Assessment of Risk-Factors for Development of Clostridium Difficile Infection in Post-Surgical Patients SCOTT BATTLE UIC SCHOOL OF PUBLIC HEALTH

Clostridium difficile  Gram negative, spore forming bacteria  Common nosocomial infection  Outcomes  Antibiotic-associated diarrhea  Dehydration  Kidney failure  Antibiotic-associated colitis  Toxic megacolon University of Washington Molecular Diagnostics

Clostridium difficile  Gram negative, spore forming bacteria  Common nosocomial infection  Outcomes  Antibiotic-associated diarrhea  Dehydration  Kidney failure  Antibiotic-associated colitis  Toxic megacolon Greg Ginsburg MD, NASPGHAN University of Pennsylvania

Risk Factors  Medication  Antibiotics  Proton Pump Inhibitors (PPI)  Chemotherapy  General Health  Age  Health care facility stay  Other diseases  Medical procedures

Post-Surgical Clostridium difficile  C. difficile infection worsens post- surgical morbidity and mortality  Incidence increasing  Post-surgical C. difficile: %  Contribution of known risk factors not well established

Question What risk factors are important in the development of post-surgical Clostridium difficile infection at UIHHSS?

Study Design  Matched case-control study  Surgical procedure at UIHHSS in 2012  Case: PCR positive C. difficile stool test within 30 days of surgery  Control: Matched 2:1 on surgical procedure (ICD-9 code)  Two closest dates  Use comparable ICD-9 code Norgen Biotek

Study Design  Medical records  Cerner Powerchart  Analysis  Conditional Logistic Regression Cerner

Variables Recorded  Medication  Antibiotics (Type and duration; admission to PCR/discharge)  PPI  General Health  Age  Charlson Comorbidity score  Length of hospital stay (Admission to PCR/discharge)  BMI

Population Characteristics  N = 72  24 cases: 48 controls  Male: 39Female: 33  Antibiotics: 81% received at least one antibiotic CharacteristicMeanMedianMinMax Age Stay Length (days) Charlson Antibiotics (class)

Case Time and Location JanFebMarchAprilMayJuneJulyAugSepOctNovDecTotal 5E Rehab O1 6E NSICU A/B OOOOO O8 6W MSICU A/B OOO3 6W Med SD OOOO4 7NE Med OO2 7SE Med SD OO2 7W WPLC A/B OOO3 7W Organ O1 Total

Characteristic Case Group (n = 24) Control Group (n = 48)Matched ORP value PPI Yes13 (54%)18 (38%)1.9 ( )0.20 Age (years) Less than 503 (12%)12 (25%)ref 50 to 6913 (54%)24 (50%)2.7 ( ) (33%)12 (25%)3.4 ( )0.18 Charlson Score 0-33 (12%)16 (33%)ref (62%)25 (52%)4.8 ( ) (25%)7 (15%)10.4 ( )0.03 Length of Stay (days) (54%)33 (69%)ref (46%)15 (31%)2.1 ( )0.21 BMI Normal10 (42%)20 (42%)ref Overweight8 (33%)15 (31%)1.1 ( )0.92 Obese6 (25%)13 (27%)0.9 ( )0.93

Antibiotic Classes AminopenicillinCarbapenemCephalosporinFluoroquinaloneGlycopeptideLincosamideMacrolideNitroimidizole AmpicillinImipenem- cilastatin CefazolinLevofloxacinVancomycinClindamycinAzithromycinMetronidazole Piperacillin- tazobactam CefepimeErythromycin AztreonamCefoxitin Ceftriaxone Cefuroxime

Antibiotic Class Case Group (n = 24) Control Group (n = 48)Matched ORP value Aminopenicillin9 (38%)11 (23%)2.1 ( )0.18 Carbapenem2 (8%)0 (0%)-- Cephalosporin16 (67%)24 (50%)2.6 ( )0.13 Fluoroquinolone6 (25%)7 (14%)2.3 ( )0.25 Glycopeptide10 (42%)9 (19%)4.2 ( )0.04 Lincosamide4 (17%)4 (8%)2.3 ( )0.30 Macrolide1 (4%)2 (4%)1.0 ( )1.0 Nitroimidazole5 (21%)4 (8%)2.9 ( )0.15

Antibiotic Administration Characteristic Case Group (n = 24) Control Group (n = 48)Matched ORP value Antibiotic Days 01 (4%)13 (27%)0.1 ( ) (17%)7 (15%)ref 3+19 (79%)28 (58%)1.2 ( )0.7 Number of Antibiotics (class) (58%)42 (88%)ref (42%)6 (12%)7.2 ( )0.01

Controlling for Other Factors CharacteristicMatched OR Matched OR (PPI) Matched OR (Age) Matched OR (Charlson) Matched OR (Stay Length) Matched OR (All) Antibiotic Days 00.1 ( )0.1 ( )0.1 ( )0.1 ( )0.1 ( )0.1 ( ) 1-2ref ( )1.1 ( )0.8 ( )1.1 ( )1.1 ( )1.0 ( ) Number of Abx (class) 0-2ref ( )7.6 ( )6.5 ( )6.0 ( )7.0 ( )6.6 ( ) Bold = p<0.05

Conclusions  Patients with higher Charlson Comorbidity score more likely to contract post-surgical C. difficile infection.  There is not strong evidence that any single class of antibiotics is associated with increased odds of post-surgical C. difficile.  Treatment with higher numbers of antibiotics significantly increases odds of post- surgical C. difficile.  No antibiotics is safer than perioperative antibiotics.  Longer than perioperative antibiotics not significantly different than perioperative.

Limitations  Sample size  Only access to UIHHSS data  Inconsistant records  Other means of diagnosis  Hospital acquired vs. community acquired

Implications  Don’t administer unnecessary antibiotics  Look more closely at perioperative antibiotics  Cost-benefit analysis  Surgical Care Improvement Project (SCIP)  Antibiotic one hour before surgery  Appropriate antibiotic  No benefit to extending antibiotic treatment beyond 24 hours

Acknowledgements Dr Susan Bleasdale Dr Monica Sikka Maria Perez Barbara Pearce Linda Wurtz Dr Ronald Hershow