1256 infection control & hospital epidemiology october 2017, vol. 38, no. 10 table 2. Continued Control Characteristic
Discharge disposition Home SNF
Other Case (N =52) (N=156)
154 32 22
32 13 7
20.8 40.6 31.8
Univariable Analysis OR (95% CI)
Reference
2.61 (1.17–5.84) 1.78 (0.67–4.73)
Multivariable Analysisb P Value OR (95% CI) ...
.020 .248
Reference
2.24 (0.88–5.69) 1.08 (0.31–3.75)
P Value ...
.092 .904
NOTE. SD, standard deviation; IQR, interquartile ratio; OR, odds ratio; CI, confidence interval; BMI, body mass index, CCI, Charlson comor- bidity index, ASA, American Society of Anesthesiologists; CKD, chronic kidney disease; PPI, proton pump inhibitor; SNF, skilled nursing
facility. aData reported as mean (SD), median (IQR) or OR (95% CI). bMultivariable analysis controls for BMI, ASA classification, and previous antibiotic use in the past 6 months. cASA classification: 1, a normal healthy patient; 2, a patient with mild systemic disease; 3, a patient with severe systemic disease; 4, a patient with severe systemic disease that is a constant threat to life; 5, a moribund patient who is not expected to survive without the operation.
Risk Factor Analysis
From univariable analysis, the following variables were asso- ciated with statistically significant increased odds of CDI: number of admissions in past year (OR, 2.25; P<.001), ASA classification of 4–5 versus 1–2 (OR, 10.45; P<.001), anti- biotic use in the previous 6 months (OR, 2.80; P=.002), proton pump inhibitor or H2 receptor blocker use in the previous 6 months (OR, 2.14; P=.026), antibiotics continued more than 24 hours postoperatively (OR, 5.44; P<.001), and nonperioperative antibiotics (OR, 3.59; P<.001) (Table 2). Controlling for BMI, ASA classification, and antibiotic use
in the previous 6 months, the following variables were asso- ciated with statistically significant increased odds of CDI by multivariable analysis: number of admissions in past year (OR, 2.33; P=.001), ASA class of 4–5 versus 1–2 (OR, 15.39; P<.001), antibiotic use in the previous 6 months (OR, 3.74; P<.001), antibiotics continued more than 24 hours post- operatively (OR, 3.38; P=.026), and nonperioperative anti- biotics (OR, 2.20; P=.038).
Outcomes
Length of stay during the postoperative admission was significantly increased on univariable analysis (OR, 1.16; P<.001) as well as multivariable analysis (OR, 1.14; P<.001) (Table 2). Length of stay was evaluated as a continuous variable, and for every additional admission in the previous year, odds of CDI increased by 14%. Discharge to skilled nursing facility versus home was also more likely for patients with CDI on univariable analysis (OR, 2.61; P=.020).
discussion
Our study examined incidence of and risk factors for CDI across multiple surgical specialties in one tertiary-care center. We found rates 4–5 times higher in the trauma and general
surgery units than in the orthopedic and neurosurgery units. This variability may be attributable to differences in patient factors such as overall health, antibiotic use, or healthcare setting exposure as well as surgical factors (eg, intra-abdominal trauma surgeries versus orthopedic joint surgeries). We found that having an ASA class of 4 or 5 increases the
odds of CDI 15-fold compared to an ASA class of 1 or 2. This suggests that the complexity of a patient’s illness may increase the risk of CDI. Interestingly, the complexity of the surgery itself, as represented by operative time and blood loss, does not correlate with increased odds of CDI. If the perioperative antibiotic is continued more than
24 hours after surgery, outside of the perioperative window, the odds of CDI increase 3.34-fold. This finding has been reported previously and highlights the importance of mini- mizing antibiotic use to only the perioperative period if possible.8 Use of antibiotics while in the hospital other than the perioperative antibiotic was also associated with 2.2 times greater odds of CDI. Antibiotic exposure as long as 6 months prior to surgery increases the odds of CDI more than 3-fold. Although the surgeon cannot change the fact that their patient received antibiotics, it should alert him or her to the fact that the patient may be at higher risk for postoperative CDI. Previous studies have shown a correlation between CDI and
hospital admission in the previous 3 months.9 Our study reports that this association extends to 12 months. We found that the number of hospital admissions in the past year increases the odds of CDI by 133% for each admission. Given the extensive environmental contamination with C. difficile in healthcare settings, this is a biologically plausible finding. This study has several limitations. First, the hospital data-
base only tracks patients within the hospital system. Therefore, CDI diagnoses, admissions, and medications from other facilities were not tracked. This study has a relatively small sample size of 52 cases, which limits the power of our statistical analysis. Further, this case-control study is subject to the limitations of all case-control studies.10
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