Paper of the Week: Clostridium difficile infection after orthopedic surgery: Incidence, associated factors, and impact on outcome

Paper of the Week: Clostridium difficile infection after orthopedic surgery: Incidence, associated factors, and impact on outcome

ICM Philly February 15, 2022

Dong Youn Kim, MD; Yu-Mi Lee, MD; Ki-Ho Park, MD; Young Jin Kim, MD; Kyung-Chung Kang, MD; Chang Kyun Lee, MD; Mi Suk Lee, MD;

American Journal of Infection Control 50(1): e72, 2022
doi: 10.1016/j.ajic.2021.08.021

Summary by John Hayden Sonnier, MS

Clostridium difficile infection (CDI) poses a significant challenge to the healthcare
system, as nosocomial infections have been estimated to increase healthcare expenditures by
$1.5 annually [1]. It is potentially life-threatening and is the leading cause of health care associated
diarrhea [2]. Patients undergoing orthopedic surgery may have risk factors for CDI such as
advanced age, underlying medical comorbidities, antibiotic use, and prolonged length of stay in
the hospital [3]. Cruz-Rodriguez et al. studied an orthopedics ward with particularly high rates of
both clindamycin use and CDI, and found that restricting clindamycin use reduced the rates of
CDI [4].

In the present study, Kim et al. sought to evaluate the incidence, associated factors, and
impact of hospital acquired CDI. To do this, they retrospectively analyzed the medical records of
all adult inpatients who underwent orthopedic surgery during their hospital stay. They then
reviewed the records of included patients to document the rate of diagnosed CDI; patients with
an infection within 3 days of admission, or within 8 weeks prior to admission, were excluded. In
order to identify other factors associated with CDI, multiple other variables were recorded
including age, comorbidities, type of surgery, time from admission to surgery, surgical priority,
operation time, and antibiotic use. Univariate and multiple linear regression was performed to
identify independent risk factors. A nonparametric multistate model was used to calculate excess
length of stay resulting from infection.

The study found that during the study period, 0.7% of inpatients who underwent
orthopedic surgery developed CDI. Independent risk factors were age >65 years, preoperative
hospital stay >3 days, operating time >3 hours, and antibiotic use for infection treatment. Excess
length of stay attributable to infection was 2.8 days.

There were several limitations to this study, such as its retrospective design. Additionally,
almost all of the CDI patients received extended prophylactic antibiotics, so the authors were
unable to calculate the risk of CDI associated with extended prophylactic antibiotic use.
Additional research is needed to clarify this relationship.


  1. Leffler DA, Lamont JT. Clostridium difficile Infection. Longo DL, ed. N Engl J Med.
    2015;372(16):1539-1548. doi:10.1056/NEJMra1403772
  2. Smits WK, Lyras D, Lacy DB, Wilcox MH, Kuijper EJ. Clostridium difficile infection. Nat
    Rev Dis Primers
    . 2016;2(1):16020. doi:10.1038/nrdp.2016.20
  3. Kim DY, Lee YM, Park KH, et al. Clostridium difficile infection after orthopedic surgery:
    Incidence, associated factors, and impact on outcome. American Journal of Infection
    . 2022;50(1):72-76. doi:10.1016/j.ajic.2021.08.021
  4. Cruz-Rodríguez NC, Hernández-García R, Salinas-Caballero AG, Pérez-Rodríguez E,
    Garza-González E, Camacho-Ortiz A. The effect of pharmacy restriction of clindamycin on
    Clostridium difficile infection rates in an orthopedics ward. American Journal of Infection
    Control. 2014;42(6):e71
    -e73. doi:10.1016/j.ajic.2014.02.018
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