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

2. 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

3. 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

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

5. Post-Surgical Clostridium difficile  C. difficile infection worsens post- surgical morbidity and mortality  Incidence increasing  Post-surgical C. difficile: 0.2-8.4%  Contribution of known risk factors not well established

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

7. 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

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

9. 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

10. Population Characteristics  N = 72  24 cases: 48 controls  Male: 39Female: 33  Antibiotics: 81% received at least one antibiotic CharacteristicMeanMedianMinMax Age60.861.52887 Stay Length (days)10.58248 Charlson5.0 013 Antibiotics (class)1.61.005

11. 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 201502321413

12. Characteristic Case Group (n = 24) Control Group (n = 48)Matched ORP value PPI Yes13 (54%)18 (38%)1.9 (0.7-5.1)0.20 Age (years) Less than 503 (12%)12 (25%)ref 50 to 6913 (54%)24 (50%)2.7 (0.5-13.9)0.24 70+8 (33%)12 (25%)3.4 (0.6-19.6)0.18 Charlson Score 0-33 (12%)16 (33%)ref 4-715 (62%)25 (52%)4.8 (1.0-23.4)0.05 8+6 (25%)7 (15%)10.4 (1.2-88.8)0.03 Length of Stay (days) 0-1013 (54%)33 (69%)ref 11+11 (46%)15 (31%)2.1 (0.7-6.4)0.21 BMI Normal10 (42%)20 (42%)ref Overweight8 (33%)15 (31%)1.1 (0.3-3.8)0.92 Obese6 (25%)13 (27%)0.9 (0.2-3.3)0.93

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

14. Antibiotic Class Case Group (n = 24) Control Group (n = 48)Matched ORP value Aminopenicillin9 (38%)11 (23%)2.1 (0.7-6.4)0.18 Carbapenem2 (8%)0 (0%)-- Cephalosporin16 (67%)24 (50%)2.6 (0.7-8.9)0.13 Fluoroquinolone6 (25%)7 (14%)2.3 (0.6-10.0)0.25 Glycopeptide10 (42%)9 (19%)4.2 (1.1-16.2)0.04 Lincosamide4 (17%)4 (8%)2.3 (0.5-10.4)0.30 Macrolide1 (4%)2 (4%)1.0 (0.1-11.0)1.0 Nitroimidazole5 (21%)4 (8%)2.9 (0.7-12.4)0.15

15. Antibiotic Administration Characteristic Case Group (n = 24) Control Group (n = 48)Matched ORP value Antibiotic Days 01 (4%)13 (27%)0.1 (0.0-1.2)0.07 1-24 (17%)7 (15%)ref 3+19 (79%)28 (58%)1.2 (0.3-4.9)0.7 Number of Antibiotics (class) 0-214 (58%)42 (88%)ref 3-510 (42%)6 (12%)7.2 (1.5-33.8)0.01

16. 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 (0.0-1.2)0.1 (0.0-1.3)0.1 (0.0-0.8)0.1 (0.0-0.9)0.1 (0.0-1.3)0.1 (0.0-1.0) 1-2ref 3+1.2 (0.3-4.9)1.1 (0.3-4.7)0.8 (0.2-3.8)1.1 (0.2-5.3)1.1 (0.3-4.7)1.0 (0.2-5.3) Number of Abx (class) 0-2ref 3-57.2 (1.5-33.8)7.6 (1.5-37.2)6.5 (1.3-31.4)6.0 (1.3-29.2)7.0 (1.4-35.8)6.6 (1.1-40.0) Bold = p<0.05

17. 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.

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

19. 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

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