Antibiotic Use Following Joint Procedures Lead to Increased C Difficile Risk

Estera Jachowicz

There are a number of post-operation factors that lead to an increased risk of clostridium difficile infections (CDI) following hip or knee procedures.

A team, led by Estera Jachowicz, Department of Microbiology, Faculty of Medicine, Medical College, Jagiellonian University, analyzed post-discharge CDI incidence in patients undergoing hip or knee arthroplasty to specify the optimal conditions for the surgical procedures and outpatient postoperative care.

The Study

In the one-year observational study at public Polish hospitals, the investigators retrospectively reviewed records for 83,525 surgery patients who underwent hip or knee arthroplasty in 2017. The records were derived from the Polish National Health Fund databases on the 192 C difficile infections observed in the 30-day post-discharge period.

The investigators also analyzed the demographic and clinical characteristics of the patient population, the number of drug groups prescribed, whether it was a primary or revision surgery according to the correct ICD-9 code, length of hospital stay, whether there was a stay in the intensive care unit (ICU), cause of surgery, postoperative infections, primary/revision surgery, and the long-term care after surgery.

Of the 192 cases of CDI, 160 were from patients who underwent hip arthroplasty (0.3 per 1000 patients) and 32 were from patients who underwent knee arthroplasty (0.1 per 1000 patients).

Case Rate Factors

The overall incidence rate of C difficile infections was 34.4 per 10,000 patients and 7.7 cases per 100,000 post-surgery patient-days.

However, the amount of antibiotics prescribed had a direct impact on the risk of C difficile infections.

Patients prescribed at least 1 antibiotic was diagnosed more often with CDI than patients with no antibiotic treatment (55.0 per 1000 patients vs. 1.8 per 1000 patients).

Another factor was combination ABX therapy in the postoperative period. Patients treated with combination ABX therapy were diagnosed with significantly more C difficile infections (2.8 per 1000 patients) than patients who were not (1.8 per 1000 patients).

This was similar for trauma patients, where 7.9 per 1000 patients experienced CDIs, compared to patients operated on because of degeneration (1.2 per 1000 patients) or complication (3.2 per 1000 patients).

Patients admitted in an emergency, post-discharge CDI were diagnosed significantly more often with CDI (4.6 per 1000 patients) compared to patients admitted for scheduled procedures (1.7 per 1000 patients).

After conducting a multifactorial analysis, the investigators identified several factors as significant, including being at least 65 years of age, trauma as the cause of surgery, length of stay over 7 days, hospital-acquired infections other than CDI, and taking beta-lactams and/or quinolones, but not macrolides in the post-discharge period.

Conclusions

“Postoperative antibiotic prescription in patients undergoing joint replacement surgery is the main risk factor for CDI,” the authors wrote. “These observations indicate the necessity of improvement of infection control programs as the key factor for CDI prevention.”

Identifying rates and key factors related to C difficile infections can be especially important as the incidence of CDI is an indicator that allows decision-makers to derive conclusions on the correctness of antibiotic administration.

Currently in Poland, there is no network of infection surveillance, leading to deficiencies in infection control.

The study, “Post-Discharge Clostridioides difficile Infection after Arthroplasties in Poland, Infection Prevention and Control as the Key Element of Prevention of C. difficile Infections,” was published online in the International Journal of Environmental Research and Public Health.