Clostridioides difficile infection after surgical myocardial revascularisation: unravelling risk factors and impact on postoperative outcomes

Maciej Łuczak; Krzysztof Greberski; Marian Burysz; Bartłomiej Perek; Radosław Jarząbek; Paweł Bugajski

doi:10.20883/medical.e1384

Authors

Maciej Łuczak Department of Cardiac Surgery, Józef Struś Hospital, Poznań, Poland https://orcid.org/0009-0000-3660-7275
Krzysztof Greberski Department of Cardiac Surgery, Józef Struś Municipal Hospital, Poznań, Poland; Faculty of Health Sciences, Poznan University of Medical Sciences, Poznań, Poland https://orcid.org/0000-0003-1002-4738
Marian Burysz Department of Cardiac Surgery, Regional Specialist Hospital, Grudziądz, Poland; Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland https://orcid.org/0009-0003-1257-0510
Bartłomiej Perek Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznań, Poland https://orcid.org/0000-0003-2398-9571
Radosław Jarząbek Department of Cardiac Surgery, Józef Struś Municipal Hospital, Poznań, Poland https://orcid.org/0000-0002-2842-3318
Paweł Bugajski Department of Cardiac Surgery, Józef Struś Municipal Hospital, Poznań, Poland; Faculty of Health Sciences, Poznan University of Medical Sciences, Poznań, Poland https://orcid.org/0000-0003-1207-2979

DOI:

https://doi.org/10.20883/medical.e1384

Keywords:

Clostridioides difficile, cardiac surgery, risk factors, postoperative impact, antibiotic usage, geographical analysis, hospitalization time

Abstract

Aim. Clostridioides difficile (CDI) poses a significant threat to postoperative cardiac surgery patients. This study examines the impact of specific pre-, intra-, and post-operative factors, along with geographical considerations, on Clostridioides difficile (CD) incidence and its consequences. The study aims to identify factors contributing to increased CD prevalence in cardiac surgery units.

Material and methods. A single-centre cohort of 3502 patients undergoing surgical myocardial revascularisation between January 2013 and March 2018 was analysed, with 48 diagnosed with CDI. Preoperative risk factors include the use of broad-spectrum antibiotics, advanced age, comorbidities, and prolonged hospital stays. Intraoperatively, attention is given to catheter-related issues, mechanical ventilation, and the use of blood products. Postoperatively, the study assesses CDI's impact on recovery, complications, and outcomes. A geographical analysis explores regional variation in CDI incidence.

Results. Results indicate a CDI incidence of 1.37%, aligning with existing literature trends. Demographically matched controls show no significant differences in age, gender, or location. Higher Body Mass Index and lower left ventricular ejection fraction are identified as significant risk factors. Laboratory findings indicate elevated CRP levels and increased platelet count associated with CDI. Postoperative CDI significantly prolongs hospitalisation time. EuroSCORE II values are higher in the CDI group, though not statistically significant.

Conclusions. The study offers a comprehensive understanding of CDI dynamics in cardiac surgery, emphasising the need for tailored preventive measures. Specific risk factors and regional variations underscore the importance of vigilant monitoring and early intervention. Future research should include larger cohorts and explore gut microbiota for refined strategies.

In the later part of the abstract the authors use the abbreviation CDI. We suggest replacing this abbreviation with CDI.

Downloads

Download data is not yet available.

References

Murphy C, Vernon M, Cullen M. Intravenous immunoglobulin for resistant Clostridium difficile infection. Age Ageing. 2006 Jan;35(1):85-6. https://doi.org/10.1093/ageing/afi212. Epub 2005 Nov 22. PMID: 16303776.

De Roo AC, Regenbogen SE. Clostridium difficile Infection: An Epidemiology Update. Clin Colon Rectal Surg. 2020 Mar;33(2):49-57. https://doi.org/10.1055/s-0040-1701229. Epub 2020 Feb 25. PMID: 32104156; PMCID: PMC7042002.

Vondran M, Schack S, Garbade J, Binner C, Mende M, Rastan AJ, Borger MA, Schroeter T. Evaluation of risk factors for a fulminant Clostridium difficile infection after cardiac surgery: a single-center, retrospective cohort study. BMC Anesthesiol. 2018 Sep 27;18(1):133. https://doi.org/10.1186/s12871-018-0597-2. PMID: 30257648; PMCID: PMC6158878.

