Postoperative Burden of Hospital-Acquired Clostridium difficile Infection

Zaid M. Abdelsattar, MD; Greta Krapohl, PhD, RN; Layan Alrahmani, MD; Mousumi Banerjee, PhD; Robert W. Krell, MD; Sandra L. Wong, MD, MS; Darrell A. Campbell, Jr, MD; David M. Aronoff, MD; Samantha Hendren, MD, MPH


Infect Control Hosp Epidemiol. 2015;36(1):40-46. 

In This Article

Abstract and Introduction


Objective Clostridium difficile infection (CDI) is a common hospital-acquired infection. Previous reports on the incidence, risk factors, and impact of CDI on resources in the surgical population are limited. In this context, we study CDI across diverse surgical settings.

Methods We prospectively identified patients with laboratory-confirmed postoperative CDI after 40 different general, vascular, or gynecologic surgeries at 52 academic and community hospitals between July 2012 and September 2013. We used multivariable regression models to identify CDI risk factors and to determine the impact of CDI on resource utilization.

Results Of 35,363 patients, 179 (0.51%) developed postoperative CDI. The highest rates of CDI occurred after lower-extremity amputation (2.6%), followed by bowel resection or repair (0.9%) and gastric or esophageal operations (0.7%). Gynecologic and endocrine operations had the lowest rates (0.1% and 0%, respectively). By multivariable analyses, older age, chronic immunosuppression, hypoalbuminemia (≤3.5 g/dL), and preoperative sepsis were associated with CDI. Use of prophylactic antibiotics was not independently associated with CDI, neither was sex, body mass index (BMI), surgical priority, weight loss, or comorbid conditions. Three procedure groups had higher odds of postoperative CDI: lower-extremity amputations (adjusted odds ratio [aOR], 3.5; P=.03), gastric or esophageal operations (aOR, 2.1; P=.04), and bowel resection or repair (aOR, 2; P=.04). Postoperative CDI was independently associated with increased length of stay (mean, 13.7 d vs 4.5 d), emergency department presentations (18.9 vs 9.1%) and readmissions (38.9% vs 7.2%, all P<.001).

Conclusions Incidence of postoperative CDI varies by surgical procedure. Postoperative CDI is also associated with higher rates of extended length of stay, emergency room presentations, and readmissions, which places a potentially preventable burden on hospital resources.


Clostridium difficile is now the most common organism to cause healthcare-associated infection in the United States and C. difficile infection (CDI) is regarded as one of the serious, expensive, and potentially avoidable consequences of hospitalization.[1,2] The emergence of the virulent NAP1/B1/027 strain and the concern over resistance to traditional antibiotic regimens have elevated C. difficile prevention to a high priority on a national level.[3] Despite the national attention, the incidence of CDI continues to grow and the financial and human costs of CDI continue to mount.[4–6] The US government's decision to withhold Medicare reimbursement for hospitals due to CDI in 2017 underscores the gravity of the problem and the severe financial penalties it is willing to levy to address this problem.[7,8]

Epidemiological data suggest that surgical patients have twice the burden of healthcare-associated infection (HAI) when compared to their medical counterparts and that the burden of CDI is increasing among surgical patients.[9] This is concerning given the fact that surgical care comprises approximately 40%–50% of all hospital stays and healthcare dollars.[10] However, prior studies devoted to the investigation of CDI and its impact on the surgical patient population are limited by the use of administrative data, failure to capture cases diagnosed after discharge, or reports from single centers. Surgical patients, although usually younger and healthier than their medical counterparts, frequently receive prophylactic antibiotics and have long inpatient hospital exposure. Large-scale, multicenter studies that focus on the burden of surgical patients gauge the effects of CDI and aim to address the current epidemiological challenges of the disease.

In this context, we designed a prospective, population-based study of hospital-acquired, postoperative CDI within the context of a statewide surgical quality collaborative. Our research questions were: (1) Which surgical procedures are associated with the highest risk for CDI? (2) Which patient characteristics are associated with CDI risk? (3) Is perioperative antibiotic use independently associated with CDI? Finally, we assessed the burden of CDI on resource utilization at the hospital level (extended length of stay, 30-day emergency department presentations, hospital readmission, and reoperation). With new reimbursement legislation and penalties on the horizon, the results from this study can help inform clinicians and administrators about timely and practical strategies to target certain surgical patient populations at high risk for CDI.