Kamrun Naher, Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
Author contributions: Shaikh DH and Patel H contributed planned, designed, conducted and analyzed the result of the study as well as drafted the manuscript; Munshi R, Sun H, Mehershahi S, Baiomi A, Alemam A and Pirzada U contributed acquired the data for the study and were involved in the critical revision of the manuscript; Nawaz I and Naher K contributed acquired the data for the study and were involved in the critical revision of the manuscript; Hanumanthu S acquired the data for the study and was involved in the critical revision of the manuscript; Nayudu S contributed supervised the design and conduct of the study as well as provided interpretation of the study results; Nayudu S was also involved in drafting, critical revision; all authors are involved in the final review and approval of the manuscript for submission.
Institutional review board statement: The study protocol was approved by the Institution Review Board at BronxCare Health System and was performed as per the Declaration of Helsinki (IRB No. 12131804).
Informed consent statement: Patients were not required to give informed consent to the study because the analysis used anonymous data, that was obtained after each patient had agreed to the hospital evaluation and treatment via written consent.
Conflict-of-interest statement: All authors report no conflicts of interest.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Danial Haris Shaikh, MD, Doctor, Division of Gastroenterology, Department of Medicine, BronxCare Health System, 1650 Grand Concourse, Bronx, NY 10457, United States. dshaikh@bronxcare.org
Received: July 18, 2021 Peer-review started: July 18, 2021 First decision: August 15, 2021 Revised: August 29, 2021 Accepted: September 15, 2021 Article in press: September 15, 2021 Published online: November 27, 2021 Processing time: 131 Days and 13.5 Hours
Abstract
BACKGROUND
Clostridium difficile infection (CDI) occurs due to a dysbiosis in the colon. The appendix is considered a ‘safe house’ for gut microbiota and may help repopulate gut flora of patients with CDI.
AIM
To study the impact of prior appendectomy on the severity and outcomes of CDI.
METHODS
We retrospectively reviewed data of 1580 patients with CDI, admitted to our hospital between 2008 to 2018. Patients were grouped based on the presence or absence of the appendix. The primary aim was to (1) assess all-cause mortality and (2) the severity of CDI. Severity was defined as per the Infectious Diseases Society of America criteria. Logistic regression, and propensity score analysis using inverse probability of treatment weights (IPTW) was performed.
RESULTS
Of the 1580 patients, 12.5% had a history of appendectomy. There was no statistical difference in mortality between patients with a prior appendectomy or without (13.7% vs 14%, P = 0.877). However, a history of appendectomy affected the severity of CDI [odds ratio (OR) = 1.32, 95% confidence interval: 1.01-1.75]. On IPTW, this association remained significant (OR = 1.59, P < 0.05). On multivariable analysis of secondary outcomes, prior appendectomy was also associated with toxic megacolon (OR = 5.37, P < 0.05) and colectomy (OR = 2.77, P < 0.05).
CONCLUSION
Prior appendectomy may affect the severity of CDI, development of toxic megacolon and the eventual need for colectomy. Since treatment of CDI is governed by its severity, stronger antibiotic regimens or earlier use of fecal microbiota transplant may be a viable option for patients with prior appendectomy.
Core Tip: Clostridium difficile (C. difficile) infection occurs due to a dysbiosis of the gut. The appendix is known to host immune tissue and favorable gut microbiota, which may indirectly influence the disease course and outcomes in C. difficile infection. We found that prior appendectomy may affect the severity of C. difficile infection, and it may also increase the risk of developing toxic megacolon or requiring colectomy in these patients. Thus, earlier implementation of advanced therapeutic options may be necessary in patients without an appendix who develop C. difficile infection.
