Clostridium Difficile Infection Haunts Cervical Disk Surgery Patients

By John Henry Dreyfuss, MDalert.com staff.

Save to PDF Infection ControlEvidence-Based MedicinePerformance-Based Medicine By
  • C. difficile infection strikes patients with co-morbid conditions significantly more often.
  • Annual cost of C. difficile infection estimated at nearly $7 million.
  • Improper use of antibiotic in the perioperative period can lead to postoperative C. difficile colitis, among other negative outcomes.
  • C. difficile infection following cervical spine surgery is associated with significantly increased cost, poor outcome, and extended hospital stay.

Clostridium difficile (C. difficile) (Figure 1) infection following cervical spine surgery is associated with significantly increased cost, poor outcome, and extended length of hospital stay (LOS). The results were published recently in the Global Spine Journal.

Figure 1. Clostridium difficile.
(Sources: Wikimedia Commons/Creative Commons.)

The authors found that postop C. difficile infection following cervical disk surgery (Figure 2) increases the risk of in-hospital mortality and costs about $7 million per year to manage in these patients. Patients who have comorbidities such as renal failure or congestive heart failure have increased a still increased probability of developing the infection following surgery.

“Accepted antibiotic guidelines in this population must be followed to decrease the risk of developing postoperative C. difficile colitis,” the authors stressed.

Figure 2. Anterior cervical disk surgery.
(Sources: Wikimedia/Creative Commons/GNU Free.)

In other studies, postoperative C. difficile infection has been reported to increase length of hospital stay, mortality, and costs. Maltenfort et al demonstrated that C. difficile infection following total knee arthroplasty increased LOS stay by 1 week, hospital charges by nearly U.S.$40,000, and in-hospital mortality from 0.24% to 4.66%, according to the report in the Global Spine Journal.

Untoward Outcomes

The authors reviewed data from the Nationwide Inpatient Sample (NIS) database in order to investigate trends of C. difficile infection following elective cervical spine surgery for degenerative causes. “Postoperative C. difficile infection in this population results in extended hospital stay, greater costs, and increased inpatient mortality,” they noted.

While C. difficile infection following elective cervical spine surgery (Figure 3) is relatively rare, “it is significantly increasing in incidence likely due to novel antibiotic-resistant strains and improper antibiotic use.” Importantly, while it is rare, C. difficile infection is not infrequently fatal. And, if it is not fatal, the infection leads to significant morbidity, increased costs, and increased LOS. The authors noted that proper use of antibiotics is particularly important in patients who are aged >65 years and in those with preoperative comorbidities such as diabetes and kidney disease.

Figure 3. Anterior cervical diskectomy and fusion (coronal view).
(Sources: Wikimedia/Creative Commons/
User: debivort - Own work, CC BY-SA 3.0.)

The Analysis

The authors evaluated 1,602,130 cervical spine surgeries that had been recorded in the NIS database between 2002 to 2011. They included patients classified as having C. difficile based on the U.S. National Institutes of Health “International Classification of Diseases, 9th Revision, Clinical Modification” procedural codes for cervical spine surgery for degenerative spine diagnoses. They then conducted multivariate analyses in order to assess factors associated with increased incidence of C. difficile infection and risk of mortality and morbidity.

The reviewers found the incidence of C. difficile infection in postoperative cervical spine surgery patients to be 0.08%, which was significantly increased since 2002 (P<0.0001). “The odds of postoperative C. difficile infection were significantly increased in patients with comorbidities such as congestive heart failure, renal failure, and perivascular disease,” the authors noted. “Circumferential cervical fusion increased the likelihood of developing C. difficile infection after degenerative cervical spine surgery (odds ratio [OR] = 2.93, P<0.0001).”

C. difficile infection following cervical spine surgery was found to result in an extended LOS (P<0.0001) and increased hospital costs (P<0.0001). Mortality rates in patients who develop C. difficile infection following cervical spine surgery was found to be nearly 8% versus 0.19% in noninfected patients (P<0.0001). Analysis revealed C. difficile to be a significant predictor of inpatient mortality (OR = 3.99, P<0.0001).


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