Advertisement

Clostridioides difficile infection after appendectomy: An analysis of short-term outcomes from the NSQIP database

      Abstract

      Background

      Clostridioides difficile infection can be a significant complication in surgical patients. The purpose of this study was to describe the incidence and impact on outcomes of Clostridioides difficile infection in adult patients after appendectomy.

      Methods

      The American College of Surgeons National Surgical Quality Improvement Program data set was used to identify all patients with the primary procedure code of appendectomy between 2016 and 2018. Patient demographics and clinical characteristics were extracted from the database, and descriptive statistics were performed. A multivariate logistic regression was created to identify predictors of Clostridioides difficile infection following appendectomy.

      Results

      A total of 135,272 patients who underwent appendectomy were identified, and of those, 469(0.35%) developed Clostridioides difficile infection. Patients with Clostridioides difficile infection were more likely to be older (51.23 vs 40.47 years; P < .0001), female (P = .004), American Society of Anesthesiology score >2 (P < .0001), present with septic shock (P < .0001), or lack functional independence (P < .0001). Patients with Clostridioides difficile infection were more likely to have increased operative time (62.9 vs 50.4 minutes; P < .0001), have perforated appendicitis (48.9% vs 23.5%; P < .0001), and underwent open surgery (7.0% vs 4.0%; P = .0006). Postoperatively, patients with Clostridioides difficile infection required a longer length of stay (4.8 vs 1.8 days; P < .0001), had increased mortality (2.1% vs 0.1%; P < .0001), higher incidences of postoperative abscess (14.9% vs 2.9%; P < .0001), postoperative sepsis (15.1% vs 4.0%; P < .0001), and readmission (30.7% vs 3.4%; all P < .0001). On multivariate analysis, older age (P < .0001), female sex (P = .0043), septic shock (P = .0002), open surgery (P = .037), and dirty wound class (P = .0147) were all independently predictive factors of Clostridioides difficile infection after appendectomy.

