Analysis of Clostridium difficile infections after cardiac surgery: epidemiologic and economic implications from national data.
OBJECTIVE
Clostridium difficile infections (CDIs) have increased during the past 2 decades, especially among cardiac surgical patients, who share many of the comorbidity risk factors for CDI. Our objectives were to use a large national database to identify the regional-, hospital-, patient-, and procedure-level risk factors for CDI; and determine mortality, resource usage, and cost of CDIs in cardiac surgery.


METHODS
Using the Nationwide Inpatient Sample database, we identified 349,122 patients who had undergone coronary artery bypass, valve, or thoracic-aortic surgery from 2004 to 2008. Of these, 2581 (0.75%) had been diagnosed with CDI. Multivariable regression analysis and the propensity method were used for risk adjustment.


RESULTS
Compared with the West, CDIs were more likely to occur in the Northeast (odds ratio [OR], 1.28; 95% confidence interval [CI], 1.12-1.47) and Midwest (OR, 1.27, 95% CI, 1.11-1.46) and less likely in the South (OR, 0.80; 95% CI, 0.70-0.90). Medium-size hospitals (OR, 0.88; 95% CI, 0.78-0.99) had a lower risk of CDI than did large hospitals. Older age (>75 years; OR, 2.59; 95% CI, 1.93-3.49), longer preoperative length of stay (OR, 1.51; 95% CI, 1.43-1.60), Medicare (OR, 1.21; 95% CI, 1.05-1.39) and Medicaid (OR, 1.60; 95% CI, 1.31-1.96) coverage, and more comorbidities were associated with CDI. Among the matched pairs, patients with CDIs had greater mortality (302 [12%] vs 187 [7.2%], P<.001), a longer median length of stay (21 vs 11 days, P<.001), and greater median hospital charges ($193,330 vs $112,245, P<.001). The cumulative incremental cost of CDIs was an estimated $212 million annually.


CONCLUSIONS
Our results have shown that CDI is associated with increased morbidity and resource usage. Additional work is needed to better understand the complex interplay among regional-, hospital-, and patient-level factors.
Department of Biology, Case Western Reserve University, Cleveland, Ohio.
Andrew
A
Flagg
Department of Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, Ohio.
Colleen G
CG
Koch
Department of Epidemiology and Biostatistics, Case Western Reserve University School of Medicine, Cleveland, Ohio.
Nicholas
N
Schiltz
Department of Epidemiology and Biostatistics, Case Western Reserve University School of Medicine, Cleveland, Ohio.
Aiswarya
A
Chandran Pillai
Department of Infectious Disease, Medicine Institute, Cleveland Clinic, Cleveland, Ohio.
Steven M
SM
Gordon
Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
Gösta B
GB
Pettersson
Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address: soltese@ccf.org.
Edward G
EG
Soltesz
D000293:Adolescent; D000328:Adult; D000368:Aged; D006348:Cardiac Surgical Procedures / Q000009:adverse effects* / Q000191:economics / Q000401:mortality; D016009:Chi-Square Distribution; D002648:Child; D002675:Child, Preschool; D016360:Clostridioides difficile / Q000472:pathogenicity*; D003015:Clostridium Infections / Q000191:economics / Q000453:epidemiology* / Q000382:microbiology / Q000401:mortality / Q000628:therapy; D003428:Cross Infection / Q000191:economics / Q000453:epidemiology* / Q000382:microbiology / Q000401:mortality / Q000628:therapy; D016208:Databases, Factual; D005260:Female; D006295:Health Resources / Q000191:economics / Q000706:statistics & numerical data; D017721:Hospital Costs; D006761:Hospitals; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011183:Postoperative Complications / Q000191:economics / Q000453:epidemiology* / Q000382:microbiology / Q000401:mortality / Q000628:therapy; D015995:Prevalence; D057216:Propensity Score; D012111:Residence Characteristics; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D055815:Young Adult