Sartelli M, Di Bella S, McFarland LV, Khanna S, Furuya-Kanamori L, Abuzeid N, et al. 2019 update of the WSES guidelines for management of Clostridioides (Clostridium) difficile infection in surgical patients. World J Emerg Surg. 2019 Feb 28;14:8.

Eze P, Balsells E, Kyaw MH, Nair H. Risk factors for Clostridium difficile infections - an overview of the evidence base and challenges in data synthesis. J Glob Health. 2017 Jun;7(1):010417. https://doi.org/10.7189/jogh.07.010417. PMID: 28607673; PMCID: PMC5460399.

Zilberberg MD, Shorr AF, Wang L, Baser O, Yu H. Development and Validation of a Risk Score for Clostridium difficile Infection in Medicare Beneficiaries: A Population-Based Cohort Study. J Am Geriatr Soc. 2016 Aug;64(8):1690-5. https://doi.org/10.1111/jgs.14236. Epub 2016 Jun 13. PMID: 27295521.

. Gelijns AC, Moskowitz AJ, Acker MA, Argenziano M, Geller NL, Puskas JD, Perrault LP, Smith PK, Kron IL, Michler RE, Miller MA, Gardner TJ, Ascheim DD, Ailawadi G, Lackner P, Goldsmith LA, Robichaud S, Miller RA, Rose EA, Ferguson TB Jr, Horvath KA, Moquete EG, Parides MK, Bagiella E, O'Gara PT, Blackstone EH; Cardiothoracic Surgical Trials Network (CTSN). Management practices and major infections after cardiac surgery. J Am Coll Cardiol. 2014 Jul 29;64(4):372-81. https://doi.org/10.1016/j.jacc.2014.04.052. PMID: 25060372; PMCID: PMC4222509.

Burke KE, Lamont JT. Clostridium difficile infection: a worldwide disease. Gut Liver. 2014 Jan;8(1):1-6. https://doi.org/10.5009/gnl.2014.8.1.1. Epub 2014 Jan 13. PMID: 24516694; PMCID: PMC3916678.

World Health Organization. Diarrhoeal disease. 2017 May 2. Retrieved from: https://www.who.int/news-room/fact-sheets/detail/diarrhoeal-disease

McDonald LC, Gerding DN, Johnson S, Bakken JS, Carroll KC, Coffin SE, Dubberke ER, Garey KW, Gould CV, Kelly C, Loo V, Shaklee Sammons J, Sandora TJ, Wilcox MH. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018 Mar 19;66(7):e1-e48. https://doi.org/10.1093/cid/cix1085. PMID: 29462280; PMCID: PMC6018983.

. Debast SB, Bauer MP, Kuijper EJ; European Society of Clinical Microbiology and Infectious Diseases. European Society of Clinical Microbiology and Infectious Diseases: update of the treatment guidance document for Clostridium difficile infection. Clin Microbiol Infect. 2014 Mar;20 Suppl 2:1-26. https://doi.org/10.1111/1469-0691.12418. PMID: 24118601.

Sanaiha Y, Sareh S, Lyons R, Rudasill SE, Mardock A, Shemin RJ, Benharash P. Incidence, Predictors, and Impact of Clostridium difficile Infection on Cardiac Surgery Outcomes. Ann Thorac Surg. 2020 Nov;110(5):1580-1588. https://doi.org/10.1016/j.athoracsur.2020.03.037. Epub 2020 Apr 15. PMID: 32304688.

Keshavamurthy S, Koch CG, Fraser TG, Gordon SM, Houghtaling PL, Soltesz EG, Blackstone EH, Pettersson GB. Clostridium difficile infection after cardiac surgery: prevalence, morbidity, mortality, and resource utilization. J Thorac Cardiovasc Surg. 2014 Dec;148(6):3157-65.e1-5. https://doi.org/10.1016/j.jtcvs.2014.08.017. Epub 2014 Aug 14. PMID: 25242055.

Chatterjee T, Bansal S, Abuzar A, Hussain H, Gupta L. Is Increased BMI a Risk Factor for Developing Severe Clostridioides Difficile Infection? A Retrospective Study. J Community Hosp Intern Med Perspect. 2022 Nov 7;12(6):43-50. https://doi.org/10.55729/2000-9666.1123. PMID: 36816160; PMCID: PMC9924641.

Mulki R, Baumann AJ, Alnabelsi T, Sandhu N, Alhamshari Y, Wheeler DS, Perloff S, Katz PO. Body mass index greater than 35 is associated with severe Clostridium difficile infection. Aliment Pharmacol Ther. 2017 Jan;45(1):75-81. https://doi.org/10.1111/apt.13832. Epub 2016 Oct 28. PMID: 27790736.

