Recent research has shown that Clostridium difficile infection (CDI) is a growing cause of morbidity and mortality in the United States and is associated with longer hospital lengths of stay (LOS) and higher hospital costs. “CDI has also been shown to be a significant complication for surgical patients,” says William Gunnar, MD, JD. Data show that the healthcare–associated burden of CDI is increasing among surgical patients and varies among types of surgery. Among surgical patients, CDI has been linked to longer mechanical ventilation, longer ICU and hospital LOS, and higher mortality.
The 134 Veterans Health Administration (VHA) Surgery Programs throughout the U.S. perform an estimated 400,000 surgical procedures each year. In 2007, the VHA modified the established VA Surgical Quality Improvement Program (VASQIP) to begin collecting 30-day postoperative CDI data from eligible non-cardiac surgical procedures. For a retrospective observational study published in JAMA Surgery, Dr. Gunnar and colleagues documented CDI incidence in the VHA from fiscal year 2010 through 2013 across different surgical procedures. They also identified risk factors associated with CDI and determined the impact of CDI on postoperative mortality, morbidity, and hospital LOS.
Examining New Data
Results of the study showed that the postoperative CDI rate was 0.4% per year, unchanged throughout the study period, and varied by the VHA Surgery Program and surgical specialty. The 30-day CDI rates were higher in emergency procedures, operations with greater complexity and higher relative value units, and those with a contaminated or infected wound classification. Patients with postoperative CDI were significantly older, were more frequently hospitalized after surgery (59.9% vs 15.4%), and had longer preoperative hospital LOS (9.1 days vs 1.9 days).
“Importantly, our analysis also showed that surgical patients who had received three or more classes of antibiotics in the 60-day preoperative period had about a six-fold higher risk of developing postoperative CDI,” adds Dr. Gunnar. Several other independent risk factors for CDI were identified. These included commonly identified patient factors, such as albumin levels, functional class, and weight loss. “The surgical program complexity was another important independent risk factor for CDI,” Dr. Gunnar says. “The more complex the procedure, the more likely patients were to develop CDI after their operation.”
Exploring the Implications
Dr. Gunnar says surgical administrators and clinical teams should consider results of the study when targeting interventions for specific patients undergoing high-risk surgeries. Potential interventions include using selective antibiotic administration and early testing of at-risk patients. Other potentially helpful interventions include hand hygiene with non-alcohol agents, early contact precautions, and specific infection control protocols.
“The results of our study can help inform best practices and provide baseline data for comparing future CDI rates,” says Dr. Gunnar. “Also, this research provides the basis for future prospective studies that aim to determine if mitigating CDI risk factors can decrease the overall incidence of CDI.”
Li X, Wilson M, Nylander W, et al. Morbidity and mortality outcomes in postoperative Clostridium difficile infection in the Veterans Health Administration. JAMA Surg. 2015 Nov 25 [Epub ahead of print]. Available at: http://archsurg.jamanetwork.com/article.aspx?articleid=2470902.
Leffler DA, Lamont JT. Clostridium difficile infection. N Engl J Med. 2015;372:1539-1548.
Murphy CR, Avery TR, Dubberke ER, Huang SS. Frequent hospital readmissions for Clostridium difficile infection and the impact on estimates of hospital-associated C difficile burden. Infect Control Hosp Epidemiol. 2012;33:20-28.