Despite increased national attention, the incidence of Clostridium difficile infection (CDI) and its associated financial and human costs continue to grow. In fact, the problem has become so critical that CMS would no longer reimburse hospitals for claims associated with this potentially preventable infection if it is acquired during the hospital stay. There are also concerns that new strains of the infection may cause resistance to traditional antibiotic regimens.
Recent data have also shown that the burden of CDI is increasing among surgical patients. This is concerning given that surgical care accounts for about 40% to 50% of all hospital stays and healthcare dollars. “Surgery patients frequently receive prophylactic antibiotics and have longer inpatient hospital exposure,” explains Zaid M. Abdelsattar, MD, MSc. Previous reports on how CDI affects surgical patients has been limited by the use of administrative data and failure to capture cases diagnosed after discharge, and reports from single-center studies.
A Large-Scale Analysis
In a study published in Infection Control & Hospital Epidemiology, Dr. Abdelsattar and colleagues conducted a large-scale analysis of patients with postoperative CDI after 40 different surgeries at 52 academic and community hospitals for a period of about 1 year. The purpose of the analysis—which included more than 35,000 patients in total—was to identify CDI risk factors and determine the impact of the infection on resource utilization.
According to the results, only about 0.5% of the study group developed CDI after surgery, but postoperative CDI rates varied significantly between surgical procedures. Three surgical groups had higher adjusted odds ratios (aOR) of postoperative CDI:
- Lower-extremity amputations: aOR,3.5.
- Gastric or esophageal operations: aOR, 2.1.
- Bowel resection or repair: aOR, 2.0.
“Postoperative CDI was associated with longer lengths of stay (LOS) as well as a higher rate of ED presentations and hospital readmissions,” Dr. Abdelsattar says. “Readmission rates and LOS were more than double in patients with CDI. Patients who were older, had chronic immunosuppression, had hypoalbuminemia, and had preoperative sepsis were at greater risk of developing CDI.” Importantly, the authors noted that use of intravenous prophylactic antibiotics—in addition to sex, BMI, surgical priority, weight loss, or comorbid conditions—was not significantly associated with CDI.
Dr. Abdelsattar says results from the study can help inform clinicians and administrators regarding timely and practical implications. “Clinicians can use this information to target surgical patient groups at high risk for CDI and downstream resource utilization when appropriate,” he says. “This will be especially important considering that new reimbursement legislation and penalties are on the horizon. It’s also important to be proactive and emphasize antibiotic stewardship, proper hand hygiene, and disinfecting all equipment and instruments when CDI cases are suspected.
Readings & Resources (click to view)
Abdelsattar ZM, Krapohl G, Alrahmani L, et al. Postoperative burden of hospital-acquired Clostridium difficile infection. Infect Control Hosp Epidemiol. 2015;36:40-46. Available at: http://journals.cambridge.org/action/displayFulltext?type=6&fid=9494398&jid=ICE&volumeId=36&issueId=01&aid=9494397&bodyId=&membershipNumber=&societyETOCSession=&fulltextType=RA&fileId=S0899823X14000087.
Krapohl GL, Morris AM, Cai S, et al. Preoperative risk factors for postoperative Clostridium difficile infection in colectomy patients. Am J Surg. 2013;205:343-347.
Lipp MJ, Nero DC, Callahan MA. Impact of hospital-acquired Clostridium difficile. J Gastroenterol Hepatol. 2012;27:1733-1737.
Abbett SK, Yokoe DS, Lipsitz SR, et al. Proposed checklist of hospital interventions to decrease the incidence of healthcare-associated Clostridium difficile infection. Infect Control Hosp Epidemiol. 2009;30:1062-1069.
Lesperance K, Causey MW, Spencer M, Steele SR. The morbidity of Clostridium difficile infection after elective colonic resection-results from a national population database. Am J Surg. 2011;201:141-148.