title: Clostridium difficile infection after cardiac surgery: prevalence, morbidity, mortality, and resource utilization.
abstract: OBJECTIVE
  Despite increasing efforts to prevent infection, the prevalence of hospital-associated Clostridium difficile infections (CDI) is increasing. Heightened awareness prompted this study of the prevalence and morbidity associated with CDI after cardiac surgery.
  
  
  METHODS
  A total of 22,952 patients underwent cardiac surgery at Cleveland Clinic from January 2005 to January 2011. CDI was diagnosed by enzyme immunoassay for toxins and, more recently, polymerase chain reaction (PCR) testing. Hospital outcomes and long-term survival were compared with those of the remaining population in propensity-matched groups.
  
  
  RESULTS
  One hundred forty-five patients (0.63%) tested positive for CDI at a median of 9 days postoperatively, 135 by enzyme immunoassay and 11 by PCR. Its prevalence more than doubled over the study period. Seventy-seven patients (48%) were transfers from outside hospitals. Seventy-three patients (50%) were exposed preoperatively to antibiotics and 79 (56%) to proton-pump inhibitors. Patients with CDI had more baseline comorbidities, more reoperations, and received more blood products than patients who did not have CDI. Presenting symptoms included diarrhea (107; 75%), distended abdomen (48; 34%), and abdominal pain (27; 19%). All were treated with metronidazole or vancomycin. Sixteen patients (11%) died in hospital, including 5 of 10 who developed toxic colitis; 3 of 4 undergoing total colectomy survived. Among matched patients, those with CDI had more septicemia (P < .0001), renal failure (P = .0002), reoperations (P < .0001), prolonged postoperative ventilation (P < .0001), longer hospital stay (P < .0001), and lower 3-year survival, 52% versus 64% (P = .03), than patients who did not have CDI.
  
  
  CONCLUSIONS
  Although rare, the prevalence of CDI is increasing, contributing importantly to morbidity and mortality after cardiac surgery. If toxic colitis develops, mortality is high, but colectomy may be lifesaving.
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Suresh
authors.initials: S
authors.lastname: Keshavamurthy
authors.affiliation: Department of Cardiothoracic Anesthesia, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Quality and Patient Safety Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Colleen G
authors.initials: CG
authors.lastname: Koch
authors.affiliation: Quality and Patient Safety Institute, Cleveland Clinic, Cleveland, Ohio; Department of Infectious Disease, Medicine Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Thomas G
authors.initials: TG
authors.lastname: Fraser
authors.affiliation: Department of Infectious Disease, Medicine Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Steven M
authors.initials: SM
authors.lastname: Gordon
authors.affiliation: Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Penny L
authors.initials: PL
authors.lastname: Houghtaling
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Edward G
authors.initials: EG
authors.lastname: Soltesz
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Eugene H
authors.initials: EH
authors.lastname: Blackstone
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address: petterg@ccf.org.
authors.forename: Gösta B
authors.initials: GB
authors.lastname: Pettersson
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000009:adverse effects; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D016360:Clostridioides difficile / Q000472:pathogenicity*; D003082:Colectomy; D015897:Comorbidity; D003428:Cross Infection / Q000175:diagnosis / Q000382:microbiology* / Q000401:mortality / Q000628:therapy / Q000635:transmission; D004761:Enterocolitis, Pseudomembranous / Q000175:diagnosis / Q000382:microbiology* / Q000401:mortality / Q000628:therapy / Q000635:transmission; D005260:Female; D006295:Health Resources / Q000706:statistics & numerical data*; D017052:Hospital Mortality; D006801:Humans; D015994:Incidence; D053208:Kaplan-Meier Estimate; D007902:Length of Stay; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009820:Ohio / Q000453:epidemiology; D015995:Prevalence; D057216:Propensity Score; D054328:Proton Pump Inhibitors / Q000009:adverse effects; D012042:Registries; D012086:Reoperation; D012307:Risk Factors; D017741:Survivors; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents; D054328:Proton Pump Inhibitors