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Postoperative Clostridium difficile infection has a differential procedure-specific association with surgical outcomes in contemporary United States practice

Published:December 19, 2022DOI:https://doi.org/10.1016/j.surg.2022.11.025

      Abstract

      Background

      The Centers for Disease Control and Prevention has made the prevention of in-hospital Clostridium difficile infection a priority. However, whether there is a differential impact of Clostridium difficile on surgical patients remains undefined. Therefore, we quantified the procedure-specific association between postoperative Clostridium difficile and surgical outcomes to define opportunities for targeted quality improvement.

      Methods

      We studied patients undergoing major cardiac, vascular, general, or oncologic procedures using the Vizient database from 2015 to 2019. Our primary exposure was postoperative Clostridium difficile infection. Our primary outcomes were postoperative length of stay, hospitalization cost, readmission, and in-hospital mortality. We used linear and logistic regression for risk adjustment.

      Results

      The incidence of Clostridium difficile infection was 1.6% (n = 6,506/397,750). Patients with Clostridium difficile were older, more comorbid, and more frequently underwent urgent surgery. The median postoperative length of stay was 7 days (interquartile range: 5–11 days), and it was 66% longer among those with Clostridium difficile (P < .001). Similarly, the median hospitalization cost was $31,000 (interquartile range: $20,000–$49,000), and it was 51% greater among patients with Clostridium difficile (P < .001). Postoperative Clostridium difficile was associated with more readmissions after coronary artery bypass grafting, small bowel resection, colectomy, gastrectomy, pancreatectomy, and infrainguinal bypass (adjusted odds ratio range: 1.4–1.7), but not after open aneurysm repair, suprainguinal bypass, or esophagectomy. Clostridium difficile was associated with increased mortality after coronary artery bypass grafting, small bowel resection, colectomy, and infrainguinal bypass (adjusted odds ratio range: 1.3–2.7), but not after open aneurysm repair, suprainguinal bypass, esophagectomy, gastrectomy, or pancreatectomy.

      Conclusion

      Postoperative Clostridium difficile infection was differentially associated with increased length of stay, cost, readmissions, and mortality across specific procedures. This was most apparent after infrainguinal bypass, small bowel resection, colectomy, and coronary artery bypass grafting. Accordingly, a targeted Clostridium difficile reduction effort for these procedures may offer a more effective approach toward reducing infection rates.
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      References

        • Center for Disease Control and Prevention
        AR Threats Report.
        • U.S. Department of Health and Human Services
        Healthcare-associated infections national access plan.
        • U.S. Department of Health and Human Services
        National healthcare-associated infection targets and metrics.
        • Centers for Medicare and Medicaid Services
        Hospital-acquired condition reduction program.
        • 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
        • Healthcare Cost and Utilization Project
        Characteristics of operating room procedures in U.S. hospitals.
        • Niederberger M.
        • Spranger J.
        Delphi technique in health sciences: a map.
        Front Public Health. 2020; 8: 457
        • Bagdasarian N.
        • Rao K.
        • Malani P.N.
        Diagnosis and treatment of Clostridium difficile in adults: a systematic review.
        JAMA. 2015; 313: 398-408
        • Rao K.
        • Malani P.N.
        Diagnosis and treatment of Clostridioides (Clostridium) difficile infection in adults in 2020.
        JAMA. 2020; 323: 1403-1404
        • Lee D.Y.
        • Chung E.L.
        • Guend H.
        • Whelan R.L.
        • Wedderburn R.V.
        • Rose K.M.
        Predictors of mortality after emergency colectomy for Clostridium difficile colitis: an analysis of ACS-NSQIP.
        Ann Surg. 2014; 259: 148-156
        • Guh A.Y.
        • Mu Y.
        • Winston L.G.
        • et al.
        Trends in U.S. burden of Clostridioides difficile infection and outcomes.
        N Engl J Med. 2020; 382: 1320-1330
        • Marra A.R.
        • Perencevich E.N.
        • Nelson R.E.
        • et al.
        Incidence and outcomes associated with Clostridium difficile infections: a systematic review and meta-analysis.
        JAMA Netw Open. 2020; 3e1917597
        • Alrawashdeh M.
        • Rhee C.
        • Hsu H.
        • Wang R.
        • Horan K.
        • Lee G.M.
        Assessment of federal value-based incentive programs and in-hospital Clostridioides difficile infection rates.
        JAMA Netw Open. 2021; 4e2132114
        • Kent K.C.
        • Rubin M.S.
        • Wroblewski L.
        • Hanff P.A.
        • Silen W.
        The impact of Clostridium difficile on a surgical service: a prospective study of 374 patients.
        Ann Surg. 1998; 227: 296-301
        • Cusini A.
        • Beguelin C.
        • Stampf S.
        • et al.
        Clostridium difficile infection is associated with graft loss in solid organ transplant recipients.
        Am J Transplant. 2018; 18: 1745-1754
        • 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
        • 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
        • Kelley K.E.
        • Fajardo A.D.
        • Strange N.M.
        • et al.
        Impact of a novel preoperative patient-centered surgical wellness program.
        Ann Surg. 2018; 268: 650-656