      Conclusion

      Clostridioides difficile infection is an uncommon postoperative complication of appendectomy and is associated with worse outcomes and higher mortality. Older patients, female sex, those with sepsis, and those undergoing open surgery are at higher risk for developing Clostridioides difficile infection.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Buckius M.T.
        • McGrath B.
        • Monk J.
        • Grim R.
        • Bell T.
        • Ahuja V.
        Changing epidemiology of acute appendicitis in the United States: study period 1993–2008.
        J Surg Res. 2012; 175: 185-190
        • Lessa F.C.
        • Mu Y.
        • Bamberg W.M.
        • et al.
        Burden of Clostridium difficile infection in the United States.
        N Engl J Med. 2015; 372: 825-834
        • Rupnik M.
        • Wilcox M.H.
        • Gerding D.N.
        Clostridium difficile infection: new developments in epidemiology and pathogenesis.
        Nat Rev Microbiol. 2009; 7: 526-536
        • Depestel D.D.
        • Aronoff D.M.
        Epidemiology of Clostridium difficile infection.
        J Pharm Pract. 2013; 26: 464-475
        • Vuotto C.
        • Donelli G.
        • Buckley A.
        • Chilton C.
        Clostridium difficile biofilm.
        Adv Exp Med Biol. 2018; 1050: 97-115
        • Czepiel J.
        • Drozdz M.
        • Pituch H.
        • et al.
        Clostridium difficile infection: review.
        Eur J Clin Microbiol Infect Dis. 2019; 38: 1211-1221
        • McDonald L.C.
        • Owings M.
        • Jernigan D.B.
        Clostridium difficile infection in patients discharged from US short-stay hospitals, 1996–2003.
        Emerg Infect Dis. 2006; 12: 409-415
        • Brown E.
        • Talbot G.H.
        • Axelrod P.
        • Provencher M.
        • Hoegg C.
        Risk factors for Clostridium difficile toxin-associated diarrhea.
        Infect Control Hosp Epidemiol. 1990; 11: 283-290
        • Centers for Disease Control and Prevention
        Severe Clostridium difficile-associated disease in populations previously at low risk: four states, 2005.
        MMWR Morb Mortal Wkly Rep. 2005; 54: 1201-1205
        • Kutty P.K.
        • Woods C.W.
        • Sena A.C.
        • et al.
        Risk factors for and estimated incidence of community-associated Clostridium difficile infection, North Carolina, USA.
        Emerg Infect Dis. 2010; 16: 197-204
        • Lambert P.J.
        • Dyck M.
        • Thompson L.H.
        • Hammond G.W.
        Population-based surveillance of Clostridium difficile infection in Manitoba, Canada, by using interim surveillance definitions.
        Infect Control Hosp Epidemiol. 2009; 30: 945-951
        • Wilcox M.H.
        • Mooney L.
        • Bendall R.
        • Settle C.D.
        • Fawley W.N.
        A case-control study of community-associated Clostridium difficile infection.
        J Antimicrob Chemother. 2008; 62: 388-396
        • Li X.
        • Wilson M.
        • Nylander W.
        • Smith T.
        • Lynn M.
        • Gunnar W.
        Analysis of morbidity and mortality outcomes in postoperative Clostridium difficile infection in the Veterans Health Administration.
        JAMA Surg. 2016; 151: 314-322
        • American College of Surgeons
        User Guide for the 2016 ACS NSQIP Participant Use Data File (PUF) October 2017.
        • American College of Surgeons
        User Guide for the 2017 ACS NSQIP Participant Use Data File (PUF) October 2018.
        • American College of Surgeons
        User Guide for the 2018 ACS NSQIP Participant Use Data File (PUF) October 2019.
        • Sawyer R.G.
        • Claridge J.A.
        • Nathens A.B.
        • et al.
        Trial of short-course antimicrobial therapy for intraabdominal infection.
        N Engl J Med. 2015; 372: 1996-2005
        • Emre A.
        • Akbulut S.
        • Bozdag Z.
        • et al.
        Routine histopathologic examination of appendectomy specimens: retrospective analysis of 1255 patients.
        Int Surg. 2013; 98: 354-362
        • Curtis G.L.
        • Yokhana S.S.
        • Samuel L.T.
        • et al.
        Clostridium difficile colitis following revision total knee arthroplasty: incidence and risk factors.
        J Arthroplasty. 2019; 34: 2785-2788
        • Randal Bollinger R.
        • Barbas A.S.
        • Bush E.L.
        • Lin S.S.
        • Parker W.
        Biofilms in the large bowel suggest an apparent function of the human vermiform appendix.
        J Theor Biol. 2007; 249: 826-831
        • Im G.Y.
        • Modayil R.J.
        • Lin C.T.
        • et al.
        The appendix may protect against Clostridium difficile recurrence.
