title: High Variability in Nosocomial Clostridium difficile Infection Rates Across Hospitals After Colorectal Resection.
abstract: BACKGROUND
  Hospital-acquired Clostridium difficile infection is associated with adverse patient outcomes and high medical costs. The incidence and severity of C. difficile has been rising in both medical and surgical patients.
  
  
  OBJECTIVE
  Our aim was to assess risk factors and variation associated with the development of nosocomial C. difficile colitis among patients undergoing colorectal resection.
  
  
  METHODS
  This was a retrospective cohort study.
  
  
  METHODS
  The study included segmental colectomy and proctectomy cases in New York State from 2005 to 2013.
  
  
  METHODS
  The study cohort included 150,878 colorectal resections. Patients with a documented previous history of C. difficile infection or residence outside of New York State were excluded.
  
  
  METHODS
  A diagnosis of C. difficile colitis either during the index hospital stay or on readmission within 30 days was the main measure.
  
  
  RESULTS
  C. difficile colitis occurred in 3323 patients (2.2%). Unadjusted C. difficile colitis rates ranged from 0% to 11.3% among surgeons and 0% to 6.8% among hospitals. After controlling for patient, surgeon, and hospital characteristics using mixed-effects multivariable analysis, significant unexplained variation in C. difficile rates remained present across hospitals but not surgeons. Patient factors explained only 24% of the total hospital-level variation, and known surgeon and hospital-level characteristics explained an additional 8% of the total hospital-level variation. Therefore, ≈70% of the hospital variation in C. difficile infection rates remained unexplained by captured patient, surgeon, and hospital factors. Furthermore, there was an ≈5-fold difference in adjusted C. difficile rates across hospitals.
  
  
  CONCLUSIONS
  A limited set of hospital and surgeon characteristics was available.
  
  
  CONCLUSIONS
  Colorectal surgery patients appear to be at high risk for C. difficile infection, and alarming variation in nosocomial C. difficile infection rates currently exists among hospitals after colorectal resection. Given the high morbidity and cost associated with C. difficile colitis, adopting institutional quality improvement programs and maintaining strict prevention strategies are of the utmost importance.
authors.affiliation: Department of Surgery, Surgical Health Outcomes and Research Enterprise, University of Rochester Medical Center, Rochester, New York.
authors.forename: Christopher T
authors.initials: CT
authors.lastname: Aquina
authors.forename: Christian P
authors.initials: CP
authors.lastname: Probst
authors.forename: Adan Z
authors.initials: AZ
authors.lastname: Becerra
authors.forename: Bradley J
authors.initials: BJ
authors.lastname: Hensley
authors.forename: James C
authors.initials: JC
authors.lastname: Iannuzzi
authors.forename: Katia
authors.initials: K
authors.lastname: Noyes
authors.forename: John R T
authors.initials: JR
authors.lastname: Monson
authors.forename: Fergal J
authors.initials: FJ
authors.lastname: Fleming
mesh_terms: D000368:Aged; D016360:Clostridioides difficile; D015331:Cohort Studies; D003082:Colectomy; D003108:Colonic Diseases / Q000601:surgery*; D015179:Colorectal Neoplasms / Q000601:surgery; D003428:Cross Infection / Q000453:epidemiology*; D013505:Digestive System Surgical Procedures; D004239:Diverticulitis, Colonic / Q000601:surgery; D004761:Enterocolitis, Pseudomembranous / Q000453:epidemiology*; D005260:Female; D006276:Health Facility Size; D006761:Hospitals / Q000706:statistics & numerical data*; D006780:Hospitals, Rural; D006784:Hospitals, Teaching; D006786:Hospitals, Urban; D006801:Humans; D015994:Incidence; D015212:Inflammatory Bowel Diseases / Q000601:surgery; D007415:Intestinal Obstruction / Q000601:surgery; D007416:Intestinal Perforation / Q000601:surgery; D007902:Length of Stay; D008297:Male; D065666:Mesenteric Ischemia / Q000601:surgery; D008875:Middle Aged; D015999:Multivariate Analysis; D009518:New York / Q000453:epidemiology; D011183:Postoperative Complications / Q000453:epidemiology*; D012002:Rectal Diseases / Q000601:surgery*; D012189:Retrospective Studies; D012307:Risk Factors; D066231:Surgeons / Q000706:statistics & numerical data*