Méndez-Bailón M, Jiménez-García R, Hernández-Barrera V, Miguel-Díez J, Miguel-Yanes JM, Muñoz-Rivas N, Lorenzo-Villalba N, Carabantes-Alarcon D, Zamorano-León JJ, Astasio-Arbiza P, Ortega-Molina P, López-de-Andrés A. Heart Failure Is a Risk Factor for Suffering and Dying of Clostridium difficile Infection. Results of a 15-Year Nationwide Study in Spain. J Clin Med. 2020 Feb 25;9(3):614. https://doi.org/10.3390/jcm9030614. PMID: 32106444; PMCID: PMC7141109.

Mamic P, Heidenreich PA, Hedlin H, Tennakoon L, Staudenmayer KL. Hospitalized Patients with Heart Failure and Common Bacterial Infections: A Nationwide Analysis of Concomitant Clostridium Difficile Infection Rates and In-Hospital Mortality. J Card Fail. 2016 Nov;22(11):891-900. https://doi.org/10.1016/j.cardfail.2016.06.005. Epub 2016 Jun 16. PMID: 27317844.

Foley MH, McMillan AS, O'Flaherty S, Thanissery R, Vanhoy ME, Fuller MG, Barrangou R, Theriot CM. Differential modulation of post-antibiotic colonization resistance to Clostridioides difficile by two probiotic Lactobacillus strains. mBio. 2025 Aug 13;16(8):e0146825. https://doi.org/10.1128/mbio.01468-25. Epub 2025 Jul 21. PMID: 40689613; PMCID: PMC12345269.

Gigli S, Seguella L, Pesce M, Bruzzese E, D'Alessandro A, Cuomo R, Steardo L, Sarnelli G, Esposito G. Cannabidiol restores intestinal barrier dysfunction and inhibits the apoptotic process induced by Clostridium difficile toxin A in Caco-2 cells. United European Gastroenterol J. 2017 Dec;5(8):1108-1115. https://doi.org/10.1177/2050640617698622. Epub 2017 Mar 13. PMID: 29238589; PMCID: PMC5721977.

Nseir W, Khamisy-Farah R, Amara A, Farah R. The Prognostic Value of Inflammatory Markers in Clostridium difficile-associated Diarrhea. Isr Med Assoc J. 2019 Oct;21(10):658-661. PMID: 31599506.

Kiersnowska Z, Lemiech-Mirowska E, Ginter-Kramarczyk D, Kruszelnicka I, Michałkiewicz M, Marczak M. Problems of Clostridium difficile infection (CDI) in Polish healthcare units. Ann Agric Environ Med. 2021 Jun 14;28(2):224-230. https://doi.org/10.26444/aaem/119321. Epub 2020 Apr 2. PMID: 34184502.

Crabtree T, Aitchison D, Meyers BF, Tymkew H, Smith JR, Guthrie TJ, Munfakh N, Moon MR, Pasque MK, Lawton J, Moazami N, Damiano RJ Jr. Clostridium difficile in cardiac surgery: risk factors and impact on postoperative outcome. Ann Thorac Surg. 2007 Apr;83(4):1396-402. https://doi.org/10.1016/j.athoracsur.2006.10.067. PMID: 17383346.

Wilawer M, Elikowski W, Greberski K, Ratajska PA, Welc NA, Lisiecka ME. Abiotrophia defectiva endocarditis - Diagnostic and therapeutic challenge: Case report. IDCases. 2023 Oct 8;34:e01906. https://doi.org/10.1016/j.idcr.2023.e01906. PMID: 37867569; PMCID: PMC10585279.

Elikowski W, Małek-Elikowska M, Greberski K, Rzymski S, Kołowrotkiewicz A, Furmaniuk J, Bugajski P. Takotsubo syndrome following mitral valve replacement and left anterior descending coronary artery bypass grafting. Pol Merkur Lekarski. 2019 Jan 28;46(271):36-41. PMID: 30810114.

Greberski K, Jarząbek R, Perek B, Łuczak M, Bugajski P. Exceptional life-threatening complication 19 years after Ravitch correction of pectus excavatum. J Card Surg. 2021 Oct;36(10):3971-3972. https://doi.org/10.1111/jocs.15889. Epub 2021 Aug 2. PMID: 34339529.