        Clin Gastroenterol Hepatol. 2011; 9: 1072-1077
        • Merchant R.
        • Mower W.R.
        • Ourian A.
        • et al.
        Association between appendectomy and Clostridium difficile infection.
        J Clin Med Res. 2012; 4: 17-19
        • Yong F.A.
        • Alvarado A.M.
        • Wang H.
        • Tsai J.
        • Estes N.C.
        Appendectomy: a risk factor for colectomy in patients with Clostridium difficile.
        Am J Surg. 2015; 209: 532-535
        • Clanton J.
        • Subichin M.
        • Drolshagen K.
        • Daley T.
        • Firstenberg M.S.
        Fulminant Clostridium difficile infection: an association with prior appendectomy?.
        World J Gastrointest Surg. 2013; 5: 233-238
        • Fagenholz P.J.
        • Peev M.P.
        • Thabet A.
        • et al.
        Abscess due to perforated appendicitis: factors associated with successful percutaneous drainage.
        Am J Surg. 2016; 212: 794-798
        • Marin D.
        • Ho L.M.
        • Barnhart H.
        • Neville A.M.
        • White R.R.
        • Paulson E.K.
        Percutaneous abscess drainage in patients with perforated acute appendicitis: effectiveness, safety, and prediction of outcome.
        AJR Am J Roentgenol. 2010; 194: 422-429
        • Brown C.V.
        • Abrishami M.
        • Muller M.
        • Velmahos G.C.
        Appendiceal abscess: immediate operation or percutaneous drainage?.
        Am Surg. 2003; 69: 829-832
        • Oliak D.
        • Yamini D.
        • Udani V.M.
        • et al.
        Initial nonoperative management for periappendiceal abscess.
        Dis Colon Rectum. 2001; 44: 936-941
        • Becker P.
        • Fichtner-Feigl S.
        • Schilling D.
        Clinical management of appendicitis.
        Visc Med. 2018; 34: 453-458
        • Jaschinski T.
        • Mosch C.
        • Eikermann M.
        • Neugebauer E.A.
        Laparoscopic versus open appendectomy in patients with suspected appendicitis: a systematic review of meta-analyses of randomised controlled trials.
        BMC Gastroenterol. 2015; 15: 48
        • Zerey M.
        • Paton B.L.
        • Lincourt A.E.
        • Gersin K.S.
        • Kercher K.W.
        • Heniford B.T.
        The burden of Clostridium difficile in surgical patients in the United States.
        Surg Infect (Larchmt). 2007; 8: 557-566
        • Orelaru F.
        • Karabon P.
        • Novotny N.
        • Akay B.
        • Brahmamdam P.
        Impact of Clostridium difficile infection on pediatric appendicitis.
        Pediatr Surg Int. 2021; 37: 865-870
        • Brown T.A.
        • Rajappannair L.
        • Dalton A.B.
        • Bandi R.
        • Myers J.P.
        • Kefalas C.H.
        Acute appendicitis in the setting of Clostridium difficile colitis: case report and review of the literature.
        Clin Gastroenterol Hepatol. 2007; 5: 969-971
        • Ridha A.
        • Safiullah S.M.
        • Al-Abayechi S.
        • Nadeem A.U.R.
        Acute appendicitis: an extracolonic manifestation of Clostridium difficile colitis.
        Case Rep Med. 2017; 2017: 5083535
        • Coyne J.D.
        • Dervan P.A.
        • Haboubi N.Y.
        Involvement of the appendix in pseudomembranous colitis.
        J Clin Pathol. 1997; 50: 70-71
        • Martirosian G.
        • Bulanda M.
        • Wojcik-Stojek B.
        • et al.
        Acute appendicitis: the role of enterotoxigenic strains of Bacteroides fragilis and Clostridium difficile.
        Med Sci Monit. 2001; 7: 382-386
        • Brown K.A.
        • Fisman D.N.
        • Moineddin R.
        • Daneman N.
        The magnitude and duration of Clostridium difficile infection risk associated with antibiotic therapy: a hospital cohort study.
        PLoS One. 2014; 9e105454
        • Curry S.R.
        Clostridium difficile.
        Clin Lab Med. 2017; 37: 341-369
        • Sung S.
        • Kwon J.W.
        • Lee S.B.
        • Lee H.M.
        • Moon S.H.
        • Lee B.H.
        Risk factors of Clostridium Difficile infection after spinal surgery: National Health Insurance Database.
        Sci Rep. 2020; 10: 4438
        • Sullivan T.
        • Weinberg A.
        • Rana M.
        • Patel G.
        • Huprikar S.
        The epidemiology and clinical features of Clostridium difficile infection in liver transplant recipients.
        Transplantation. 2016; 100: 1939-1943
        • Keshavamurthy S.
        • Koch C.G.
        • Fraser T.G.
        • et al.
        Clostridium difficile infection after cardiac surgery: prevalence, morbidity, mortality, and resource utilization.
        J Thorac Cardiovasc Surg. 2014; 148 (3157-65e1-5)