Clostridium difficile colitis in patients undergoing lower-extremity arthroplasty: rare infection with major impact

Abstract

Background: The prevalence of Clostridium difficile colitis is reportedly increasing in surgical patients and can negatively impact their outcome. However, as yet there are no clear estimates of the C difficile infection colitis rate and its consequences among patients undergoing total joint arthroplasty (TJA).

Questions/purposes: We asked: (1) What is the rate of C difficile colitis in TJA patients? (2) What are the risk factors of C difficile colitis in these patients? And (3) what is the effect of C difficile colitis on length of stay, in-hospital mortality, and estimated total charges?

Methods: Using ICD-9-CM diagnosis and procedure codes, we queried the Nationwide Inpatient Sample database for patients undergoing TJA for the years 2002 to 2010. Demographic data, comorbidities, occurrence of C difficile colitis, length of hospital stay, mortality, and hospital charges were extracted. Logistic regression was performed to identify predictors of C difficile colitis and its impact on in-hospital mortality.

Results: The incidence of C difficile remained less than 0.6% during the study period. Revision TJAs (odds ratio=6.9 and 4.4 for hip and knee, respectively) and number of comorbidities (odds ratio=1.5) increased risk of C difficile colitis. C difficile increased length of hospital stay by a week, hospital charges by USD 40,000, and in-hospital mortality to 4.66% from 0.24%.

Conclusions: Using lower and fewer doses of antibiotics in revision TJAs and among patients with many comorbidities may diminish risk of C difficile colitis and its consequent mortality.

Level of evidence: Level II, prognostic study. See Instructions for Authors for a complete description of levels of evidence.

Fig. 1A–C

(A) The number of TJAs and (B) the number of C difficile diagnoses for all hospitalizations are climbing nationwide. (C) The rate of C difficile infection after TJA is holding steady. Pri = primary; rev = revision.

Fig. 2

The IQR of length of stay is longer and associated with wider variation in stay when C difficile is present.

Fig. 3A–B

(A) A histogram shows the age distribution of Cdifficile cases in TJA. (B) A graph shows possible sex-related differences in age versus rate of C difficile, although this is not supported in statistical analysis (see text).

Fig. 4A–B

The effect of C difficile on mortality outstrips effects associated with (A) increasing age or (B) number of comorbidities. No Cdiff = no C difficile present; Cdiff = C difficile present.