title: Antibiotic prophylaxis and risk of Clostridium difficile infection after coronary artery bypass graft surgery.
abstract: OBJECTIVE
  Antibiotic use, particularly type and duration, is a crucial modifiable risk factor for Clostridium difficile. Cardiac surgery is of particular interest because prophylactic antibiotics are recommended for 48 hours or less (vs ≤24 hours for noncardiac surgery), with increasing vancomycin use. We aimed to study associations between antibiotic prophylaxis (duration/vancomycin use) and C difficile among patients undergoing coronary artery bypass grafting.
  
  
  METHODS
  We extracted data on coronary artery bypass grafting procedures from the national Premier Perspective claims database (2006-2013, n = 154,200, 233 hospitals). Multilevel multivariable logistic regressions measured associations between (1) duration (<2 days, "standard" vs ≥2 days, "extended") and (2) type of antibiotic used ("cephalosporin," "cephalosporin + vancomycin," "vancomycin") and C difficile as outcome.
  
  
  RESULTS
  Overall C difficile prevalence was 0.21% (n = 329). Most patients (59.7%) received a cephalosporin only; in 33.1% vancomycin was added, whereas 7.2% received vancomycin only. Extended prophylaxis was used in 20.9%. In adjusted analyses, extended prophylaxis (vs standard) was associated with significantly increased C difficile risk (odds ratio, 1.43; confidence interval, 1.07-1.92), whereas no significant associations existed for vancomycin use as adjuvant or primary prophylactic compared with the use of cephalosporins (odds ratio, 1.21; confidence interval, 0.92-1.60, and odds ratio, 1.39; confidence interval, 0.94-2.05, respectively). Substantial inter-hospital variation exists in the percentage of extended antibiotic prophylaxis (interquartile range, 2.5-35.7), use of adjuvant vancomycin (interquartile range, 4.2-61.1), and vancomycin alone (interquartile range, 2.3-10.4).
  
  
  CONCLUSIONS
  Although extended use of antibiotic prophylaxis was associated with increased C difficile risk after coronary artery bypass grafting, vancomycin use was not. The observed hospital variation in antibiotic prophylaxis practices suggests great potential for efforts aimed at standardizing practices that subsequently could reduce C difficile risk.
authors.affiliation: Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY. Electronic address: jashvant.poeran@mountsinai.org.
authors.forename: Jashvant
authors.initials: J
authors.lastname: Poeran
authors.affiliation: Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: Madhu
authors.initials: M
authors.lastname: Mazumdar
authors.affiliation: Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: Rehana
authors.initials: R
authors.lastname: Rasul
authors.affiliation: Department of Pharmacy, The Mount Sinai Hospital, New York, NY.
authors.forename: Joanne
authors.initials: J
authors.lastname: Meyer
authors.affiliation: Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: Henry S
authors.initials: HS
authors.lastname: Sacks
authors.affiliation: Icahn School of Medicine at Mount Sinai, New York, NY; Infection Prevention and Control, Mount Sinai Health System, New York, NY.
authors.forename: Brian S
authors.initials: BS
authors.lastname: Koll
authors.affiliation: Icahn School of Medicine at Mount Sinai, New York, NY; Infection Prevention and Control, Mount Sinai Health System, New York, NY.
authors.forename: Frances R
authors.initials: FR
authors.lastname: Wallach
authors.affiliation: Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: Alan
authors.initials: A
authors.lastname: Moskowitz
authors.affiliation: Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: Annetine C
authors.initials: AC
authors.lastname: Gelijns
mesh_terms: D000900:Anti-Bacterial Agents / Q000008:administration & dosage / Q000009:adverse effects*; D019072:Antibiotic Prophylaxis / Q000009:adverse effects*; D002511:Cephalosporins / Q000008:administration & dosage / Q000009:adverse effects; D016360:Clostridioides difficile / Q000187:drug effects* / Q000472:pathogenicity; D003015:Clostridium Infections / Q000139:chemically induced* / Q000175:diagnosis / Q000453:epidemiology / Q000382:microbiology; D001026:Coronary Artery Bypass; D016208:Databases, Factual; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D006801:Humans; D016015:Logistic Models; D015999:Multivariate Analysis; D016017:Odds Ratio; D010818:Practice Patterns, Physicians'; D015995:Prevalence; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D014640:Vancomycin / Q000008:administration & dosage / Q000009:adverse effects
chemical_list: D000900:Anti-Bacterial Agents; D002511:Cephalosporins; D014640:Vancomycin
keywords: Clostridium difficile; antibiotic prophylaxis; coronary artery bypass graft; vancomycin